Spine surgeon Shannon McCanna, MD, has one key factor in mind for all of his cases — functionality.
Dr. McCanna, of Carmel, Ind.-based Goodman Campbell Brain and Spine, spoke with Becker's about how he approaches spine care and discussed misconceptions in the specialty.
Note: This conversation was edited for clarity and length.
Question: Can you elaborate about how you say you can take a conservative spine approach and still operate?
Dr. Shannon McCanna: What I would say is, the most important factor that I watch for in patients is their functionality. It's all to me about function. If we plot your function as a course of time, over time and we see that your function is going downhill, I would typically recommend surgery in that case. For me, when I think about when to operate it's mostly in relation to the patient's function. That's the algorithm I typically go through with patients. It's not always about pain, because pain is very complicated.
Q: When you're assessing functionality over time, how long are you assessing things to wait until you make a decision on surgery?
SM: I don't have to wait at all. I just take a history, and if the patient can be descriptive about where they're at in their life, sometimes it becomes very obvious that the intervention that would be most effective and the least amount of runaround is sometimes surgery. Sometimes you can tell on the very first visit, but that's very uncommon. Most patients that we see have been neglecting their bodies over the course of their entire lifetime, and there needs to be some buy-in to an overall health kind of and wellness initiative. But there are certain types of problems that certainly will require surgery in order to get the ball rolling in the right direction.
Q: How does conservative spine care and conservative approaches play a role?
SM: I think there's always been an initiative by surgeons to advocate for nonsurgical pathways to improved health. Most of what we see in the office. If you were to be with me for a few office sessions when I'm talking to patients, what you'd see is that it's a distinct minority of patients that were signing up for surgery, maybe 10% on a good day.
In my training I learned that you should employ nonsurgical strategies for most of these problems because a typical back flare up, like a sprain or strain in the back or just a bout of pain in the back that comes out of nowhere. Typically those things will subside without any intervention. No imaging is needed. In terms of the way I was trained, that's always been the case, and I don't really perceive there being a trend in the way I've treated or been taught to treat patients because we've always advocated for a conservative approach.
Q: Can you talk about some of the costs associated with taking that conservative approach?
SM: Sometimes the costs are difficult to calculate. I remember one patient from when I first started my practice, and I recommended surgery for his neck. This was a problem of cervical myelopathy where the spinal cord is pinched. The patient had just had a surgery on a different part of the body and thought that he could go through with a conservative pathway. Well, at this particular pathology, spine issues in the neck or the thoracic spine that's pinching the spinal cord, that's not a good idea. So for him, there was a cost of conservative treatment.
When you're thinking about conservative treatment strategies for spinal disorders, the thing that you must hold up first and foremost is function. The cost of conservative measures can sometimes be to the detriment of that person's functionality. If you are blind to that component, that may cost society much more in the end, because that person may not be able to be employed in the workforce. You always have to look out for red flags or signs that there could be neural impingement that would cause permanent, irreversible nerve damage. Anytime a surgeon talks to anybody about conservative treatment options for spinal disorders I think it's the surgeon's job to really stress the importance of having a good exam with a clinician that really can understand some of these types of pathology.
My primary goal, especially when we talk to medical students, would be to educate them about the neurologic exam, testing reflexes, making sure that they know how to properly diagnose nonsurgical issues. Because although 90% of what we see is nonsurgical, sometimes primary care physicians are afraid to send patients our way because they don't think that any surgery is indicated. I would much rather have patients sent to me so that I can evaluate them, and then we can initiate the conservative path of treatment.
Q: What innovations and methods and conservative spine care are exciting you the most?
SM: There are certain interventional pain procedures that can be very effective in the treatment of low back pain. I think our understanding of spinal biomechanics and structural stability and mobility issues can be that that practice is probably ancient, but we hopefully are doing an OK job with that, with physical therapy. But in terms of a surgeon's mindset for new procedures, there is something called dynamic stabilization. Instead of doing a fusion procedure, we can stabilize the unstable joints of the spine, whether it be neck or in the low lower back, with something that preserves the motion of that joint, which can lead to improved outcomes when thinking about adjacent segment problems down the road.
Q: What's the most common misconception you hear about conservative spine care among your peers?
SM: A pretty pervasive stereotype of surgeons is that if you have a hammer, everything looks like a nail. There is a stereotype that some surgeons offer surgery to every single patient they see. But I think here we have really good spine surgeons and very responsible spine surgeons who offer the full gamut of treatment. We're not going to just offer surgery when we think that there may be other pathways.
Another very common stereotype is that there's no spine surgery that works well, but that's completely untrue. We follow our outcomes in our practice, and so I'm not necessarily an advocate for non-surgical treatment. I don't take a five year approach to my patient's care. I really try to project forward into their future and see what consequences that surgical intervention would have down the road and also the consequences of not doing surgery. It goes back to the functional question.
Q: Is there anything else you wanted to discuss?
SM: One way, I think I'm more conservative than the general public of surgeons is I'll sometimes advocate for prehab. Let's say I see a patient that I know will benefit from surgery, and we are trying to maximize our outcome by initiating certain health parameters that the patient needs to fit into, such as smoking cessation and getting their weight into a slightly healthier range because we feel that helps maximize their outcome of success. We are improving their bone metabolism, improving their own health.
We are really trying to allow the patient to take ownership of their own health. If their spinal condition is what stimulates them to start caring about their overall health, I think it'll yield much more positive results than only the outcome of surgery.