Do You Need Back Surgery — Really?

Johns Hopkins Magazine

Do You Need Back Surgery -- Really? | Johns Hopkins Medicine

Launched a little over a year ago with $3.2 million infunding from U.S. Surgical Corporation, the lab at Blalock12 has served over 1,500 Hopkins medical students,residents, and surgeons, as well as visiting physicians andmembers of medical associations attending lectures.

A suite of rooms on the 12th floor, MISTC (pronouncedmystic) offers an Internet-linked lecture hall, surgeon'sscrub room, two state-of-the-art operating theaters, andother surgery prep rooms.

Among the center's goals: toprovide training that can reduce time spent in theoperating room at Hopkins and other teaching hospitals, andto give surgeons simulated surgical environments in whichto practice with evolving technology and instruments.

Paul W. Flint, Hopkins professor of otolaryngology and MISTC co-director, plans to use therobotic system in head and neck surgeries: “Any newtechnology has associated with it potential complications,”Flint says. “This helps to remove that component. It takessome of the training the operating room.”

On a cold afternoon in January, the third-year medicalstudents first gather in the lab's lecture hall, perusinghand-outs that detail various surgical sutures — Lembertstitch and whip stitch — as well as illustrations ofsponge forceps, towel clips, needle drivers, and othersurgical instruments.

Brett Nelson says he's benefited from the new lab'sapproach for novice surgeons. “It is needed. Oftentimes wedon't get all the hands-on experience we want in the OR,”says Nelson. “It gives us the opportunity to practice, andnot on patients.”

For many decades, Hopkins offered such a surgical labcourse, first developed by Hopkins surgeons at the turn ofthe 20th century.

The course continued into the late 1990s,closing down due to financial constraints, including thecosts associated with animal subjects.

Brown, who steppedin to the void to develop the new course, says, “There is ahuge tradition of training in surgery here at Hopkins. Alot of medical schools [have] copied us.”

Blalock 12 is in fact rich with the the spirit of medicalinnovation. The building is named for Hopkins surgeonAlfred Blalock, and the 12th floor housed his researchlabs.

Blalock, along with Hopkins pediatrician HelenTaussig and surgical assistant Vivien Thomas, developed amedical procedure in the 1940s to correct a congenitalheart defect in children, resolving what was known as the”blue baby” syndrome in which the heart did not pumpsufficient blood to the lungs. Such surgery was previouslydeemed too risky.

Decades before Blalock's contributions, noted Johns Hopkinsphysicians were making pioneering contributions to theworld of surgery — from William Halsted's successfulimplementation of the first radical mastectomy in the late1800s, to Walter Dandy's daring removal of brain tumors inthe mid-1920s. In more modern times, Hopkins surgeonPatrick Walsh has dramatically altered the outcome ofprostate cancer surgery with his nerve-sparingprostatectomy.


Electrical stimulation aids in spinal fusion

Do You Need Back Surgery -- Really? | Johns Hopkins Medicine

Spine surgeons in the U.S. perform more than 400,000 spinal fusions each year as a way to ease back pain and prevent vertebrae in the spine from wiggling around and doing more damage. However, reports estimate that on average some 30% of these surgeries fail to weld these vertebrae into a single bone, causing continued back pain.

Now, after reviewing 16 studies in humans and 17 in animals that tested three types of electrical stimulation — one implanted and the others worn — Johns Hopkins researchers have determined that only using an implanted direct current stimulation device worked successfully in both animals and people. Direct current stimulation devices are implanted under the skin next to the spine during the fusion procedure and remain in place for the six to nine months of recovery, and then are removed.

Patients who received these devices were more than twice as ly to have their vertebrae fuse successfully, and the rate was higher in animals. While this implanted device seems to be a helpful tool for surgeons, it may not allow for MRIs, and the devices do have a small risk of infection, discomfort and immune reaction.

“Although the direct current stimulating device is more invasive because it's implanted, there is 100% compliance,” says author Ethan Cottrill, M.S., an M.D./Ph.D. candidate at the Johns Hopkins University School of Medicine. “The other two devices we analyzed have to be worn and there is a higher risk that patients might forget to use it, making it potentially less effective.”

The findings were published Oct. 8 in the Journal of Neurosurgery: Spine.

Because each electrical device can cost around $5,000, the researchers only recommend that people at high risk for failed fusion procedures get them, such as older patients, people with prior failed fusions, and those who have diabetes or who smoke.

Other authors on the publication include Zach Pennington, A. Karim Ahmed, Daniel Lubelski, Matthew Goodwin, Alexander Perdomo-Pantoja, Erick Westbroek, Nicholas Theodore, Timothy Witham and Daniel Sciubba, all from the Department of Neurosurgery at Johns Hopkins.

The researchers don't have funding to report for this work.

Goodwin consults for Augmedics and ROM3, has an ownership stake in AOSpine/NREF and receives royalties from Kendall Hunt. Theodore receives royalties from DePuy and Globus Medical Inc. and consults for Globus. Witham receives funding from Eli Lilly and Company and consults for DePuy Synthes Spine. Sciubba consults for Baxter, DePuy Synthes, Globus, K2M, Medtronic, NuVasive and Stryker.

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Materials provided by Johns Hopkins Medicine. Note: Content may be edited for style and length.

Journal Reference:

  1. Ethan Cottrill, Zach Pennington, A. Karim Ahmed, Daniel Lubelski, Matthew L. Goodwin, Alexander Perdomo-Pantoja, Erick M. Westbroek, Nicholas Theodore, Timothy Witham, Daniel Sciubba. The effect of electrical stimulation therapies on spinal fusion: a cross-disciplinary systematic review and meta-analysis of the preclinical and clinical data. Journal of Neurosurgery: Spine, 2019; 1 DOI: 10.3171/2019.5.SPINE19465


Would a surgeon tell you if something went wrong during your operation?

Do You Need Back Surgery -- Really? | Johns Hopkins Medicine

When something goes awry during surgery, national guidelines recommend doctors and hospitals make a full disclosure to the patient and their family members. A new survey of surgeons in 12 specialty areas reveals that most follow at least some of the guidelines, but many fall short of offering a straight-out apology when a medical error occurs.

The study, published in JAMA Surgery, involved a web-based survey completed by more than 60 surgeons who worked at three Veterans Affairs medical centers.

The vast majority said they had followed five eight recommended disclosure practices when an adverse surgical event occurred, including:

  • Explaining to the patient or family why the error happened.
  • Disclosing the error within 24 hours after the operation.
  • Expressing regret that it happened.
  • Showing concern for the patient's welfare.
  • Taking steps to treat any additional problems that result.

However, only 55 percent of surgeons surveyed said they apologized or discussed whether or not the error was preventable, according to the researchers from the Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System.

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The authors were also interested in learning how disclosing medical errors to patients affected the surgeons.

They found that those who were less ly to talk about prevention, and who pointed out that the error was “very” or “extremely serious,” as well as those surgeons who reported “very” or “somewhat difficult” experiences discussing the event, were more ly to be negatively affected by it.

And surgeons who had more negative attitudes about disclosure at the study's start had greater anxiety about their patients' surgical outcomes or events after a disclosure.

“It's very difficult to talk about these things if you're a doctor. They are disappointing, upsetting and frightening,” Dr. Albert Wu, a professor of health policy & management, medicine, and surgery at Johns Hopkins Bloomberg School of Public Health, told CBS News.

Wu, a leading expert on issues related to disclosure, said the new study shows signs of positive change, though. “I think there was a wall of silence, a code of silence. Secrecy was pretty much the rule back when I started looking at this in the eighties. Since then, there has really been a sea change and people acknowledge it.”

He added, “I think we now widely accept that patients should be told when things go wrong, when there are unexpected events, when things go other than planned. It's their right to know about it.”

To some extent, to be a great surgeon, you have to suspend disbelief and believe you can do some things that are seemingly impossible, Wu explained. Disclosing errors complicates that.

“I was watching Red Bull cliff diving last week. It's that. You have to believe you can jump off a 90 foot cliff and survive. I'm not a surgeon but I've seen people in an emergency make a 2-foot-long incision in one second and to be able to do that you need to have a certain amount of confidence,” said Wu.

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If a medical error occurs on a surgeon's watch and they lose that sense of confidence, it can be detrimental and damaging to a surgeon, he explained.

At Johns Hopkins, they implemented one of the first error disclosure policies in 2000. Under it, a health care worker will not be punished or disciplined for reporting an error.

“We disclose very promptly, very fully apologize, take responsibility and take action to avoid future similar events. We try to be as transparent as possible,” Wu said. “That said, I think there are probably things that don't get disclosed.”

“Anyone who sees patients and who is a human being will have things go wrong. Particularly for a surgeon, there are technical errors — errors where you might be clumsy. Might slip. Have a lapse and do something you are not supposed to do.

And when things are happening quickly, when there's an emergency or trauma, sometimes you need to do things where you can't see.

Some surgery requires a microscope or telescope to do the procedure, or things that require strength if you're an orthopedic surgeon.”

Other “classic” errors include inadvertently damaging a structure within the body — for example, cutting a nerve or accidentally puncturing the bowel during gall bladder surgery. Or a surgical sponge can get left behind.

“If you think about it, if you're poking people with sharp objects, there are going to be essentially slips. I was in a surgery once where eye glasses dropped into a patient. It's stupid and clumsy and makes you seem ridiculous. So would you tell the patient? The answer is yes.

Anything that requires a change in therapy or an additional test or action. Or where you'd be embarrassed if it came out later. It didn't happen at Hopkins. It was a case where a student leaned over to look and glasses accidentally dropped in.

The patient got an extra dose of antibiotics,” said Wu.

In 2004, Hopkins developed disclosure video training and started teaching courses on it in the medical school.

“For quite a few years now we've required that all medical students in their second year get an hour-and-a-half class on how to disclose an adverse event. They practice on each other. They look at video scenarios.

It is surprisingly difficult and uncomfortable, even when it is a student disclosing to another student who is pretending to be a patient. People are always nervous and fearful. They may even laugh nervously sometimes,” said Wu.

Others cry.

A punitive response to medical error doesn't benefit the doctors or patients, he said, unless of course someone shows repeated negligence.

But not all medical centers approach disclosure the same way and some staff lose their jobs for actions that led to medical mistakes. The repercussions can be devastating for medical staff as well as patients.

Wu pointed to the case of a Seattle Children's Hospital nurse, Kimberly Hiatt, who accidentally gave an infant a fatal overdose of medication in 2010. After the baby's death, Hiatt was put on administrative leave and then dismissed, and subsequently battled to keep her nursing license. She eventually took her own life.

Medical errors overall are pretty common, said Dr. Martin Makary, surgical director of the Johns Hopkins Multidisciplinary Pancreas Clinic and a professor of surgery at Johns Hopkins Medicine.

Medical errors range from misdiagnoses to botched surgeries to prescription medication mistakes, and taken as a whole are the third leading cause of death in the United States, according to Makary, the author of a study out this past May in The BMJ that found more than 250,000 Americans die due to medical mishaps every year. That's greater than the toll from any major medical condition except heart disease or cancer.

The new VA study tackles an underrepresented yet important topic in medical education, said Makary.

“What do we do when things go wrong? How do we communicate uncertainty and risk and how do we communicate when something went wrong? There's a science to it,” he said.

“The study points out the consequences of not having good communication skills in what's often a very messy series of events that can result in patient harm,” he said.

When looking at things from a medical ethics standpoint, Wu said that patients deserve to know when things don't go as planned in the operating room.

“The golden rule is that people expect to be told when something goes wrong. The patient can benefit from the knowledge.

It's possible they might be upset by it, too, if there are potential harms.

But in almost all cases the patient benefits from accepting that something, some sort of injury or harm, has been done,” said Wu. “And they expect an apology and expect you to be honest with them.”

“If this study were done 25 years ago, a smaller percentage of people would disclose. I think you're never going to get to 100 percent, but I think things are getting better,” Wu added.