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Questions and
Answers

Why is there such a long wait to see a spine specialist?

There are multiple reasons - spinal problems are very common and the sheer number of people who require advice and seek treatment alone is large. Then cases are often triaged according to clinical need and urgency. In the public system there is then the added pressure of needing to assess and treat urgent cases such as tumors, trauma (e.g. spinal cord injuries) and infections added to the elective waiting burden.  In private, there are often competing interests where specialists may have other commitments (public hospital or teaching / research responsibilities) or a desire to achieve a work life balance where it is only possible to effectively see a certain amount of patients per consulting session / clinic. It may often be necessary to seek multiple referrals to different specialists although this is not generally encouraged.

What is the difference between an Orthopaedic and Spinal Surgeon

Orthopaedics is a broad field concerning musculoskeletal areas and surgeons can have an interest or sub-specialist expertise in one or more areas (e.g. spine and hip or paediatrics and knee, foot and ankle, upper limb, trauma and tumor etc.). Spinal surgeons can be orthopaedic or neurosurgeons and generally have undertaken further sub-specialist training in spinal procedures after attaining their primary surgeon qualification (Fellowship of the Royal Australasian College of Surgeons or equivalent). In other words, Spinal surgery is one field within orthopaedics (and Neurosurgery) but orthopaedics can also refer to other musculoskeletal areas.

What is 'general orthopaedic trauma'?

 

General orthopaedic trauma refers to the commonly non-subspecialist trauma frequently performed in Secondary and Tertiary Orthopaedic training centres that orthopaedic surgeons achieve competence in prior to the completion of their training. Common examples include fractured neck of femur surgery as well as common wrist, forearm and ankle fractures.

 

Why is it so expensive to see a spine specialist or have spinal surgery?

Spinal specialists generally undergo many years of rigorous training and meet large expenses for training only arriving at a point of being a specialist in their mid-late 30s in most cases. Spinal specialist practices also tend to have large overheads to run a private practice and its associated costs to provide you with the required care (staff, insurance, premises, internet, practice software, equipment, professional development courses etc.).

 

I have been told I should not have surgery but had to pay a lot for a consult - is this justified?

The training required combined with knowledge, understanding of scientific literature and evidence and pattern recognition can provide a patient with a rapid and accurate opinion on their suitability, need and expectations for spinal surgery compared to the lengthy and potentially inaccurate decision making gained from talking to non-spinal surgeons (including friends and relatives) and searching the internet or reading books about spinal surgery. To put it another way it would be like trying to represent yourself in court without a lawyer on a complex legal matter or trying to rewire your power lines without being a licensed electrician -  it is safer and knowledge is more rapidly available by seeing a trained specialist.

Why is so little gotten back from the consulting fee?

The rate of remuneration received from medicare for specialist consultations has been fairly static over the last few decades compared to the ever rising cost of running a practice and inflation.

 

Why does spinal surgery have such a bad name?

For many reasons. Historically surgeries were often done poorly for the wrong patient, wrong reason (indication), wrong type of surgery and without preparation or adequate diagnostics. There were little advances in spinal surgery until around the 1990s where improved diagnostic techniques (e.g. MRI) and instruments (e.g. pedicle screws and intraoperative CT scans) became more common place. Spinal surgery has greatly advanced in the last decade or so with improved diagnostics, predictors of who will benefit and improved safety and techniques available from modern advances. The science and production of spinal tools and implants continue to strive for lower complications and better outcomes. Further, spinal surgeons have often been criticised for treating back pain too aggressively and enthusiastically with operations, some of which can be detrimental (short or longterm) or are performed before really necessary.

Why are there so many tests being ordered for my spinal condition?

The cause(s) of pain aren't fully accurate through having any single scan, although scientists are working on it. Often, it will take multiple scans to best assess where the 'problem' is that is likely causing pain in your spinal area or radiating away from it. It is important prior to any major operation, as opposed to injections, to be very clear where the problem is. Other test such as Electromyogram (EMG) and nerve conduction studies can help clarify the extent of involvement of nerve(s). Tests such as MR spectroscopy, facet blocks and discography can help provide valuable information that can clarify the back pain generator which is important in setting expectations regarding a surgical outcome. For example, there have been instances that a fusion or disc replacement has been done but the painful level is a disc that hasn't been included in the operation and sometimes the painful structure is actually another local structure (such as the hip or shoulder) rather than the spine.

Why doesn't Dr Zotti just use one Radiology clinic? Why is there a fee at some clinics for injections and MRIs but other clinics bulk bill?

There are many factors other than cost and location that Dr Zotti considers in referring you to specific clinics. For example, only some radiology clinics have the expertise or equipment to perform a specific procedure or test that Dr Zotti will use the information from to help make important clinical decisions. As such, not all radiology requests can necessarily be performed locally to you or at a comparable cost between radiology clinics (which Dr Zotti has no control over). For example, only certain clinics will have the EOS scan or MR spectroscopy available, the ability to do intravenous sedations or a radiologist(s) trained in specific spinal injection techniques (e.g. Radiofrequency ablation or cervical epidural injections). However, referrals by Dr Zotti can be utilised at a radiology clinic that better suits geographic, cost or logistical needs of a patient in most cases. Where there is a specific need to go to a specific clinic Dr Zotti will generally inform you of the reason for this. Bulk billed specialist MRIs generally have waiting lists applicable whereas privately paying patients or patients where the investigation has been approved by insurance generally do not have the same waiting times apply.

Why can't I just book in for spinal surgery /injections without first seeing a specialist for assessment? Why not book surgery through Telehealth?

While there are practices where surgeries are booked off an MRI and a Telehealth consult, Dr Zotti believes that meeting and assessing the patient physically is essential in any decision making. Dr Zotti not only needs to physically examine you but also values  establishing rapport and assessing compatibility of your personality and beliefs about your condition to his, as this has been shown to be a key determinant in therapeutic alliances between patient and surgeon.

Why will Dr Zotti not guarantee that I will get the result I expect from spinal surgery? Why did Dr Zotti refer me to another specialist?

Dr Zotti is cautious to recommend procedures to patients whom he feels he cannot meet their expectations with any procedures. Dr Zotti will counsel patients on what is realistic and achievable and the course of treatment (that may be no operation or injections) that he feels is appropriate. Dr Zotti may recommend another opinion when he would value counsel of a colleague on what type of operation would be best for a patient, what outcome could be expected or if he feels the patient is better treated with their condition by another specialist. 

Why is the surgery or surgeries recommended by surgeons not the same?

 

Spinal surgeons are well known for having differing opinions about how to treat common spinal problems. Opinions very commonly differ on how to treat the same condition with no intervention, injections, decompressions or fusions/disc replacements depending on the anatomy and patient. Some of this is informed by past experience, skillsets, risks and patient factors while some is informed by surgeon preference. For example, if fusion is recommended, there are several different ways to perform lumbar fusion with unique pros and cons. It is common for patients to seek a second opinion before spinal surgery, particularly where the problem and solution proposed is not straight forward. Particularly in the instance where a patient has been recommended or offered multiple level fusions or disc replacements for a complaint of predominantly back pain would be well advised to gain another opinion to see if this is likely to be successful. 

Why does Dr Zotti generally not accept referrals for patients without insurance?

While some specialists are happy to see patients without insurance, Dr Zotti feels that there are more ethical pathways for specialist review already in place and that the cost of spinal surgery without insurance is beyond the reach of most Australians. Should a complication occur even if one can afford self-funded spinal surgery, the costs can dramatically increase and place large strains on the patient and their family. Dr Zotti also understands there is growing pressures to be reviewed by a specialists for welfare entitlements ("Disability Support Pension"), compassionate release of superannuation for non-surgical purposes and impairments from motor vehicle accidents (e.g. for whiplash). Dr Zotti prefers that patients seeking opinions on these matters see an alternative specialist as it is his preference as a surgeon to see and treat surgical candidates.

Why does Dr Zotti not provide prescriptions of opioids for my chronic pain?

It is not Dr Zotti's place to begin and provide prescriptions for opioids for chronic pain. There is increasing regulation and preference for there to be a sole provider for such scripts which is usually the general practitioner or, occasionally, a pain physician. Dr Zotti is happy to discuss this with your referring doctor if required.

Why must I write in to ask for copies of my files and records?

There are several privacy, ethical, legal and professional reasons for this.