Dr. David Hanscom on Spine Surgery & Science-Backed Pain Relief
Dr. David Hanscom on Spine Surgery & Science-Backed Pain Relief An expert's take on if and when you need spine surgery, how he got out of chronic pain, and how you can too.
David Hanscom, MD practiced complex orthopedic spine surgery for 32 years. He quit his practice in Seattle, WA to present his insights into solving chronic pain, which evolved from his own 15-year battle with it. He eventually escaped from the ordeal and discovered that mental pain is the biggest issue. He is the author of the book Back in Control: A Surgeon’s Roadmap Out of Chronic Pain, and of the online self-directed pain relief action plan called The DOC Journey’” that can be accessed at www.thedocjourney.com. Most recently, Dr. Hanscom launched the “Dynamic Healing” movement, which recognizes the interaction between stress and one’s coping capacity.
Q: Hi Dr. Hanscom! Thanks for taking the time to chat with us. So I hear that you have a story about healing your own chronic pain. Could you share a bit about that and how it impacted your work in the pain management field?
A: I was trained in the traditional medical model. And in medicine, we're taught to treat disease and illness and we're not necessarily taught about the reasons why they occur. So, around 1990, when I started developing these symptoms of ringing in my ears, burning in my feet, skin rashes, and I actually went from being a fearless spine surgeon, to having panic attacks in one day. I thought anxiety was a psychological issue, I did not know it was physiological. So for the next 15 years I developed 17 different physical mental symptoms of what we now know as chronic pain, but I didn't know what happened. Nobody could tell me anything about what was going on.
Being a physician, I had multiple workups, everything was fine and of course you think it's in your head. I actually went to psychotherapy counseling for years, but that also did not help. And in 2003 by a series of unusual circumstances, I got lucky and I emerged from chronic pain. When I still couldn't figure out what happened. Why did I develop all of these symptoms, and how did I come out of it? All 17 symptoms resolved! That sounds a little unreal. How can you have 17 different symptoms? What would cause that to and why would all of them improve? It turns out there's a common basis for all chronic mental and physical disease. It is deeply documented in the medical literature, but these core concepts have not broken into the current medical care environments. I would have no insight into what I've learned now, unless I hadn’t gone through it myself.
Q: Common basis - what do you mean?
A: It turns out when you're under chronic stress, it fires up your body's fight or flight response. It fires up your immune system, you develop these “warrior monocytes”, which are killer white blood cells that start destroying your own tissues. And all these disease states have a common source, which is elevated metabolism or rate of fuel consumption and inflammation - every one of them. I didn't really understand that until about three years ago. We started looking at the deeper research and what I'm discovering is not new news. This has actually been in the science research database for 30 some years or longer. So, I was shocked to find out I was not taught this in medical school. We're now looking at the whole body as one unit.. About 90% of all physical or mental symptoms are created by your body's physiology and when you are in a sustained fight or flight response, your body breaks down.
There's definitely something wrong because your body's physiology is off, and it's destroying your own tissues. So, physiology or the state of the body's chemistry is actually a physical change. It’s been a very humbling experience for me but what's exciting is I now understand the situation in more detail, and I can present it more clearly.
We now have very focused techniques that allow people to control their own body's physiology. Chronic pain is generally considered to be untreatable, but it's definitely treatable. It turns out that essentially every chronic disease arises from a common set of physiological changes..
Q: Wow - that was super informative. From your perspective, as someone who clearly knows the field and the science of pain incredibly well, are there any challenges to helping people in pain that stand out to you? And why are you optimistic about conquering those challenges?
A: Well, this is a tricky deal because we're all programmed by the business of medicine, that there's always a structural problem and we have a procedure that can fix it and solve your pain. So with the wrong paradigm, chronic pain is considered untreatable by the medical world. Only 20% of physicians are comfortable managing chronic pain, less than 1% enjoy it.
The problem is if you don't have the correct paradigm of how to address it and treat it, you're going to be frustrated. So, the physicians and the healthcare providers are frustrated and the patients are really frustrated and all those frustrations translate into fight or flight or inflammatory response, which makes it worse. So you have a deadly cycle of increased frustration... More pain, more frustration, that you get bounced around the medical system and it gets worse and worse and worse.
On top of that, we've been programmed by everybody that there's always a structural problem and that we can fix it. Those are profitable procedures for people and the effective treatments which have been proven in thousands of research papers to be effective, are not reimbursed very well. So there's a major problem in medicine by looking at the body from a structural standpoint, instead of a physiological standpoint. Maybe 10% of symptoms in the body are created by structural problems, but 90% are created by the body's physiology.
There's a particularly deadly term that has emerged called, “medically unexplained symptoms” (MUS), which is the doctor's way of saying, "well, we know something is wrong but we don’t have a good solution". In other words, "we're not saying it's imaginary, but we don't really know the cause and we'll do the best we can manage you but have a good life". That is absolutely false, 90% of the symptoms in your body are from your body's physiology being altered. For example, we all know with acid-base that if you put something into a very acidic environment, it destroys it.
That's a physical effect, right? It's physiology. So when your body's acid baseline balance goes too far off, people die. So your physiology determines everything and the reason why there are so many symptoms that are created is that each organ is bathed in this new chemical bath and responds in a different way. There are over 30 physical and mental symptoms created by being in a sustained fight or flight state. I had 17 of them myself during the worst part of my ordeal, including tinnitus, migraine headaches, irritable bowel, back pain, neck pain, burning sensation, skin rashes, and they are all gone. They've been gone for over 15 years. In medicine right now, we're so programmed to think that there is always a structural issue causing symptoms, it has been difficult to help people, including physicians, to transition over to physiological issues. What I find disturbing is that we all learned this in medical school, and you actually learn this in high school science class, maybe even middle school. If you feel threatened either mentally or physically, your heart races, you start sweating, etc.
We all know what fight or flight means, with real symptoms. When that is sustained, your body predictably breaks down. When you teach people how to adjust their own body's physiology, they heal and symptoms disappear. So, that's where I don't really understand the disconnect, is that we've been programmed to do procedures largely because they are profitable. We're actually pushed to do procedures that are known to be risky AND ineffective. Right now medicine is really going in the wrong direction. It's a big problem.
Q: So far we’ve spoken about your insights as a pain patient and a care provider. But one area you seem to specialize in is the spine and back surgeries. Could you tell us a little about the work you’ve done there, including some of the books you’ve written on the topic?
A; I have deep expertise in spine surgery and structural problems but my current interest has gravitated towards the physiology of chronic disease. It turns out that we're doing a lot of spine surgery on anxiety. I will tell you unequivocally that as people age, their discs dry up, they lose water content and they degenerate. So, people develop degeneration, bone spurs, ruptured disc, herniated disc, arthritis, spinal stenosis, and none of those have been shown to cause back pain - none of them. The correct term is, “normally ageing spine.”
Yet, we are doing over $20 billion a year of surgery on normal aging spines. The success rate of a spine fusion for back pain is about 20 to 25% if that, and if people get better, it's probably the rehab around the surgery. So it turns out that what's happening, we're operating on a normal spine with devastating results. It's tragic because if somebody comes to you with back pain, there's so many ways of solving it and surgery is actually not one of them. People say, well, there's no other options. That's not true. Surgery for back pain, other than a tumor or infection is never an option. So, right now there are a few of us that feel that a back fusion for back pain, is like doing a frontal lobotomy, it makes no sense at all. But what's really disturbing is that instead of doing one and two-level fusions that aren’t effective, we're doing eight, 10, 12, and 14 level fusions that don't work and are damaging..
In fact, a colleague of mine just told me about a girl back East, who had her spine fused from her skull to her pelvis. Her entire young spine was fused. She can't turn her head or tilt her chin. She's basically going to spend the rest of her life in a straight jacket. What gives a human being the right to invade somebody's body at that level without any basis is beyond me. To think you can take beautiful young tissues, muscles, tendons, ligaments, multiple mobile discs and think that turning it into a mass of scar tissue and bone is going to help your pain, makes no sense. These stories are happening on a larger scale with spine surgery becoming more aggressive, not less aggressive. People are being hurt badly.
In contrast, I met another young woman years ago in 2013, who was 32 at the time. She came to one of our workshops. She had experienced four years of neck pain and was on high dose narcotics. She had seen 10 physicians in Manhattan, undergone six injections, and kept spiraling down and down and down. She started working with tools that effectively address chronic pain, participated in the workshop, and one week she went pain-free. The following year was up and down as she continued to master her skills. I talked to her a few days ago. Eight years later, she's married, has two beautiful children, is working, has no pain, no narcotics, and she's living a normal full life. Think of what medicine did to that 26-year-old girl versus the other girl who is thriving. Medicine badly damaged this 26 year-old girl who is going to require medical care the rest of her life.
That's what drives me. We see so many incredible results based on harnessing the body's healing physiology. And what doesn't work is doing surgeries on normal spines - especially 26 year-old ones. I can guarantee there wasn't even a bone spur in someone that age. It is so distressing. We are offering documented effective procedures versus this horrible debilitating operation and I have hundreds of these stories. In fact, I just started a spot on my website called “surgical stories of despair.” A failed spine surgery is brutal. It destroys your life, and this girl's life is decimated.
Q: Well, those stories are both disheartening and the others are uplifting. And it was interesting to hear about the shift that you talk about from spine surgery to emphasizing mental health. Could you explain a little more how you made that transition?
A: How did I go from being a fearless spine surgeon experiencing 17 physical and mental symptoms, including crippling anxiety? And there's a group of surgeons around the world that perform high-level complex cases and it's stressful. And I was extremely competent, fearless. I dealt with it by having an attitude of,” just bring it on.” You could not give me enough stress. I thrived on it. I was suppressing stress at a level that was unbelievable and I now know that repressed thoughts and emotions really fire up the fight or flight response. While I didn’t feel anxiety, I had migraine headaches, tinnitus, migratory skin rashes, burning feet, the list was long. I simply ignored them all. It is when I had a spontaneous panic attack, that I was forced to seek attention. I thought anxiety was a sign of weakness and a psychological problem. I went to counseling for a long time and it became much worse to the point I developed an obsessive compulsive disorder (OCD). It is manifested by intrusive thoughts and severe anxiety. It took me a long time to realize that anxiety is just the sensation you feel when you are in a flight or fight mode and is a reflection of your body’s physiology. It is not a psychological problem. It wasn’t until I stumbled onto that fact, did I begin to heal.
Here is the sequence. Every living creature has to process the environment that they live in every second. Your circumstances range from allowing you to feel extremely safe to being terrorized. Your body processes your situations through input sent to the nervous system from sensors located throughout your body - eyes, ears, skin, touch, feel, et cetera.
The central nervous systems send out signals to adjust your body's physiology to optimize your chances of surviving or allow you to rest and regenerate. Your body is either in a state of safety or threat. Safety physiology is anti-inflammatory, includes oxytocin the love drug, dopamine the rewards drug, and serotonin an antidepressant. So when you're in a state of safety you feel great and relaxed.
When your stresses overwhelm your coping skills, your body perceives danger or threat and you go into fight or flight. Your body’s chemistry changes to adrenaline, cortisol, inflammatory cytokines, your metabolism's up, and your blood flow shifts in your brain from the thinking to survival centers. Your brain itself becomes inflamed and sensitized. It's supposed to because that's how you survive. So when your body's in fight or flight, you feel tense, anxious, and agitated. It's automatic and hardwired. My cat has the same function. Every creature has this automatic hardwired reaction to a threat. So humans have a word that we call it anxiety. So it turns out anxiety is a physiological state, it is not psychological.
Anxiety is the result of stress, not the cause. I reminded myself of this a few years ago. I learned this in high school. When you are threatened, your body is intended to be on high alert and when sustained, it starts to break down. The sensation that we call anxiety is intended to be so unpleasant that it forces us to take action to solve the problem and live. It is the gift of life.
Anxiety isn't pleasant and it'll always be incredibly unpleasant. It is a hardwired automatic survival reflex. It's not responsive to rational interventions. Yet we spend much of our life energy trying to cope and mask this sensation. It often consumes much of our lives. We try to distract ourselves, end up with various addictions, engage in aggressive behaviors that feel powerful, and use rigid thinking to gain a sense of control. Most psychological diagnoses arise from trying to cope with this sensation.
We know that chronic stress causes disease. You can’t heal when you are consuming resources to survive. You have to be in a state of safety to regenerate and heal. Humans have a major problem that my cat doesn’t have and that is language and consciousness. Unpleasant thoughts are perceived as a threat with the same bodily response as a physical threat. I call it the “curse of consciousness.” Since we can't escape our consciousness, every human being has some level of sustained fight or flight that my cat doesn't have. It may be the core driving force in all chronic pain. When you are in this sustained state of alert, your body also creates dozens of physical symptoms as I mentioned above.
It is beyond the scope of this particular conversation, but the solution lies in understanding how your body reacts to stress and then learning tools to regulate your body’s chemistry from flight or fight to safety. None of them are difficult but it does require repetition to master them. Here are the portals of intervention:
- The input - there are ways of changing how you process stress and getting rid of the stresses is not one of them. Avoiding stress becomes its own stress.
- The state of the nervous system - is it calm or hypervigilant? Diet, sleep, exercise are some of the approaches that lower the inflammation of the brain.
- The output - the body’s physiological state. Are you in flight or fight or rest and digest. There are many ways of stimulating the anti-inflammatory response of your autonomic nervous system.
I have a term for the effective healing approach - “Dynamic Healing.” Addressing the interactions and between your stresses and coping skills allows you to minimize the time your body is in threat physiology. As you learn to create safety, your symptoms will abate and you can heal.
Q: Thanks for that high level but comprehensive dive into back pain science. I also want to talk about another part of the pain space in which you’re heavily involved - patient education. Why is that so important for people and how can it help them recover?
A: Please look at the model of dynamic healing. You have the input, the nervous system, and the output. If you're unaware of what's going on, you can get frustrated. Remember that essentially all chronic disease has been deeply documented to be a result of chronic inflammation and elevated metabolism. The documented diseases include autoimmune disorders, anxiety, depression, bipolar, OCD, Parkinson’s, Alzheimer’s, cardiovascular disease, hypertension, adult-onset diabetes, obesity, migraines, irritable bowel syndrome, and this list is long. Fortunately, as you learn ways to lower your body’s inflammation, the symptoms resolve and disease progression can be stopped - if you use the tools..
Q: When you are not working on helping people tone down their pain, what do you do for fun?
A: I do some bird watching. I exercise in the weight room, and my wife and I play ping pong in the backyard. I like to read on a lot of different topics. I used to play basketball, softball, volleyball, but my hips don't allow me to do that anymore. I love to play golf, and stay fairly physically active. My wife is a tap dancer and she's been bugging me to do the tango and salsa for years but I am clearly just not a dancer, so that's not going to happen.
Q: Where can people find more about your work?
A: You can find me online at theDOCjourney.com, www.backincontrol.com, and my books include Back in Control: A Surgeon’s Roadmap Out of Chronic Pain, and Do You Really Need Spine Surgery?. We are also releasing an app this fall, The DOC (Direct your Own Care) app.