For Sam, just walking down the street used to be a struggle. His back would hurt so much he would need to sit down, the pain shooting all the way down through his left leg. The condition of his back and leg was long past being a nuisance; it was severely limiting his quality of life. So he decided to do something about it.
His search for less pain started at his primary care office with Neil Wagle, MD, of Brigham and Women’s Hospital. Since Sam had back pain for some time, even undergoing another spinal laminectomy about fifteen years ago, Dr. Wagle evaluated his physical function by asking him structured questions, called Patient Reported Outcome Measures (PROMs). His physical function score was severely low, reflecting his inability to walk appropriately, and his pain score was severely high. Since Sam had already tried physical therapy and anti-inflammatory medications, Dr. Wagle suggested he see an orthopedic surgeon at Brigham and Women’s Spine clinic. “My option was to complain or to do something about it,” says Sam, “So I decided to do something about it.”
Choosing a Treatment
Dr. Wagle referred Sam to Jay Zampini, MD, an orthopedic surgeon at Brigham and Women’s Hospital specializing in spinal surgeries. Dr. Zampini explains that his patients have an escalating range of care choices—surgery isn’t necessarily the best choice for all his patients. According to Dr. Zampini, there are basically five levels: the patient can live with the condition and adjust their life around it (no intervention), they can take medication like an anti-inflammatory, they can do physical therapy, they can get injections like cortisone, or finally, they can have surgery. “If they’ve been through everything, including injections, they can see why surgery is at least on the table,” says Dr. Zampini.
Sam had already tried medication and physical therapy, and while he felt relief at first it didn’t last. His spinal stenosis (a compression of nerves in his back) had progressed to the point where surgery seemed like the best option. After an initial discussion with Dr. Zampini about a possible laminectomy, Sam returned to Dr. Wagle for more information. Even though he had undergone back surgery before, this time the surgery would be comprehensive—more vertebrae would be involved as well as a fusion. “I relied on Dr. Wagle,” says Sam.
Collaboration Between Physicians
Physicians at Partner’s hospitals and health care centers don’t work in silos; our institutions rely on a robust culture of collaboration. “Throughout Partners it’s so easy to communicate with multi disciplinary teams on complex cases,” says Dr. Zampini. Only an hour or two after sending an initial email, every team member has weighed in and everybody knows what everybody else is doing. The entire care team, from the primary care physician, to a specialist like an oncologist or an endocrinologist, are all on the same page. “I think that’s pretty unique that we’re able to do that,” says Dr. Zampini. “It was definitely not like that in my old practice.”
“Many patients worry that ‘to a hammer, everything looks like a nail,’” Dr. Wagle says. “I feel confident that my colleagues here won’t operate unless conservative management has been exhausted, and surgery is needed to help a patient meet their goals.” He encouraged Shared Decision Making while discussing the possibility of surgery, making sure Sam had given other options a fair shake as well as evaluating all aspects of Sam’s life and health before coming to a decision together.
“Here is a guy who is getting older, but is fit, energetic, and motivated. He didn’t want to run marathons, but it was a trip to Florida where he couldn’t even walk around with his family that made us both realize that he couldn’t realize his needs without surgery,” says Dr. Wagle. It wasn’t just pain that was bothering Sam now, it was neurological symptoms in his legs. While there was a lot to think about, Sam was confident after his discussion with Dr. Wagle that this was the right path for him. “Bottom line is, I think I made the right decision,” says Sam.
During the pre-surgery visits with Dr. Zampini, Sam had a thorough explanation of what he should expect. During these appointments, Dr. Zampini points out exactly where the problem is with the help of an anatomical spine model alongside patients’ MRIs. “After being shown a model of what a normal spine should look like, most patients can see where it’s compressed or where there’s slippage,” says Dr. Zampini. “I want to show them how a spine surgeon sees the world. I want them to understand exactly what’s wrong.”
He also takes time to walk through the procedure in laymen language, explaining exactly what he will do and using the model to show exactly where. According to Sam, the education process felt much different than the first time he had surgery. “I was more conscious of what was being done in the second surgery,“ says Sam. “If I had a choice between the first and the second I think the second is what I would choose as far as the process itself.”
After his surgery, Sam stayed in the hospital for only one night before getting back up on his feet. “The back pain basically went away after the surgery,” he says. “I felt pretty good.” Sam started doing physical therapy at a clinic right down the road from his house and met with Dr. Zampini for regular follow-up appointments to check his progress and chart his recovery using PROMs. His Physical Function score, previously severely low, rose past the national average for all healthy adults. In fact, his score showed he had better function than two thirds of the country.
While Sam had excellent outcomes, Dr. Zampini explains that PROMs are even more valuable for patients who aren’t doing so well. Sam’s main concern was the pain in his legs, which in these situations usually goes away pretty quickly after surgery. But for people with severe pain limited to their back, the healing process can be much longer and the gains less dramatic immediately after surgery.
“PROMs are really useful to show somebody what they were like before and what they’re like now. A patient will say, You know, I just don’t feel like I’m going anywhere or I’m not where I expected to be,” says Dr. Zampini. “I can show them their PROMs data. It reinforces that they are making progress, they just need a little more time to get to the final stage of healing.”
Sam recently saw Dr. Zampini for his one year follow-up. He feels fully recovered, and has no problem going for a long walk on his treadmill every morning. “Today I feel great. The pain is basically gone. I call Dr. Zampini my miracle maker,” he says. “I guess now the only thing I have to complain about is the weather!”