Chronic pain? To operate or not

I find that one of the most difficult things to do as a doctor is explain to someone that the treatments I have to offer will not help with their pain. Often a specialist is seen as the last hope for relief from chronic back or leg pain and that surgery will be the answer. Sometimes surgery may have a role, but more often it does not. The reasons are a complex interplay of physical problems with the spine, an individual’s response to their original injury and the development of ‘pain memory’. The pain is real and sometimes severe, but surgery has the risk of just stirring the problem up rather than solving it. It takes time and understanding to explain this to people who have this kind of pain. I try to frame the problem as one of acceptance through understanding.

The next question I get is, ‘so what can be done?’ and this is hard too. Despite all the technology we have, there is no easy or fully effective cure for chronic pain. Pain management should be multi-disciplinary, using medications, exercise and cognitive training. Pain killers in combination can be more helpful than one agent alone, but this requires expertise to manage well. Keeping on moving with exercise is important, even when it hurts. Maintaining function is good for sense of well-being. Cognitive training deals with the beliefs and misunderstandings that people have about their pain that can magnify its effects.

Even if pills and exercise don’t sound like they may work, it is better to avoid surgery if there is no good reason to do it because the results can be worse than before. Sometimes, all I can do is advise someone not to make that mistake.

Dr Ralph Stanford

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