The game is won or lost in the outpatient clinic.

Patient selection for surgery can be challenging. This is clearly an understatement. To simplify this process for lumbar degenerative disk disease, one might divide patients into several categories: nonoperative, potentially operative, and definitively operative. Nonoperative patients often have an undiagnosed chronic pain syndrome. These individuals often have numerous pain complaints (multiple unrelated somatic complaints) that are not attributable to a specific dermatome or myotome. Their pain is often characteristically atypical, e.g., burning pain. One of the most significant mistakes in the lumbar degenerative disease decision-making process is to treat chronic pain as if it were acute pain. These patients often have a low energy level and complain of nonrestorative sleep. Unfortunately, they may also have “pathology” on imaging studies. This “pathology” often tempts the surgeon to recommend surgery. The outcome is often predictably suboptimal. The bottom line here is to maintain a low threshold for establishing the diagnosis of a chronic pain syndrome and to treat the patient accordingly – usually without surgery.

Operative patients can be divided into two groups based on a simple question. Would the surgeon have this surgery if he/she were the patient? If the surgeon honestly answers this question, the rest of the process is greatly simplified. During a national spine meeting approximately 8 years ago, audience members during a plenary session were asked if they would recommend surgery for a case presented to the group. Eighty percent of the surgeons responded in the affirmative. When asked if they would have the same surgery themselves, only 20 % of the audience responded in the affirmative. This is damning to the profession of spine surgery. Performing an operation that one would not undergo him/herself, at the very least, raises questions regarding the surgeon’s specific operative indication process and the motives for such. There are, of course, patients that harbor a clear-cut indication for surgery and are, therefore, much easier to select. Regardless of the strategic plan derived, the spine surgeon should be fiscally responsible when crafting the plan of attack on the patient’s malady. The surgeon should act (i.e., manage and advise the patient) as if he/she were paying the bill.