Medicine

Cooling out the great ‘sipped disc’ furore

Wayne Clark October 16 1978
Medicine

Cooling out the great ‘sipped disc’ furore

Wayne Clark October 16 1978

Cooling out the great ‘sipped disc’ furore

Medicine

For the medical profession, what happened may have become a pain in the neck, but it was also a measure of how many people have a pain in the back. In early September at the Second World Congress on Pain in Montreal an American neurosurgeon presented a paper describing what one newspaper headline heralded next day as “a new operation to cure slipped discs fast.” CBS television borrowed the four-minute film that illustrated the report and ran a clip on the network news. It seemed as if most of the millions of North Americans with back trouble then started telephoning their doctors asking about what they interpreted as a new wonder cure for a medical problem almost as prevalent as the common cold. Yet few physicians (even among orthopedists and neurosurgeons) had even heard of the operation, so far being performed in only four centres in the United States and none in Canada. It may well be years before it becomes widely available—but public interest

has certainly been aroused.

The popular statistic is that every adult can expect at least once in his or her life to have disabling lower back pain. At the Montreal conference, it was stated that pain costs Americans more than $50 billion a year and of that, lower back trouble and related pain cost $15 billion. According to the Ontario Workmen’s Compensation Board, timeloss claims for back problems in that province alone last year amounted to more than $90 million—and this involved only industrial accidents. Not that all back trouble can be blamed on a slipped disc—and what is called a slipped disc isn’t.

Discs don’t slip. They’re doughnutlike pads of gristle and jelly that serve as shock absorbers between the vertebrae, and instead of slipping they rupture or herniate. This causes gristle to move to the outer edge of the doughnut and, to mix an already painful metaphor, create a bulge on the rim “like a soft spot on a tire,” according to Dr.

Harold J. Goald, the man who presented the paper in Montreal and chief of neurosurgery at Jefferson Memorial Hospital in Alexandria, Virginia.

He’s been doing the new operation—intended, like the conventional one, to relieve pressure on the nerve root—for three

years, and has established a success rate of 96 per cent among nearly 300 patients. For 15 years he had operated on discs using conventional surgery and wasn’t happy with a success rate of 70 per cent— often cited as normal. Enter Dr. Robert Williams, chief of neurosurgery at Sunrise Hospital in Las Vegas, Nevada. The two met at a medical conference and when Dr. Goald expressed his dissatisfaction with the usual method, Dr. Williams invited him to visit Las Vegas. Dr. Goald did and spent six months studying a new operation devised by Dr. Williams.

In this procedure the surface of the disc is not

cut with a knife. Instead, the layers are parted with a blunt-nosed dissector to reach the crushed interior fibres that are causing the pressure, and the pain. These are carefully removed using microforceps just two millimetres wide—the entire operation being done under a microscope with microinstruments developed by Dr. Williams. Since the surface fibres have not been cut they close over the hole again, Dr. Goald explains, reducing the likelihood of further rupture. He calls it a “minimal operation” that causes less trauma, virtually no loss of blood (none of his pa-

tients need a transfusion) and gets them out of hospital within 2Vz days, instead of what can be up to nine days with the conventional operation. The skin incision is only an inch wide, compared to as much as three in conventional surgery, and causes little pain, making narcotic drugs unnecessary in the post-operative period.

To back-pain sufferers who view any spinal operation with horror—and many do, despite their misery, because there is always the possibility that a damaged nerve root will produce paralysis of some sort or that in time a

second, and always more difficult, operation might be required—the delicate procedure described by Dr. Goald understandably sounded like a godsend.

But is it? Dr. Goald himself was taken aback by the rush of public interest in his report, responding to all inquiries with “a word of caution” and expressing alarm at the prospect of any doctor undertaking the new procedure without proper training. And one notable Canadian specialist in the field has put the new operation in better

perspective.

Dr. Hamilton Hall is a Toronto orthopedic surgeon who in 1974 founded the Toronto Back Education Unit to offer courses to people with back problems—a scheme since broadened to reach thousands of sufferers throughout Ontario. He describes the Williams and Goald operation as a “fine, gentle method for doing what it’s intended to do—simple, uncomplicated disc operations. But nerve-root pressure accounts for only five to 10 per cent of the back pain population and not all

nerve-root pressure is due to herniated discs.”

The publicity about the new procedure, he says (as does Dr. Goald), has been out of all proportion to its real significance. “I have a comparable success rate with conventional surgery,” Dr. Hall says, “and if a surgeon doesn’t, it’s because of bad surgical technique. And if he needs to have more blood run through the patient he’s not doing the operation neatly enough.” He says the conventional method is “one of the nicest, most rewarding operations to do. It’s fast and simple and terrible pain is relieved.” His patients leave hospital in six to seven days and “so what if it takes a little more pain-killer? I doubt if I would learn the new procedure even if it were available. It’s not worth my time [six months of study] just to get patients out a few days earlier.”

Some surgeons are too quick, Hall says, to operate on backs. “Most back trouble—in fact the Swedes claim 99 per cent—can be dealt with through time and therapy.” Asked why he has a higher success rate than some other doctors claim, he said, “I’m picky about who I do. I see 95 backs to cut five ... Do you really want me to answer honestly why too many people are operated on? Money. I get $25 to see a patient and talk to him about therapy, and to operate I get $250.”

Wayne Clark