Day of Destruction – The disc collapse

A recent conversation:


Patient: I met a guy recently who was in a mobility scooter. Out of curiosity because of my injury I asked him, “Did you injure your back?” To which the guy in scooter replied, “yup 4 compression fractures and a collapsed disc that ended up pushing on my spinal cord and now I’m in this mobility scooter.”

Me: Then what did he say?

Patient: The guy told me, “My surgeon said to me that if I had opted for spinal surgery 10 years ago I wouldn’t have been in this situation. The scaffold that is placed in my spine would have prevented me from ending up like this.”

Me: And correct me if I’m wrong because this person said that to you about his spine does that relate to your injury somehow?

Patient: Yeah, my surgeon has said that I have two options, I can either stay the same carry on with conservative treatment or I can have the surgery which will help to support my spine, as I understand it.


The patient had been weighing up his options regarding lumbar fusion surgery. Is it my place to tell him not too, after he has made his decision? After what experiences he has encountered with other people. Well, what the hell do you say to something like that? I have a number of caveats I would like to share from this conversation.


Firstly, that word ‘collapse’. What kind of image does that conjure up? A building with cracks in it’s walls, with every breath of wind or piece of concrete that falls off the building is slowly falling to the ground. Some buildings stay up but there’s always that sense of will it or won’t it. You certainly wouldn’t venture anywhere near it.


Secondly, the hindsight conversation that my patient had with the guy in the mobility scooter. This is a terrible example of I told you so! I’ll admit we don’t know the full story of the guy in the wheelchair and this is something that was explained in the consult, but you can’t stop yourself thinking what if, what if??


Thirdly, the surgeon using a poor form of decisional balance (an ultimatum) in a way to favour him and not the patient. To make a claim that conservative treatment was inferior or a waste of time to his superior surgical procedure. This is not how you use decisional balance! It is to encourage a patient to make a decision on how they can make a change that they have control over, that challenges their current beliefs, behaviours and habits and promote an internal locus of control. Not to be coerced into opting for spinal surgery as there is no other choice or hope


Fourthly, that the explanation from the surgeon was as invasive as the procedure itself.



Fifthly, Is my thinking of the surgeon’s financial personal gain just unprofessional on my part? I think of Neil Maltby’s blog when I reflect, deep down it is unprofessional but I am only human. Is it a dogmatic or hierarchical condescension? It is something I have experienced more and more lately.


It exhausts me and makes me sad, should I be angry with the surgeon? Perhaps, but maybe the surgeon has been left with no other option, because all other options have failed and that he has a desperate patient sitting in his office.


The questions that come from this reflection:

Do I want to be the one that convinces the patient not to have surgery, to have him come to me in 10 years sitting in a mobility scooter?


Do I want to be the one that picks up the pieces if the surgery fails?


Do I want to be the physio that uses a multi-dimensional approach for a multi-dimensional problem, at a risk of futility?


Should I contact the surgeon (with the patient’s permission) and discuss collaboratively the patient concerns?


Should I let things run their course or should I approach the funding provider and discuss my concerns, again at a risk of futility or patient upset?


Do I want to be dogmatic and condescending to my peers and clinical colleagues?


Keep on questioning, learning, communicating and educating.


Thanks for having a read









One response to “Day of Destruction – The disc collapse”

  1. Keith McCarroll Avatar
    Keith McCarroll

    Thanks for this Paul..I have been struggling with this issue a lot recently, way more since gaining a better understanding of pain science. So many surgeons say some variety of “you can try that conservative thing, but you are just putting off surgery” And if the client doesn’t get full recovery in an absurdly short amount of time their viewpoint is confirmed. And of course when you say maybe it could be a few months of rehab to conservatively correct something they think that is way too long, never considering that surgery recovery will be even longer most likely. It seems like if you live in the gray area as a PT there are always more questions than answers. Thanks for your writing.


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