The Other End of the Pendulum

While it’s true that going under the knife is risky and sometimes performed too readily, a minimalist approach to surgery is also unwise — from the viewpoint of either the doctor or the patient.

For instance, minimally invasive TLIF and PLIF spine procedures are also often minimally effective and may be associated with more risks and complications than open procedures. This is because they fail to adequately expose the pathology, putting neural tissue at risk, and increasing the frequency of nerve damage, spinal fluid leaks, and infection.

Too often, says Dr. Epstein, pain management physicians are treating patients for months or even years with epidural steroid injections (ESI) before they come in for necessary surgery. This is problematic because ESIs have no documented long-term efficacy and are associated with major risks. For instance, cervical injections can cause quadriplegia and stroke resulting in coma and/or death.

As pain management specialists are not trained to perform neurological examinations and many cannot read spinal MR or CT studies, they therefore offer ESIs to patients who should actually undergo definitive surgery. “More and more, I am seeing patients who have been treated with months of unnecessary epidural steroid injections or anti-inflammatory pills with pain management specialists,” says Dr. Epstein.

With so many factors to consider, how does a patient decide whether or not to undergo spinal surgery? Since some spinal operations are offered unnecessarily, Dr. Epstein recommends going for a second opinion — and not within the same group. Also, Dr. Epstein cautions, consider the significance of your complaints versus the potential risks and complications of surgery that are listed on the pre-operation consent form. If your first- and second-opinion spine surgeons discuss no risks, go for a third opinion.

Although it is a surgeon’s call as to who is a good candidate for an operation, patients today also need to be informed. For instance, if a patient has multiple cardiac stents and is on major blood thinners, coming off the blood thinners may be life-threatening. Other patients may have lung disease or other major medical risk factors that make them unsuitable candidates for surgery.

In The Delivery Room

It’s not news that cesarean sections are often performed unnecessarily. And yet, despite extensive press coverage on this issue, the numbers are still high — the national average varies from the mid-20% range up to 40%. The percentage is significantly lower in the Orthodox community, according to Dr. John Fisgus, who has been the director of obstetrical anesthesiology in four major hospitals across the US. Still, the question remains: Why are so many women undergoing c-sections when they’re not medically needed?

There may be a host of reasons, explains Dr. Fisgus. “Often women will come in for induction of labor when it’s not always medically indicated. Sometimes induction of labor is attempted when the mother is not ready for delivery. After a period of time, the labor is deemed ‘failure to progress’ and a cesarean results.”

Also, in general, society seems to have developed a laissez-faire attitude when it comes to cesarean sections. It’s easier, more convenient, more predictable, and it fits into people’s schedules. The attitude of some patients is “why not?” — especially if they only plan on having one or two children.

From the view of the physician, there’s the risk of litigation. By way of illustration, Dr. Fisgus points to the use of external fetal monitoring during labor. “EFM is great for lawyers but not necessarily great for the doctor or patient,” he explains. “Where monitoring has had little effect on the rate of complications, all it does is give lawyers something to point at to claim OB providers have done something wrong. Remember, malpractice cases are very traumatic to a physician and, as you might imagine, an easy fallback position is why take a chance?”

You also have to consider that if everything goes smoothly, no one will ask an OB why he performed a c-section, even if there are signs it wasn’t really necessary. But if something does go wrong, the OB will certainly be asked, “Why didn’t you perform a cesarean section?”

When there is fetal distress in the delivery room, the response varies from provider to provider. Some OBs are much “quicker on the trigger” to do an emergency cesarean than others. The proper protocol, Dr. Fisgus shares, is for hospital staff to quickly and calmly deal with signs of fetal distress. “There are maneuvers we have been trained to do to relieve the problem before running to the operating room. Should fetal bradycardia occur, for instance, oxygen will be applied. Other options include scalp stimulation, changing the position of baby or mother, and placement of a fetal scalp monitor for a more accurate assessment. Often, one of these procedures will be all that’s needed to resolve the problem.”

Then there are human factors that can lead to unnecessary c-sections, such as exhaustion from long hours without sleep or obligations to be elsewhere. Even financial considerations can come into play.

If a woman wants to avoid a c-section (assuming mother and fetus are both healthy and there are no issues, such as diabetes, which can significantly impact the baby’s health), she must choose her OB wisely. “Choice shouldn’t be based on how nice someone is or their gender,” says Dr. Fisgus. “Choose a provider with a low history of performing c-sections.” An important caveat: if you are using a “high risk” OB provider, they’ll most likely have a higher rate of c-sections, but that may well be due to the population they serve.

What happens after you’ve had a cesarean section? This doesn’t necessarily mean that future births must be c-sections. In many situations, a natural birth can follow a c-section. But there is an increased risk to the mother who has had a cesarean and the decision should not be made lightly. A discussion of the pros and cons is in order, and you must make sure that your provider is comfortable with a natural birth before you go into labor, if you definitely want to go that route.

“I cannot stress enough the importance of choosing the right provider for you,” says Dr. Fisgus. “Clear lines of communication are the best ways to achieve the best outcomes.”

Not All Doctors Are Equal

For Sarah, it was a routine checkup for her acne. Upon examination, the dermatologist discovered a suspicious-looking skin lesion on her nose and decided to biopsy it. The results returned positive for basal cell carcinoma. Although the dermatologist stressed that Sarah did require surgery to remove her basal cell, he also mentioned it was nothing serious. Since he didn’t explain further and because he and the surgeon continued to use the scary, anxiety-inducing word of “carcinoma,” Sarah was not reassured. She panicked for years with the thought she was dying.

As a result of the surgery, Sarah was instructed to continue with yearly checkups. The first few years passed with no presenting symptoms. For insurance purposes, she then transferred to a new dermatologist. At that year’s appointment, the doctor circled each mole, each raised lesion, each brown spot on her body, and said, “We need to biopsy everything over the next few months.” Anxious not to have any more basal cells, Sarah acquiesced. (What she didn’t realize was that the doctor was searching for not just basal cell carcinoma, but the much more serious melanoma that presents differently as moles.)

So began the biopsying every two weeks. “They were slightly painful, definitely uncomfortable, always nerve-racking, and I still have small scars from the one near my eyebrow and the one on my lower cheek,” Sarah reports.

After six weeks of these appointments, Sarah’s husband called the original doctor and questioned the necessity of the biopsies. “Totally unnecessary,” he confirmed, and encouraged them to find a more competent physician. For the last seven years, Sarah has gone to her new dermatologist. He occasionally photographs an atypical appearing lesion, but she’s never had another biopsy.

While Sarah doesn’t believe her dermatologist was guilty of criminal intent, there have been cases of dermatologists who have. In 2006, a dermatologist accused of preying on the elderly for monetary gain was arrested and ordered to pay back millions of dollars he allegedly scammed from his patients’ insurances. This dermatologist of many years would frequently falsely diagnose skin cancer, surgically removing multiple layers of skin from his patients. He convinced these patients, many of them multiple times, to endure unnecessary surgeries that scarred and sometimes disfigured them. He’s currently serving jail time.

“Of course, this is the exception to the rule,” claims Micole Tuchman, MD FAAD, in private practice in Manhattan. “Most dermatologists aren’t crooks. They do sincerely want to help.” Since the risk of leaving a potentially malignant mole could have lethal outcomes and the risk of removing it is only cosmetic, doctors often err on the side of caution and remove moles that appear irregular.

But there are patients who have many moles and skin irregularities and, in Dr. Tuchman’s opinion, each person is unique and in some patients multiple biopsies can be avoided. For instance, for a patient with no real risk factors and a history of benign moles that have already been biopsied, there may be other options such as close measurement, regular pictures, and frequent exams.

The legitimate concern is that an atypical mole might be a melanoma. In reality, she explains, the number of times this actually occurs is only in the single-digit percentage range. However, even a small chance of a mole turning into a melanoma is worth a small biopsy, especially in someone who has risk factors that put that chance even higher.

“As the physician, what I’ll do first,” says Dr. Tuchman, “is view the patient’s history. If there’s melanoma in the family or if the patient has had melanoma, then obviously I will be quicker to biopsy. If the mole is visible, for example on the face, and the patient is reluctant to remove it, and I don’t feel that the mole is very atypical looking, I’ll agree to closely monitor it. I will photograph it from different angles and have the patient come back in a month.

“However, if a mole does not look right and something feels different and wrong about it, a small biopsy is essential, even with the inconvenience to the patient. If the mole still appears the same, I will have the patient return again the following month. If it is a melanoma and the patient waits six months before returning, it can already have metastasized, which carries with it a terrible prognosis at that point.”

Dr. Tuchman is also careful to explain the different terminology she uses when describing what she’s seeing. “For instance, it’s crucial for the patient to understand the difference between basal cell carcinoma, squamous cell carcinoma, and melanoma. A basal cell rarely metastasizes. A squamous cell also has a very low metastatic, only in 2% to 6% of cases, but it can grow locally and cause disfigurement and potential complications depending on what it grows into. For example, squamous cell carcinoma can affect the eye. But far and away, melanoma you have to be most concerned about.”

Which means, had Sarah’s original dermatologist properly explained that basal cells rarely metastasize, despite being called “carcinoma,” she’d have saved herself years of unnecessary emotional agitation. As she now understands, it was important to remove the basal cell — had she left it alone, it would have grown and interfered with her vision (it was on her nose). But although the surgery to remove her basal cell was warranted, the manner in which it was explained was not.

In previous generations, many patients had personal, long-standing relationships with their health care providers. Not so today. This is especially the case with specialists, who patients may see once or infrequently at most. We need to be well informed about our particular health issues and to advocate for ourselves — whether that’s by asking doctors dozens of questions or by seeking a second opinion. After all, the patient will be the one making the final call when the doctor hands over a pre-operation waiver form to sign.

Necessary or Risky?

Surgery is commonly performed for these three medical issues, but should that be the case? Take a look at the facts (you’ll notice that going under the knife is always a last-resort option):

CARPAL TUNNEL SYNDROME

The Basics: This hand and arm condition is caused by a pinched nerve in the wrist. Symptoms include numbness and tingling.

1st Line of Defense: It’s best to treat immediately upon diagnosis, advises the Mayo Clinic. When symptoms are mild, discomfort can be eased by frequent breaks to rest hands, avoiding activities that worsen symptoms, and applying cold packs to reduce swelling.

Plan B Option: If these techniques are ineffective, wearing a wrist splint at night can relieve symptoms. Nonsteroidal anti-inflammatory drugs like ibuprofen can also help. Other nonsurgical options include cortisone injections to decrease inflammation, which relieves pressure on the nerve, thus reducing pain.

If All Else Fails and the pain is severe, a surgeon can relieve pressure on the nerve by cutting the ligament pressing on it. Risks include incomplete release of ligament, infection, scarring, and nerve or vascular injury. Soreness can take several weeks to months to resolve after surgery. If symptoms were severe before surgery, symptoms may not disappear completely after surgery.

HEARTBURN

The Basics: This scorching sensation in the chest is felt most commonly after eating certain foods and results from acid reflux into the esophagus. Frequent heartburn may indicate gastroesophageal reflux disease (GERD).

1st Line of Defense: In most cases, heartburn is treatable and requires abstaining from particular foods and drinks. Some other alternatives to beating heartburn: Wear comfortable clothes (no tight belts, for example); hit the gym — shedding pounds eases symptoms for overweight people; wait at least two hours after a meal before exercising; eat meals at least two hours before lying down so food can digest first; stop smoking.

When to Operate: Although heartburn may seem minor, gastroenterologists caution that brushing off frequent symptoms can lead to serious health issues. Over time, stomach acid may damage the esophagus, teeth, and more. If symptoms intensify despite maximum nonsurgical treatment, GERD surgery should be considered, especially if tests suggest there’s a good chance the procedure will be successful.

CORONARY ARTERY DISEASE (CAD)

The Basics: This disease is defined as the blockage or narrowing of the arteries by a sticky material called plaque. Common symptoms include chest pain, shortness of breath, or extreme fatigue after exertion. A completely blocked coronary artery can also cause a heart attack.

1st Line of Defense: Studies led by Dean Ornish, MD, founder of the Preventive Medicine Research Institute and professor of medicine at the University of California, have continually shown the impact of major lifestyle changes on CAD. Ornish’s lifestyle plan, which includes a low-fat, whole foods, vegetarian diet; aerobic exercise; stress management; smoking cessation; and group therapy, has significantly reversed CAD in study participants, helped them avoid bypass and angioplasty, decreased heart attack rates, and improved risk factors and quality of life.

“Most people are told to make moderate changes in their diet,” says Dr. Ornish, “and when it doesn’t do much, they’re told, ‘We have to operate.’ But if they’re willing to make bigger changes, most people can avoid surgery.”

Going under the knife inevitably comes with risks — the complications associated with angioplasty include blood vessel damage from the catheters, kidney damage and/or allergic reaction caused by the dye used during the procedure, heart attack, etc. Therefore, CAD sufferers with mild symptoms should consider medicines (such as aspirin, beta blockers, nitroglyerine, and statins) before surgery.

If All Else Fails, patients generally have two surgical options — angioplasty or bypass surgery. Angioplasty is a procedure performed to reduce chest pain caused by reduced blood flow to the heart, or to minimize damage to heart muscle from a heart attack. Because it’s less invasive than bypass surgery, it poses less risk and is most often done when only one artery is blocked. If, however, the arteries are narrowed or blocked in multiple areas, doctors may recommend coronary bypass surgery.

(Originally featured in Family First, Issue 499)