comes will be compromised. It is critical
to calm down the nervous system prior to
undergoing surgery or even making any
decisions about it.
Since what cannot be seen cannot be
fixed, Dr. Hanscom does not recommend surgery, under any circumstances,
for non-structural issues. His focus is on
explaining why the patient likely does
not need surgery and how he or she can
overcome chronic pain by using a self-directed structured spine care program.
He uses a process that evolved out of his
personal experience with chronic pain —
Defined Organized Comprehensive Care
Much of spine surgery is performed
on patients with non-specific pain and
no identifiable source. The success rate in
this circumstance is less than 30 percent
at two-year follow up, and the downside
Dr. Hanscom notes that for a patient
to be ready for any surgery, he or she
must also be sleeping at least seven hours
a night for three months and have an
anxiety/frustration level below a five on a
scale of 10. Additionally, he or she should
be actively engaged in learning about the
pain and exercising. Even when these
goals are achieved, surgery should be
performed only on an identifiable structural problem with matching symptoms.
Surgery rarely, if ever, solves non-specific
lower back pain (LBP).
Over the years, workers’ compensation
insurers and self-insured organizations
have seen clusters of spine surgeries
emerge in their claims data. In discussions
with medical professionals, claims adjusters, risk managers, and environmental
and health safety (EH&S) professionals,
the conversations usually come back to
injured workers being told that spine surgery was a “cure all” (e.g., spine fusion).
These spikes have often been observed in
certain areas of a state where word spreads
throughout the workforce about a surgical
remedy or a treating physician performing a high number of these surgeries.
Surgical outcomes in the workers’
compensation population are less suc-
cessful than the general population. Dr.
Hanscom realized about 15 years ago that
people on workers’ compensation tend to
be angrier than the general population.
Not only are they experiencing ongoing
pain, they are often caught up in a system
that provides limited options and have a
feeling of no control, which leads to frus-
tration and anger. When angry, the body
chemistry changes to a “fight-or-flight”
mode, and the perception of pain is am-
plified. The additional stress of surgery
performed in the context of an amped-up
nervous system has a lower chance of re-
Medical Professional Liability
National malpractice data shows that the
top two categories of malpractice cases
are diagnosis-related cases and surgical
cases. With some regional variability,
diagnosis cases account for somewhere
between 24 to 30 percent of all cases, and
surgery is close behind at 20 to 25 percent. The dollars associated with these
two categories are astronomically high,
largely because the majority of cases represent high-severity injury events.
A close examination of surgical malpractice cases reveals that the three most
frequently named surgical specialties are
general surgery, orthopedic surgery, and
neurosurgery. This begins to sharpen the
focus as to where the greatest risks lie. A
further analysis into procedure type fills
out the risk profile: the surgery most frequently involved in malpractice-related
scenarios is spine.
These spine cases may relate to any one
of the following:
• Technical errors — in spine cases, just
the slightest slip in technique can some-
times lead to a catastrophic outcome.
• Errors in cognition/judgment — making a wrong decision while the surgery
is in progress.
• Human factors/systems errors — operating on the wrong level, or other scenarios which result from interruptions
in the surgeon’s concentration.
• Poor outcomes associated with operating on a patient where surgery was not
But is malpractice data meaningful?
Many would argue that it is such a thin
slice of the world of healthcare data,
there is limited value in using it for analysis. However, we would take the opposite position.
In many event types, data traditionally
— and routinely — collected by healthcare organizations (whether hospitals
or other entities) largely misses the factors that are actually driving the greatest
vulnerabilities in safe patient care. Much
is known about slips and falls, hospital-acquired infections, retained foreign
bodies, lost test results — all the visible
misadventures in the care delivery environment. But the more subtle risk factors
are frequently missed, largely because
traditional approaches to reporting are
not designed to capture them. As a result,
there is very little monitoring and ongoing reporting related to poorly designed
processes, human factor issues, communication breakdowns, cognitive failures,
and skill-based issues.
This is exactly why malpractice data
should have attention paid to it. Even
though it can — and often does — defy
statistical significance, malpractice data
and associated case studies represent
critical signals as to where patient care has
been at risk, and where it may continue
to be at risk.
Legislation passed in Minnesota last fall
is directly related to spine surgery. Injured workers who participate in the pilot
program will get a clearer understanding
of the pros and cons of having a spine
fusion. Through what is essentially “a
second opinion,” the injured worker and
his/her family can make a more educated
decision about the treatment options. The
Minnesota Department of Labor & Industry also provides a two-page fact sheet
explaining what injured workers should
know about lumbar fusion surgery as a
treatment for degenerative disc disease.
The fact sheet notes that studies of injured workers show that about half get
better after the surgery, with one-third of
patients reporting a “poor” result.
The departments of labor and industry in a number of other states routinely