Most of my patients view surgery as like getting a part fixed in their car. A part wears out, so you replace it or “fix it” with a new one. As I spoke to a patient this week about pursuing back surgery or continuing to try to avoid it with orthobiologics, I was struck how he didn’t understand that back surgery would damage his spine. He didn’t get that the procedure would only be worth it if we had no other option and if the damage from the surgery was less than the good we thought it might do. At that moment, sitting there, struggling to get him to understand, I coined a phrase: “Surgery is damage to accomplish a goal.”
Let’s say that you have a nerve that’s being compressed by a disc bulge. If a surgeon goes into “fix” that problem, he or she must first cut through the muscles that stabilize the back. The act of just placing a retractor tightly against those muscles to allow the surgeon to visualize the area will also damage them in direct proportion to the pressure and the amount of time that the device is in place. If the surgeon removes the part of the disc pressing on the nerve, the structure of that disc will be forever compromised as it won’t grow back. If the surgeon must remove part of the local bone to open up the area, then the whole vertebra will be less stable.
Let’s take this surgical damage concept to the knee, shoulder, and ankle. A torn piece of a knee meniscus can’t be removed without also increasing the forces on the cartilage. When a surgeon removes the biceps tendon because where it attaches is torn, it will negatively change the way that biceps muscle and the shoulder work. And so the examples continue from the ankle ligaments replaced with tendons to an ACL replaced with a hamstrings or patellar graft. There is no surgery-free lunch, meaning it’s all controlled damage to accomplish a goal.
Is the Damage Less Disabling Than the Goal?
This, of course, is the billion-dollar question. First, the answer is very easy when research shows that the surgery doesn’t produce positive results better than physical therapy or a placebo. So for these surgeries, unless it’s a unique scenario, no amount of damage is acceptable:
- Knee meniscus procedures
- Spinal stenosis surgeries
- Shoulder SLAP lesion repairs
- Partial shoulder rotator cuff repair
Reducing the Damage
One way to move the balance of damage and outcome into your favor is to reduce the damage. So for the spine patient above, we discussed getting a true muscle-sparing, minimally invasive surgery where they would remove the least amount of disc and bone feasible. This is why we practice interventional orthopedics, allowing us to get stem cells and platelets to the right spot using an injection that does no or little damage. This is also why we’re working on the next generation of injection-based tools that will replace surgery, allowing us to do things through needles that used to only be possible with surgery.
The upshot? Surgery is damage to accomplish a goal. There’s just no way around it; modern orthopedic surgery is often like a bull in the china shop. None of these procedures are like replacing a worn-out part with a new one. In fact, they all involve damaging the musculoskeletal system to some degree. So the million-dollar questions is always, is the amount of damage this surgery will cause worth the end game?