If there’s one big mistake I see most patients make that places them at risk, it’s not understanding how to gauge the risk of procedural-based care. So the goal this morning is to help you understand how to protect you, and your loved ones, from us doctors. Let’s dig in.
Complications can happen in any medical procedure, no matter how small or big. Meaning a doctor can place a small needle in the wrong spot and harm a patient or a big surgery can go seriously wrong and produce the same result. However, as I always tell my patients, my job is to pick the least invasive procedure for you that’s the most likely to help, even if that doesn’t make me the most money.
What is Invasiveness?
Invasive means more tissue damage. You see this word used all the time these days. Oftentimes, it’s in the context of “minimally invasive”. Obviously, this means less tissue damage. However, be VERY careful, as this term is thrown around and used frequently even when the procedure is very invasive. For example, an injection guided with fluoroscopy is minimally invasive, but the term is also used to describe fairly big surgeries. Hence, in order to understand how much risk you’re taking with a procedure, you need more information.
Ordering The Procedure Risk by Tissue Damage
Every procedure produces some amount of tissue damage. The risk of the procedure generally follows the amount of damage done. Meaning more tissue damage generally means more risk. While there are exceptions, this is one easy way to look at how much risk you’re taking by signing up for the procedure. I’ll be referring to the figure above that goes over all procedure types and ranks them by their level of invasiveness.
If we look at the risk of all injections being equal and causing the least tissue damage as compared to surgery, then we can divide these procedures into three different risk categories. First, the least invasive procedure would be injecting a substance that can heal. This could be PRP or stem cell injections or anything capable of initiating a repair response. Next up would be an injection that might help someone’s pain or function, but the substance likely damages tissue. Injections in this category include steroids shots that can kill cartilage cells and/or other tissue and certain anesthetics that can also harm tissue. Finally, last up and the most invasive in this category, is an injection-based procedure that destroys tissue. For example, a procedure like radiofrequency ablation. This procedure heats up and destroys nerves to relieve pain.
“Minimally Invasive Procedures”
As I wrote above, be very careful with the phrase “minimally invasive”, as it gets applied to both procedures that are closer to injections than surgery and surgeries that are less invasive. Here I use this term to apply to procedures that use an injection like approach. The “needle” in these procedures is a bigger version of what would normally be considered a needle and is generally a small hollow tube where something is inserted. Hence, this device does more tissue damage than a typical injection, because the apparutus is bigger.
Everything from removing tissue to inserting small devices can be accomplished through a small hollow tube. In addition, the “tube” can get quite big to insert devices, causing even more tissue damage. So the rule here is that procedures that use small tubes are less invasive than big tube procedures.
Less invasive in this category would be procedures that remove or modify tissue. For example, a procedure like the MILD protocol that removes tissue (in this case a ligament in the spinal canal that causes lumbar stenosis). More invasive here would be a procedure where an implant is inserted. So an example is an interspinous spacer to treat lumbar stenosis like the Superion system used to treat spinal stenosis.
Obviously, surgery using scalpels does more tissue damage than just inserting a needle or a hollow tube. Hence, surgery is the most invasive on this scale. Obviously, there are less and more invasive surgeries. Less invasive is a surgery where something is cut out. For example, a spine surgery called a laminectomy where a piece of the vertebral bone is removed. Or a procedure like a knee arthroscopy to perform a partial meniscectomy.
More invasive still is implanting something with a surgery. For spine surgery, this would be a fusion where the vertebra bones are bolted together. For joints, this could be a knee replacement where the joint is amputated and a prosthesis is inserted.
Climbing the Ladder of Invasiveness
The way to keep safe as a patient is to start with less invasive procedures first. Many patients get frustrated with their pain and jump over critical rungs of this ladder to try to get a quick fix. I see these patients all day when these procedures fail or complications happen. They often didn’t know less invasive options to treat their problem existed. Hence, it’s clear that we have medical providers who aren’t fully informing patients of all of their options.
I showed the MRI images of a low back stenosis patient the other day. She found relief on the first rung of this ladder through a precise imaged guided injection of her own platelets. However, if that had failed, the next step would be to try something like a steroid shot to relieve pain, understanding that this may harm some of the local tissues. After that would have been a radiofrequency procedure, which can sometimes provide relief. If that didn’t work, then she could have tried a MILD or Superion procedure. Finally, if that wasn’t effective a surgical decompression. You get the idea, start with less invasive and only if that procedure fails, move to more invasive.
In another example, there are patients who just aren’t a candidate for an injection procedure. For example, a patient with very severe hip arthritis. My recommendation for those patients is often to skip to a much more invasive hip replacement. That’s because, in my experience, the less invasive stuff usually doesn’t work.
The upshot? As a patient, you can keep yourself safe by always trying the least invasive option that might work. However, you may have to do your own online homework to find out all of your options!