Dr. Reidler: To have a good surgical outcome, several arrows must intersect with one another. For example, the patient’s symptoms should be concordant with the physical exam, and both the physical exam and the history should match the imaging findings. If these items align, I will typically feel that I have the right diagnosis for the patient.
Once the right diagnosis is found, the right procedure must be selected. This includes determining if the procedure will be less or more invasive and which technique ought to be applied. For example, if a patient needs a fusion but you only perform a decompression, then this patient may require a second surgery. If a decompression would have sufficed instead of a fusion, then the healing process may be needlessly longer and more complex.
The third element of importance is the surgeon themself: Do they have the skills and experience necessary to perform the selected procedure?
Finally, the patient’s biology and comorbidities must be considered, including their age, past surgical history, risk of infection and so forth.
In general, if there is a focal neurologic deficit and the etiology of this deficit can be identified, this portends a high chance of success with surgical intervention. Patients with nerve impingement and spinal stenosis with claudication symptoms will typically respond well to surgery. If, on the other hand, symptoms are vague and generalized, then surgery may not necessarily be the best option.
TR: Can you discuss a few important concepts that rheumatologists should know about with regard to the management of chronic back pain in their patients?
Dr. Reidler: My first inclination is always to think about nonsurgical approaches for the management of back pain. This can often involve physical therapy, weight loss and outpatient procedures like epidural injections when indicated. It may be helpful to involve a spinal surgeon in the care of these patients because there are different degrees of spinal degeneration and the radiology report may not tell the whole story on its own. I like to look at all imaging studies myself and interpret these studies in the clinical context. A patient may have had 20 years of back pain and only have one spinal level with severe degenerative changes that are amenable to intervention. In contrast, a patient with multilevel changes is unlikely to improve with one surgical intervention alone.
When I work together with rheumatologists, I convey to them the importance of ensuring that the underlying autoimmune condition is under adequate control by the time of surgery. Surgeons may sometimes be eager to operate when they see a focal finding that would typically respond to surgery, but if the underlying inflammatory arthritis is not well controlled when the patient goes to the OR, then the results are likely to be poor.
