Suryanarayanan Bhaskar, Jaskaran Singh Gosal, Mayank Garg, Deepak Kumar Jha
  1. Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.


Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Bhaskar S, Gosal JS, Garg M, Jha DK. Letter to the editor regarding “why would two patients with no disease be offered unnecessary transforaminal lumbar interbody fusions?”. Surg Neurol Int 06-Dec-2019;10:238

How to cite this URL: Bhaskar S, Gosal JS, Garg M, Jha DK. Letter to the editor regarding “why would two patients with no disease be offered unnecessary transforaminal lumbar interbody fusions?”. Surg Neurol Int 06-Dec-2019;10:238. Available from:

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We read with interest the editorial “Why Would Two Patients with No Disease Be Offered Unnecessary Transforaminal Lumbar Interbody Fusions?”[ 5 ] The editor has rightly described the current state of the industry, rather than the patient-driven spinal surgery. We fully agree with the views of the editor on this important topic of public health; to maintain the virtuous doctor- patient relationship in the coming times.

These days, apart from the nexus between the surgeon and the implant industry leading to this growing trend of unnecessary spinal fixations, we feel there are other critical reasons for this lack of proper doctor-patient communication.[ 1 - 4 , 6 ] The key question every patient should be asked is: “What do they want from this surgery?” or “What are their expectations from this surgery?” Further, each patient must be encouraged to ask themselves this question before surgery. This is irrespective of age and gender. Even in children who can understand that they are going to undergo some treatment in the hospital, come up with interesting, and surprising answers.

These answers go a long way in understanding the connect and disconnect between the doctor and patient and may avoid future discord and conflicts. For example, a patient presents with a lumbar disc herniation, back pain, and lower extremity weakness. The surgeon correlates the clinical examination with the radiological findings and recommends surgery. This is the correct decision as per current treatment guidelines and the surgical outcome is excellent. The discectomy is performed and the root was decompressed. The patient’s foot weakness improved, but there was no significant relief of his back pain. The patient thought the surgery was done to relieve him/her of the back pain that was troubling him more than the foot weakness. A simple question at the preoperative level – “What do you want from this surgery?” would have sorted out the problem. We as physicians are so involved in the outcomes, statistics, guidelines, recommendations, costs, complications, etc., that at times, we tend to forget that all those issues are essential, but not to the person who is undergoing a particular treatment. In the current day and age, the patient is given all the rights and informed consent, etc., but at times, is just not asked what it is that they really want from the treatment.

A patient undergoing treatment of a malignancy with a poor prognosis might have expectations like making it to near or dear ones’ important date (e.g. birthdays). Knowing this will not change our treatment plan but will make us more empathetic. The connection between the person/patient being treated and the treating person/physician is what needs to be brought back into focus in modern medicine. This connection will automatically make us more conscientious and prevent us from doing unnecessary procedures that we know might not benefit the patient. If we collectively do not do this, this “noble” medical/surgical profession will lose its nobility and charm.

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1. Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I. Evidence for overuse of medical services around the world. Lancet. 2017. 390: 156-68

2. Deyo RA, Mirza SK. The case for restraint in spinal surgery: Does quality management have a role to play?. Eur Spine J. 2009. 18: 331-7

3. Epstein NE. “Evidence of overuse of medical services around the world” by brownlee et al., lancet, 2017: Does this apply to transforaminal lumbar interbody fusions (TLIF)?. Surg Neurol Int. 2019. 10: 154-

4. Epstein NE. Lower complication and reoperation rates for laminectomy rather than MI TLIF/other fusions for degenerative lumbar disease/spondylolisthesis: A review. Surg Neurol Int. 2018. 9: 55-

5. Epstein NE. Why would two patients with no disease be offered unnecessary transforaminal lumbar interbody fusions (TLIF)?. Surg Neurol Int. 2019. 10: 114-

6. Ramani PS. Spinal surgeon, implant industry and patient care: Where do we draw the line!. Neurol India. 2016. 64: 368-71

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