^^ u mad?

3/14/2010 9:45:11 PM

yup

3/14/2010 10:07:47 PM

Quote :

"Yeah OB/GYNs definitely have it the worst when it comes to this sort of stuff. Who do you figure is 2nd for completely pointless lawsuits? Maybe oncologists? "

neurosurgeons......no one wants to live with any sort of neurological defect resulting from one of the riskiest, most complicated types of surgery out there.

3/15/2010 3:17:08 AM

Most neurosurgeons do back surgery as well, which has an incredibly high rate of not helping people with a risk of making you worse...although you can significantly prevent further damage to someones spinal cord by doing the surgery. I have an uncle who does orthopedic surgery who won't touch anyones back b/c of malpractice insurance, even though they stand to make a ton of money if they do enough of them and do them well. (keeping in mind that orthopedic surgeons are trained to do spine surgery)

[Edited on March 15, 2010 at 4:42 AM. Reason : ]

3/15/2010 4:41:47 AM

took care of a guy once that had a sacrectomy.

it ended up being the craziest, riskiest, most complicated back surgery i've ever seen.


poor guy ended up with a fuckton of complications from it as well.

3/15/2010 8:24:46 AM

Yeah my mom had 9 back surgeries and they just made things worse

3/15/2010 8:42:04 AM

i went to 'the carolina back institute' for two years and while i was there the dr tried.....

physical therapy, massage therapy, tens units, anesthetic muscle injections, steroids, and epidural steroid injections.

after those two years (with no improvement) i went to a different general practitioner who recommended me to a rheumatologist and i was diagnosed with ankylosing spondylitis and started my first helpful treatment. the first doctor never once mentioned AS...so i have experienced overtreating. and wish i had just experienced over testing.

3/17/2010 1:08:55 PM

^ I'm not surprised you had to see a rheumatologist to find the correct diagnosis of AS. Sucks you had to wait two years, which seems like a long time to wait before considering an alternative etiology.

3/17/2010 2:04:18 PM

^^ who did you see at carolina back?

3/17/2010 5:33:53 PM

^^^How old were you, and how long into it did you have your first scan? My guess is under 30. That sounds more to me like someone missed something rather than being over treated. That said, if your symptoms likely related to some injury or something else really common in your age group its easy to miss, and you probably never had labs drawn until you saw the rhuematologist. Easy to sit here and armchair quarterback it once I know the answer...it is a little surprising that someone didn't draw some basic, inexpensive labs to rule out an inflammatory condition in a young person with chronic back pain. Wouldn't cost more than a few hundred dollars if that to get a set of inflammatory markers if you paid out of pocket, although the more specific markers are more expensive, usually only read by a specialist, and the cheaper ones are much less accurate.

Which goes back to the topic of the thread. You can spend a lot of money on things chasing your tail and not come up with the correct diagnosis, even though you did everything right.

[Edited on March 17, 2010 at 7:35 PM. Reason : ]

3/17/2010 7:33:54 PM

^ I was wondering about some of the same things. Even if we assume the 'back institute' had AS in mind as part of a differential, two years and all those therapies before considering scans and blood work is crazy. Yes, ESR and HLA tests have limitations with SA. Yes, SI joint involvement may not show itself on x-rays until the disease has progressed. But, with a typical presentation you can just about get there with a history.

3/17/2010 8:09:04 PM

^^^^^ you are a bitch

3/17/2010 8:48:19 PM

haha welcome to TWW. i think you'll do just fine here

[Edited on March 17, 2010 at 8:56 PM. Reason : ]

3/17/2010 8:56:33 PM

LOL ftmfw

3/17/2010 9:45:14 PM

Quote :

"who did you see at carolina back?"

godbout

Quote :

"How old were you"

im only 19 so it is still early for AS. but he did not once even mention it.

Quote :

"and you probably never had labs drawn until you saw the rhuematologist. "

true



im not blaming him for not catching it, but the fact that he didnt once mention it, or even consider it as the reason for my problem is kinda ridiculous considering that he is a professional...

3/17/2010 10:47:24 PM

after these last 2 nights at work



i will think three times before i EVER have back or neck surgery


watching helplessly while someone spirals towards brain death sucks ass.

3/18/2010 8:32:06 AM

^how are back/neck issues related to brain death?

serious question

3/18/2010 9:11:25 AM

CSF leak? meningitis? Had to be infection or something.

3/18/2010 3:31:04 PM

elective ACDF

vertebral artery tear

clot broke off and lodged in the basilar artery

another cause bilateral PCA artery occlusions

they did the mercy/penumbra procedure to retrieve the basilar clot but were unable to get the flow restored to the PCA distribution.


she developed a huge cerebellar infarct

[Edited on March 18, 2010 at 5:49 PM. Reason : its that FREAK thing that rarely ever happens, but FUUUUUUUUUUUUUUUUck when it does]

3/18/2010 5:48:26 PM

^ I don't think a vert injury should really cause that much concern over ACDs. An ACDF is one of the most ubiquitous spinal procedures done and retrospective data has the incidence of a vert injury <0.5% with ~12% mortality if you do hit it. EXTREMELY rare, but it does happen - it is a risk of the surgery, as is hitting the carotid, jugular, esophagus, trachea, etc... Question is - how did the manage it intra-op: Primary repair v. Ligation? Interesting they they did a MERCI device post-op - did they go straight to endo post-op?


Back to the subject at hand though - I'm in the midst of my neurosurgery residency and have a little insight to the issue. The medical community absolutely over orders labs and tests, no question about it -- CYA being the number 1 rationale. First day of med school you're told the history and physical are the most important components of evaluating a patient. Those days are gone, labs and scans come before the basics are done all the time -- which is very disheartening. Long lost are the days of reliance upon the physical examination and THINKING of how a lab/scan will confirm your diagnosis or change the management -- because most of the time it won't, its just more information/data (ie. the Swan Ganz). Example: Emergency medicine (at least those that I interact with) -- complete shotgun approach to labs and scans, if something sticks they consult everyone under the sun. When questioning the ED faculty about what the patients exam is, the majority of time I get, "well I haven't seem them yet". Beyond Clinician's reasoning for ordering something there is a patient satisfaction component - many patient do not feel they've been listened to or had their problems addressed unless labs or a radiographic examination is done.

3/18/2010 6:39:26 PM

So will the healthcare bill make this better or worse?

3/18/2010 7:52:03 PM

Probably worse.

More people entering the system adds to the load of patients on primary care physicians (most of whom are already seeing too many patients as it is). Add the Medicare cuts on to that, and they'll be pushed to see more patients, meaning spending less time with each of them, and they'll have even less time to spend taking a history and physical...thus doing even more shotgun-style lab and imaging ordering to try to fill the gaps.

3/18/2010 8:41:58 PM

^^If it includes the so-called "death panels," it would make this problem better because it would help eliminate a lot of the unnecessary/unwanted testing/treating we do at the conclusion of life.

3/18/2010 9:37:56 PM

Quote :

"Interesting they they did a MERCI device post-op - did they go straight to endo post-op?"

Reversed anesthesia, patient didnt wake up, gave narcan and romazicon patient still didnt wake up

stat CT/CTA showed the occlusions, patient was then whisked off to angio

it was basically the "lightning strike" of ACDF complications.

she lost her exam at midnight

3/19/2010 8:31:04 AM

^ That's really unfortunate. We did a C4 corpectomy in November and the attending (who did a prominent spine fellowship) hit the vert -- the vessel ran an aberrant course into the middle 1/3rd of the body. They were able to tamponade the vessel, but went straight to angio from the OR for eval. Post-op MRI showed thromboembolic injuries and they decided to sacrifice the vessel -- most of the trauma literature recs sacking the vessel if you can't primarily repair/ligate in the OR.


^^^^ I can't say I'm well versed on all the details of the new bill - which is sad, especially living in DC. I've tried to keep up with what all of the big advocacy groups send out (AANS, CNS, AMA), but I know it carries significant bias. Here is the AMA's cliff notes on physician impacts:

Quote :

"House Releases Legislative Language for Bill with Refinements to H.R. 3590 Advocacy Alert March 18, 2010 Key provisions for physicians that we have identified include: * Improved Medicaid payment rates for primary care physicians to equal 100 percent of Medicare payment rates, including payments for office visits and immunizations, in 2013 and 2014. Provides 100 percent federal funding for the increased costs to states. (Sec 1202) * Extended health insurance market reforms (dependent coverage up to age 26, prohibition of lifetime limits and rescissions, limitations on excessive waiting periods) to grandfathered plans six months after enactment. For group health plans, prohibits pre-existing condition exclusions in 2014, restricts annual limits six months after enactment, and prohibits them in 2014. (Sec 2301) * Closes the Medicare prescription drug donut hole through a process beginning in 2010 and completed by 2020. (Section 1101) * Increased federal medical assistance percentage (FMAP) paid to states for individuals newly enrolled in Medicaid as a result of the expansion of eligibility to 133% FPL (100 percent for 2014-2016, 95 percent in 2017, 94 percent in 2018, 93 percent in 2019, and 90 percent for 2020 and later years), repeal of the special FMAP for Nebraska, and changes in the formula used to calculate the amount of increased FMAP that will be paid to states that had expanded Medicaid eligibility to adults with incomes up to 100 percent FPL prior to enactment of the Act. (Sec 1201) * Sets a 75% assumed utilization rate for expensive diagnostic imaging equipment (priced at more than $1 million/MRI, CT). (Sec 1107) House Majority Leader Steny Hoyer (D-MD) announced on the floor today that debate will not begin until after members have had 72 hours to review the new provisions, which sets the time for the first potential floor votes at Sunday afternoon"

Beyond this bill, another concern is the impending 22% reimbursement cut in less than 2 weeks and it isn't addressed in this bill. Neurosurgery is a little different from most fields because as a whole most of our billing is done through federal funds -- so other then the amount of reimbursement, I'm not sure if/how our practice would change.

I completely agree that WAY to much money is spent on end of life care, funding preventative medicine would be a more fruitful endeavor. That thought can't ring more true then in Neuro. Many pathologies leave people with some functional dependency and unfortunately, not enough people express their desires to their family + through living wills. We routinely operate/spend enormous sums of money on poor grade subarachnoids, severe TBI, primary/metastatic brain tumors, etc. because the majority of families/POAs don't know the patient's desires and don't want to make the decision to let them go. Ex. Glioblastoma Multiforme -- generally 12mo prognosis from diagnosis. Surgical resection will usually provide an additional 3mo or so. Intra-op Gliadel Wafers -- tumor bed chemotherapeutic for GBMs, cost $5000+ a wafer (usually 3-5 placed) for a survival benefit of 2 weeks. I think we get too wrapped up in numbers and forget to ask what is that patient's quality of life now and can surgery/intervention maintain that? Will that mortality benefit mean something to the individual or simply to the mortality statistics.

I feel as a community, medical practioners are reluctant to speak with patients about death and how they want to live. Having that dialogue along with what the future can hold (good + the bad) makes the bad situations easier to cope with as a patient and less of treatment dilemma (especially in the Onc fields). Don't get me wrong, I'm not one to immediately give up hope and say treatment is futile or "pull the plug". I love taking care of very sick patients and if was the patient's desire to be alive even if vegetative then I will do as such. However, many times a family has held any progression of care of patient (whether it be trach/peg vs. withdrawal) because they didn't know what they wanted to do or it took them 6 weeks to a mass all 35 family members to come in... This results in worse outcomes for the patients, waste of resources, and higher medical costs.

3/19/2010 9:38:12 AM

^what he says




I'd be careful about using the term "elective" when talking about spine surgeries. It makes it seem like the procedure wasn't necessary, when in fact our neurosurgeons won't operate (I don't think) on someones neck unless they are myelopathic or have some kind of impending doom scenario from an injury. Many of these patients who have elective spine surgery may otherwise have devastating neurologic deficits just a year or so down the road if they don't have the surgery. I mean sure they might not die but if you can't functionally use your arms or you have to shit/piss through a tube that less than 1 percent risk of death/stroke from the operation doesn't seem so bad. Maybe spankmepete can chime in on that topic.

That said, I can't speak for people in private practice either. They always are made out to seem like they operate a lot more than they should, although they still help a hell of a lot more people than they hurt, they just increase their risk.

[Edited on March 19, 2010 at 12:54 PM. Reason : ]

3/19/2010 12:52:20 PM

Elective vs emergent in this spine sx case. She was functional but in great pain despite
medication and pt.

I agree that spine sx should be a last resort.

3/19/2010 2:09:31 PM

What annoys me the most is that some spine surgeons don't properly explain the risks. My idiot mother thinks that dying in the OR is worst case scenario and refuses to realize that it can be a hell of a lot worse than that (brainysmurf's example).

3/19/2010 2:24:34 PM

^^^ With regards to spine surgery, when I hear "elective" v. some other types of cases (emergent, urgent, etc...) - it doesn't mean to me that it is unnecessary, but that no harm or irreversible damage will result from an interval between scheduling and operating.

When to operate is the subject of textbooks and definitely something that I am still learning at this juncture. As one attending told me -- it's easy to schedule cases, but the hardest thing to learn is who NOT to operate on. In terms of the literature, the last expert consensus on cervical spondylosis (ie. arthritis / degenerative changes of the spine) really didn't offer many opinions because there isn't much prospective data on management. What is out there says that >70% of patients with cervical spondylosis will not have progression of their symptoms with conservative management. Our guys here are also pretty conservative as well, we usually do not operate unless there is evidence of structural instability, neurologic changes / myelopathic symptoms, or radiographic evidence of cord signal change (including central cord syndrome -- which in itself is a controversial topic among surgeons on when to intervene).

Another great example about management is a herniated lumbar disc. Studies show that all comers, those managed conservatively will have the same results/satisfaction at 1 year time as compared to operativly treated patients. However, what this data fails to show are the indirect costs lost and gain. Operative intervention leads to quicker functional recovery and less time lost from activities/work. But because there is no difference in the long term should we abandon surgical intervention?

^ Failure to thoroughly discuss expectations and risks of surgery is unfortunately too common. I can only be accountable for myself when consenting patients about surgery and would like to think I address both topics. I would advocate for patients to ask questions, especially if you there is any question on what the surgery will do for the complaint being address, what is the expected post-op course, and what are the potential risks of surgery (and death is more commonly caused by general anesthesia then a spine case). There are many indications for operating, but a significant portion of spine surgery's goal is to prevent further neurologic deterioration rather than guaranteeing that Mama will walk again. I think this is where one problem comes in, people expect to immediately be better - but don't realize their situation deteriorated over months and operating is one facet to recovery - it takes time and effort (ie. rehab) to recover.

Another problem posed here - there are a lot of great spine surgeons as well as plenty of guys looking to make that $1-2 mill/year salary who operate on anything. Many patients do not see the benefit to conservative management (PT, WEIGHT LOSS, NSAIDs,...) and seek out someone who will operate on them (or more likely they are not interesting in conservative management). I routinely see 3rd and 4th opinions in my attendings clinics that are trying to find someone who will operate. America is all about the magic bullet and quick fix -- effort is overrated. Some surgeons use this an capitalize on it and make a lucrative salary for it.

The spine world is pretty f'd up in a lot of ways. Prime example is spinal instrumentation. Pedicle screws and current fixation techniques are relatively new (starting mid/late 80's) -- but it changed the landscape and now people get fused up and down. Instrumentation and implant devices are an area of medicine that runs neck and neck with drugs in regards to driving up medical costs. No matter what the patients insurance status is and how much or if the hospital gets reimbursed, the instrumentation company gets paid full price by the hospital for their stuff used. (ex) $200 for a temporary screw that was in their body for 5 mins then pulled out, $5000 for use of rBMP for bone fusion... insane (/end rant)

3/19/2010 4:29:53 PM

^Thanks.

I agree with the point that we're in a society where people want instant gratification, when it isn't always the best option. Thats fine and dandy, but one problem is that nobody wants to pay for it anymore. As a whole, whether its spine surgery or any other type of medicine, we'd all be better off if we just took care of ourselves and tried to avoid needing the big guns in medicine. If you want to use the big resources that you may not need, fine, just don't ask the rest of us to pay for it.

3/20/2010 3:07:58 PM

Quote :

"if you walked out your door and were mauled by a bear, you'd be sorry you didn't carry a can of bear mace"

I just died laughing

3/21/2010 12:06:08 AM