About three years ago I, along with my team, decided to become more systematic with our pre-surgical process, coining the term: prehab. Why? Because there are well-documented factors that have a negative effect on the outcomes of spinal surgery. Currently, the medical profession is ignoring these treatable variables, which frequently result in catastrophic results. Findings report that anxiety, depression, catastrophizing and fear avoidance adversely affect the results of surgery, as reported in more than 1,000 peer-reviewed research articles. Others include:

  • A fusion for LBP is successful only about 25 percent of the time at two-year follow up.
  • Surgeons cannot accurately assess patient stress in an office setting.
  • Sleep is a well-documented factor that affects the perception of pain.
  • Degenerative disc disease is a part of the normal aging process and has been shown to have little if any correlation with back pain.
  • Ten to 40 percent of the time, any kind of surgery can create chronic pain, and roughly five to 10 percent of the time it is permanent.
  • High-dose narcotics not only create a tolerance, but they also increase the level of perceived pain.
  • Physical conditioning and activity are important for decreasing pain.
  • Focused structured care can markedly improve both surgical and non-surgical outcomes.


So, how do medical practitioners handle issues related to spinal surgery? Not exactly what you may think:

  • Surgeons are monitored on productivity and discouraged from spending time with patients.
  • Less than 10 percent of surgeons assess stress before making the decision to perform surgery.
  • Frequently, major life-altering decisions are made on the first visit with inadequate data and patient education.
  • Surgeons feel they can assess mental stress in the clinic, yet it actually happens less than 45 percent of the time.
  • Sleep is rarely addressed as a factor.
  • In spite of the overwhelming evidence that the outcomes of surgery for degenerative disc are poor and unpredictable, there are hundreds of thousands of them performed annually in the United States.
  • Narcotic usage is seldom defined and stabilized before surgery.
  • Although physical therapy is often prescribed, there is no long-term conditioning plan implemented.
  • A multi-faceted approach to resolving chronic pain is rarely available. Most physicians are not well trained to deal with chronic pain and dislike dealing with it.
  • Surgery is simplistically viewed as the definitive solution, however, it is just one tool and can be dangerous. What’s more, chronic pain is seldom mentioned as a complication of surgery.


Because of all the issues that are too frequently ignored in the medical world, our decision to administer “prehab” was created in hopes to avoid problems such as this. We will not perform elective spine surgery unless the patient is willing to work through his or her part of the protocol for at least six weeks. I also do not perform surgery for back pain. Here is the protocol:

  • Surgical decisions are not made on the first visit.
  • Specific educational material is available for a shared decision-making process on follow-up visits.
  • Psychosocial variables are obtained and acknowledged on the first visit.
  • Anxiety, anger, and depression are assessed and treated.
  • The patient must have some degree of improvement prior to proceeding with surgery.
  • Sleep is taken into account.
  • The patient should be sleeping at least six hours per night for more than six weeks.
  • Medications are defined and stabilized.
  • Pain consultation is administered if daily opiate intake is more than 100 mg. of Morphine equivalent.


After the six-week protocol, I have observed that patients’ post-operative pain is less, rehab is easier, the outcomes are more consistently excellent, and there is a quicker return to full functioning. What has been surprising is that we are now reporting on more than 30 patients who have had their pain resolved without surgery in spite of having significant anatomical problems that I had planned on solving with surgery.

Bottom line: Think before you go under the knife, and make sure it isn’t something that can be handled with better sleep, rehabilitation and stress management. Find a doctor who is willing to fully take into account your condition before jumping to any conclusions.

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Dr. David Hanscom

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