In every encounter in our practice within our Worker’s Compensation ecosystem, each interaction is modified by our personal experience. During my career pursuing cost-containment measures within Worker’s Compensation, two of the most dreaded words were “lumbar fusion.” The issues related to lumbar fusion often included persistent pain, long-term disability, and significant changes to the lifestyle of the affected employee.
Personally, I have a long history of chronic low back pain, beginning with my tenure working overseas for my Uncle Sam. First Sergeant O’Brien felt it was a good idea for me to jump out of a hovering helicopter with my rucksack and aid bag, leading to my first insult to healthy normal lumbar anatomy. Subsequent multiple lumbar injuries occurred while wearing the uniform, and throughout the rest of my adult life, with several additional comorbidities.
It came to a point where I could not pass what I call the “early morning test.” That is to say, which hurt worse –my full bladder or my low back pain? I visited an incredibly good friend/orthopedic surgeon who sent me for MRI/CT scan. When the studies came back, he texted, “Dude, really?”
There were significant degenerative changes, and I developed a condition called DISH, a condition where ligaments turn into bone. My entire lumbar spine and thoracic spine had fused, except for two levels. Given the ongoing symptomology, the only realistic treatment option was to tolerate the pain or undergo, you guessed it, lumbar fusion surgery.
I am sharing this not as a medical case study, but because it fundamentally changed how I evaluate post-fusion complaints, disability duration, and credibility in workers’ compensation claims.
As a PA in orthopedic surgery, I have taken part in this procedure many times. I must tell you that lying down on the hospital gurney and looking up at those surgical masks, is a far dissimilar experience than being the guy standing over that patient going into the OR. Somehow, I remembered a book I read during my training, Physician Under the Knife. It was a surgeon whose perspective changed after undergoing surgery.
After my 4:30 AM arrival at the hospital and undergoing all the routine preoperative protocols, my memory was that after being wheeled into the spine surgery OR suite, the room was flipping cold! I mentioned that to the anesthesiologist, who reiterated my complaint. That was the last thing I remember. The utility of the newer anesthesia medications is spectacular. I had no memory after my complaint about the environment until I awoke in my hospital room some eight hours later. It took that long to complete a four-level fusion and to successfully recover from anesthesia.
While there was some post-operative discomfort, candidly, it did not hurt all that much. While following a preemptive analgesic protocol, the biggest challenge I encountered, other than the hospital food, was finding a comfortable position that kept my spine as straight as possible. I returned home after spending two days in the hospital. Continuing with the same protocol, I did well. On postoperative day four, I successfully discontinued administration of opioid analgesics and stopped the muscle relaxant regimen. Approximately one week later, the lumbar brace was applied and I continued to improve.
Since I work mostly from home, I resumed modified duties five days after surgery. One of my clients, a skilled worker’s compensation attorney, was astonished that an individual who underwent a four-level thoracolumbar (T11-L3) fusion was back at work on that fifth day.
I have been thinking about this reality of post-fusion protocols, with some increased clarity. Candidly, I am not sure why I had such an exceptional outcome, but it was my personal belief system that this surgery was not going to slow me down.
Another project I am working on with Mark Pew and Bob Wilson is WorkCompCollege.com WRP training. This training enables Worker’s Compensation professionals to look at that injured employee not just from the pathological perspective but from the whole person perspective. What motivates that injured employee, what issues are compromising the response, and other noted entities. While noting my medical background and personal experience dealing with injured employees undergoing this type of surgery, these are several of the biopsychosocial factors that all comp professionals need to incorporate into their decision-making.
In my case, my sole frustration was that I could not return to work as quickly as I had hoped. Going forward, when I am dealing with a case where there was a lumbar fusion, there is insight into what specific factors are driving the current complaints. Given my response, careful questioning as to the objective basis for the ongoing complaints will be the standard. And I can honestly say, yes, I have experienced all that you are experiencing.
The main idea is that each case is different. Not all reports of back pain following fusion surgery are justified, unless there is a clear clinical reason. Look at the entirety of the claim, the 360° perspective of the injured individual, and proceed as appropriate. It is quite possible that exceptional results can occur after a particularly gnarly clinical situation. Our goal should not be to fear the fusion; it should be to identify the factors—like motivation, support, and clear communication—that turn a ‘dreaded’ surgery into a success story.
