Why Surgery Doesn’t Always End Pain: Exploring Anatomy vs. Pain Circuits with Dr. Nair

I often tell my patients, if you had back surgery once and you didn't get any pain relief, having a second back surgery may be a full zeria because you're doing the same thing expecting a different result. At that point, it's important to have a second opinion and also maybe to seek out individual pain specialists in their area who can offer alternative treatments.

Surgery. For many Kentuckians, surgery feels like the final answer, the moment when something is finally fixed. And in many cases, surgery is absolutely the right call. But what happens when the structure is corrected and pain still remains? In this episode, Dr. Nyer helps us understand the difference between fixing anatomy and addressing pain circuits and why some patients continue to suffer even after technically successful procedures. If you or someone you love has had surgery and still struggles with pain, this conversation is for you. So let's continue. Hi, Dr. Nyer. How are you?

Doing great.

Good, good. So let's start here. After someone has tried medication therapy and imaging, uh, like we've talked about in our previous episodes, surgery often feels like the next logical step. So why does surgery seem like the definitive answer for so many patients?

Well, it's quite easy to understand because very often, let's say a patient suffers from sciatica and they're told that it's a disc herniation that's causing the problem. Well, in most people's minds, the results or the answer would be well, if the disc is the offending agent, take it out. Now, there are many parallels. So, for example, if somebody's got a history of gallbladder disease, very often the surgical resolution to that would be to remove the gallbladder. Or if let's say somebody had a tumorous growth, the solution would be to remove the growth. So, in general, there is this understanding that if there's a problem or a medical problem, the solution would be take it away.

That makes sense to me.

Well, by and large, it does make sense, but we're not machines, we're human beings. And there's a lot of other things that come into consideration when you decide to take a surgical solution for a problem.

I see. All right, so when is surgery absolutely the right decision? It seems like you were alluding to this is not a very black or white, uh, like my top jacket today solution. So um, you know, it seems like it could be uh a very gray area as a decision for patients. So when is surgery absolutely the right decision?

Well, um, back surgery would be indicated if, let's say, there are certain ominous signs, such as severe weakness and pain, or even the inability to feel your limbs. A second good reason to have surgery would be if you have difficulty with moving your bowels or urine. That is a clear sign that the nerves that control these functions are being severely compromised. So those are the reasons that you would actually go in to have surgery fairly quickly. Now, other circumstances would be severe pain. Now, I can tell you my personal experience, even though you know I would advocate for patients to avoid surgeries as much as they can. I had a situation where I had picked up a box that was about 50 pounds, and I developed a perniated disc which was sitting smack on the nerve. I can tell you, Jamie, the pain was unbelievable. The only way that I could describe it was that I felt like my right leg was about to explode.

Oh, I I hate to hear that. I'm so sorry. And that has to be such uh almost an out-of-body experience when the the doctor then becomes the patient.

I I know. And I went to the hospital, went to the ER, I had a surgeon evaluate me, and interestingly enough, he said, Well, if you don't do anything, this pain is probably going to resolve in two weeks. You may want to have an epidural and see if that helps you. And so I took his advice. I had an epidural done, and believe it or not, for 24 hours my pain had gotten substantially better. Now I even went back home. But 24 hours later, the came the pain came back with a vengeance. Again, went back to the ER. I could hardly move, I couldn't stand. And once again, the surgeon said, Okay, if you absolutely want me to do the surgery, I will go ahead and do it. He did the surgery. Right after surgery, I could feel my legs again. The pain was about 90% better. Now, I do have some residual numbness in my heel, but I have no regrets in having the surgery. So it's kind of paradoxical because I generally generally will tell my patients, try your best to avoid surgery. But here I am having surgery. So there are certain circumstances, like I had mentioned earlier, and my own personal experience. But by and large, if a patient has pain, it is continuous, and if it's for a protracted period of time, that would be a good time to reach out to a surgeon to get an opinion from them and to weigh the pros and cons of what the next step should be.

Great advice. Um, all right. So here's it seems where where some patients might get confused. Um, some people like yourself might have technically successful spine surgeries, yet they still have pain or the pain still lingers. And, you know, like you said, you had a 90% improvement. Uh, is that normal? And is perhaps maybe surgery actually meant to eradicate the pain 100%? Let's talk about what the correct expectation should be post-surgery.

Fair enough. Now, I believe that with conditions like sciatica, back surgeries, which mainly consists of a dyscectomy, um, usually helps with the ridicular pain by about 80% or above. However, for some patients, unfortunately, they may develop something known as fail back surgery syndrome. And what that is, is the mere fact that during the healing process, scar tissue develops in the area where they've taken the disc out. So now you're going from taking away the pain caused by a disc, having that replaced with scar tissue formation that can cause even more pain. And at that point, you can't go back and take the scar tissue out because more surgery means more scar tissue, which could worsen the condition further. So it's like a catch-22 situation. Fortunately, the number of patients or the percentage of patients that develop scar tissue is anywhere between 15 to 20 percent. So, in other words, if you do end up having a dysquectomy, there's a very good chance, about 80% chance, that you're gonna do better. And of course, unfortunately, there is a small subset of patients that may run into trouble.

Well, you said um something powerful before that the surgery fixes the structure, uh, like you mentioned, but not necessarily the pain circuits. Um, and perhaps maybe that has to do with uh, like you just mentioned, um, the scar tissue. Can you explain in more detail what that means in simple terms? How surgery fixes the structure, but not necessarily those pain circuits.

Well, now, when a patient, let's say they develop a herniated disc, they wait for about you know three, four, five months to get seen by a specialist. Remember, during that period of time, that herniated disc is either causing irritation to the spinal nerve or it is compressing the spinal nerve, which in effect is what causes the pain. Now, the longer that pain exists, the more likely the nerves start changing and they start developing a chronic circuit where the brain perceives the pain in that particular limb, and chronic circuits, permanent circuits, then develop. So the unfortunate thing is let's say this patient has developed these chronic circuits, and then they have surgery to relieve the nerve of that pressure or irritation. You may structurally correct the problem, but the pain can very often still exist or continue to exist. So then at that point, many patients feel disillusioned in thinking that, well, they they listened to their doctors, they went through the surgeries, and then they continue to have pain. So this is one aspect of lingering pain after surgery. Now, another very uh common phenomenon is when a patient has had maybe more than one back surgery, they are recommended to have something known as a spinal fusion. Now, a spinal fusion is essentially the placement of instruments that include screws and cages that will limit the movement in a particular segment in the back. So when the movement in that segment is reduced, there's going to be less movement and less opportunity to cause pain. In other words, the structure is stabilized, which in many ways is a good thing. But if the patient has had long-standing nerve irritation or develop up development of further arthritic changes in the spine, now what can happen is that you have an area of your spine that's limited in movement, and areas above the fusion retain its ability to move, but now it's moving against a fixed area in the spine, which can actually cause more ergonomic dysfunction, thereby increasing pain. So that's part of the reason why you see patients who've had back surgery who still complain of chronic pain.

Is there uh is there any way to sort of circumvent that? Or I because I can imagine, you know, if we if we stabilize one portion in the top part, it almost reminds me of you know those things outside car dealerships that kind of move like the windsol. Yes, the bottom is stable, but the top can the top can move. I can it it makes me think that that could cause pain in in a different area, though.

It it very well can, in addition to the area that's been fused, because that area is now stiff because there's no movement. Right, exactly. So now I have spoken to a number of my uh spine colleagues, and I've told them that you know, if you've done the back surgeries that you would recommend, including dysquectomies or spinal fusions, and if you still see that the patient is very dependent on pain medication, then maybe these patients would benefit from having something like a pain pump. So, on one hand, the orthopedic surgeon has corrected the spinal problem, but pain lingers on. At that point, a pain pump that would deliver pain medication directly into the spine then would address the painful condition. So now your structure's fixed and now your pain is also controlled. I think that you know works out to be a happier patient.

Absolutely. Absolutely. Um, Dr. Nair, at what point does that pain shift from being that structural problem that we were speaking of to then perhaps being a nervous system problem? Uh, how does that work?

Now, in the uh chronic pain management world, the definition of chronic pain is having persistent pain for over three months in duration. So if you've had pain for over three months, and let's say it's a simple disc herniation that is compressing the nerve, I believe at that point having a disquectomy may in effect resolve the entire problem. Now, what could occur is sometimes patients will continue with a lifestyle that involves lots of heavy lifting or strenuous activity that may cause that same disc to reherniate or it may cause another disc herniation at a different spinal level. Now, at this point, if further surgery is advocated, it's always important to remember that anytime an area in the body is intervened surgically, it hastens the development of arthritis. So let's say if a patient has knee pain and requires arthroscopic intervention. Let's say they needed to shave off some of the cartilage in the knee. Well, structurally, the cartilage is now made smooth and there's less friction when you walk. But the fact that that joint space has now been intervened instrumentally, it can hasten the development of arthritis. So temporarily, that knee pain will get better, maybe for six months to a year, but arthritis will now set in faster. So it's kind of like you know, you solve one problem, but you create another one. So it's also very important that patients who do have these types of surgeries, they strictly adhere to a rehabilitation program, back strengthening exercises. And another aspect that we haven't mentioned is pain can cause a significant psychological issue, especially back pain with sciatica. It can really undermine an individual's uh ability to do things, their ability to stay positive about things. And this is an aspect that healthcare providers uh need to pay more attention to, is to encourage the patient and try and engage with the patient so that they don't feel that there's no hope in treating their pain.

Yeah, that's an excellent point. Um I can't imagine feeling just so physically ailed for so long, right? It almost makes you think that the whole world's kind of collapsing around you and nothing can go right because you're just in this constant constant state of um pain and frustration that you can't operate and move around like you want to, or even perhaps at rest. Um, you mentioned earlier uh the term failed back surgery syndrome. Uh, let's talk about that a little bit more, unpack it a little bit more. What does it mean, and how common is it?

Well, I have a spine model here, and I may be able to show you some structures that are pertinent to a uh uh discectomy. So during a diskectomy, the surgeons will identify an area in the spine, the bone called the lamina. In fact, this surgery is known as a laminectomy, where they make a small hole in the bone, and then they use a special instrument to navigate to where the disc is herniated. They will then scoop out the offending disc portion, and the incision is then closed without filling in the area where they took the bone out. That is the very area where scar tissue develops during the healing process. And sometimes the scar tissue can get stuck onto the nerves, which then perpetuates the pain, in which the patient may get a short duration of pain relief, maybe usually about for a month or two, and that's the time it takes for scar tissue to develop. So two months later, the patient's sciatica comes back with a vengeance. Now, very often, what doctors will do is if they do suspect scar tissue, then they will send the patient to get an MRI done with a special dye that they inject through the vein. And what that dye does, it is actually absorbed by the scar tissue. So when the MRI is being performed, you can actually see the scar tissue take up the dye and it will light up like a Christmas tree. But of course, if the patient does develop scar tissue, the unfortunate thing is there isn't a remedy to take that scar tissue out. As I was telling you earlier, if you attempt to do that, you're risking the formation of even more scar tissue. Kind of think of it like keloids formation in the spine.

So it seems like uh that repeated surgery can more so often than not increase the complexity of the pain instead of resolving it as you're alluding to. Is that correct?

That's correct. Now, first, I want the audience also to know that there are a lot of patients who will benefit from back surgeries. So back surgeries are needed. I can tell you with my personal experience that that was a needed procedure. So there are many patients who would benefit from it. But my focus is more about after having back surgery, is the pain control. And if it's not adequately controlled, there are better ways to control pain other than just doing injections or pain medications.

Understood. Um, so if surgery, like you're mentioning, doesn't always 100% solve the pain, which it seems like more often than not, it doesn't, even though it can greatly improve it. So it still is uh uh a worthy and acceptable treatment uh route, what is the missing piece in that traditional pathway? What's the piece of the puzzle that isn't being addressed or that we need to consider?

I think that uh there's a general tendency in the healthcare fraternity to feel that if once the back surgery uh doesn't completely take care of the pain, perhaps going to a level above the where they previously did back surgery may help address the painful condition. And that can actually happen a number of times, but in effect, it only makes the pain worse. So I think I often tell my patients if you've had back surgery once and you didn't get any pain relief, having a second back surgery may be a fool's error because you're doing the same thing, expecting a different result. So I think at that point it's important to have a second opinion and also maybe to seek out uh individual pain specialists in their area who can offer alternative treatments. Pain pumps are just one example. I emphasize pain pumps because a lot of these patients continue to take pain pills. However, there is another entity known as a spinal cord. Stimulator, which is also an implanted device, but it uses electrical energy to try and divert painful impulses that originate in the spine from going up into the brain and being perceived. Now, I would only advocate that for patients that are not heavily dependent on pain pills. Because what's the point in placing a stimulator in a patient who has sciatica who then continues to require high doses of pain pills? It kind of defeats the purpose of the device itself.

It sure does. It sure does. Well, any final thoughts uh from you before we wrap up this episode? It has been most enlightening.

Losing hope can truly do a psychological number on you, especially younger folks in the 30s, 40s, they develop a herniated disc. It really undermines their confidence. And um, very few healthcare providers address that, partly because patients don't really say anything about that. They're not going to tell you, hey, you know what, I'm getting tired more often, or I'm not able to help out with house chores, or I'm feeling depressed. I don't feel that I'm able to be intimate at home. They don't really talk about these things because it's fairly personal. And also they don't connect the dots. They don't see that it's because their pain is not adequately controlled that all of these other things are happening. So it's important to get that awareness out there that it's not just the pain that's doing all this, it's this whole undermining of confidence and your ability. I believe the most important takeaway is you know, developing chronic pain is unfortunate, but it doesn't mean that there aren't options. Secondly, it is so important for patients who suffer from chronic pain to get assistance in the form of therapy or pain coping skills so that they are mentally stronger to deal with this painful condition. Then, of course, you need to find somebody that can actually treat the pain. So there are these healthcare providers in everybody's uh locality. They just need to look hard enough and they also have to weigh the pros and cons. Being dependent on pain pills for decades, it is definitely not something worth pursuing because there's so many things that can happen, so many problems that can develop, hormonal problems, constipation, not being able to think clearly, just to mention a few. So important to do research. The information is out there, you just need to look for it.

Well, and we're so grateful that we have you to educate us along on this journey, Dr. Nyer. Um, so everyone, thank you so much for joining us for episode four of the Kentucky Pain Reversal Show. Today's conversation reminds us of something very important that surgery can correct structure, but chronic pain often lives in the nervous system. And when that piece isn't addressed, patients can be left confused, discouraged, and still searching for answers. So if you've had surgery and you still live with pain, you're not a failure. Your body is not broken. It simply may mean that another layer of the problem needs to be treated. Again, lower the pills, lower the surgeries, and stop the pain. Thank you, Dr. Nyer, again, and we will see you in episode five.