A Clinical Psychologist’s Reflections on the Process of Electing for Neurosurgery

My lower lumbar herniation first reared its bulgy little head in the fall of 2017 and by January 2020, I was considering my second back surgery at the age of 28. I was becoming rather existential about the prospect of surgery. “I am too young for these issues,” “Is this how the rest of my life will be?,” “What if something goes wrong in surgery and I have even worse pain, or become paralyzed, or die?” I would have haunting daydreams of getting wheeled back to the operating room after saying goodbye to my wife, being anesthetized, and then entering a dark, unfamiliar void of nonexistence. Unfortunately, I think this is my disposition as a clinical psychologist—to think deeply about things that only get worse with deep thinking.

There was no mistaking I was depressed and anxious about the prospect of surgery. To make matters worse, the pandemic hit March of 2020, and without regular visits to my medical and physical therapy teams, I could barely do anything without experiencing constant pain. I was getting worse by the day, and after trying countless alternative treatments, surgery was shaping up to be the most logical option.

My surgeon and I met in his exam room in July 2020. “Based on all of the conservative treatments you have tried, I can tell you are committed to doing everything you can to manage this without surgery. I fully support you if this is what you want to do. Surgery will always be an option, but it doesn’t need to be your first and final.” This felt empowering, and importantly this conversation had helped resolve some ambivalence regarding surgery as one option but not the only option. My surgeon and I developed a plan for surgery and a potential date in December of 2020. If there was improvement before then we could adjust that plan accordingly. Unfortunately, with ongoing physical therapy twice a week, I was not getting any better.

When December finally came and I received a call from the anesthesia team the week before the surgery was scheduled. “I can’t schedule you for blood work—it appears your surgery date has been held due to it being elective currently.” This is when I learned that my surgery had been put in hold “indefinitely” due to rising numbers of COVID-19 in the state and the capacity disaster protocol put in place at the hospital due to the pandemic. Any non-emergent procedure which requiring an overnight stay at the hospital was cancelled per state order.

I was … relieved? My reaction surprised me given how “ready” I was for surgery. What I now know is that my avoidance “doubled down” in that moment. I began thinking, “the surgery was not going to work anyway” and “perhaps it’s for the better—maybe this is a sign.” My mind was really trying to negotiate the cognitive dissonance of really needing the surgery but not wanting to have it. Despite elective surgeries returning by February 2021, my psychological avoidance was strong, and I had not made the call to reschedule. I allowed myself to silently fall through the cracks. My body was pain ridden, my mood was plummeting, and unfortunately, my new saddle region numbness and significant leg weakness symptoms were clear signs of worsening. During one particular instance in April 2021 where I snapped at my wife due to my pain-fueled short temper, I was (lovingly) ordered by her to return to the neurosurgeon as soon as possible. She reminded me that the intention of surgery was to improve my life, and she challenged me to begin thinking about what the surgery might afford me if it were successful. I wanted to get back to exercise and recreation. I wanted to have better moods and be a better partner and friend. I wanted to form a new relationship with my relatively young body and actively take care of it. Hell, I just wanted a good night’s sleep.

Arriving at the neurosurgery office after my imaging appointment, the team reviewed imaging with me and discussed that the spinal stenosis at L4 S5 had transitioned from moderate to severe which explained the new weakness in both my legs. The NP displayed the study, showing my spinal canal looking like a “cinched garden hose.” August 6^th, 2021 was now my new surgery date. “Deep breaths—this was the right decision” I told myself leaving the office.

On the day of the surgery, my procedure was delayed several hours due to the surgery before mine being more complicated than anticipated. Hours went by in the pre-op room, and I began noticing my mind and its all too familiar script of avoidance. “Maybe my surgeon will be too tired to operate on me,” “Maybe the current surgery is going poorly” “Maybe this is a sign to not have the surgery,” “Maybe they will need to cancel the surgery.” It’s amazing how quickly the mind generates negative content.

Eight hours had passed when neurosurgery fellow arrived at bedside. I shared my concerns about the wait and whether the surgery would still happen. The fellow said without skipping a beat, “Oh yes. This is your first time here in our unit and it can seem a little scary. But believe me, this is a ‘normal day at the office.’ You have nothing to worry about. Let me go through the procedure and answer any questions you have.”

The anesthesiologist arrived and had a very similar, reassuring approach. “I want to make sure you are comfortable. I will explain everything to you. My goal is to make sure you are safe, comfortable, and pain free.”

“How are you feeling?,” my neurosurgeon stated as he entered my pre-op room. “How are you?! It’s been a long day for you. Are you feeling alright? Do you want to grab a bite to eat before we go back?,” I said with concern. Behind his mask I could tell he smiled and said, “that's very kind of you—some water is all I need.”

The anesthesiologist’s script (“this first one will feel like… then the mask… and then you will wake up”) did not penetrate my anxiousness. The oxygen mask came over my face and before I could filter my own thoughts, a voice from deep within me came out. “Can someone please hold my hand?” I spoke. A fraction of a second passed and the anesthesiologist and perhaps the nurse anesthetists or fellow had both my hands in theirs.

Conclusion

As far as I am concerned, you can be the world’s most “self-actualized” person and your mind can still take you to dark places when it comes to surgery. There is something psychologically unsettling about the process: an initially unsolvable problem, despair and hopelessness, a radically invasive solution, a planned physical trauma, consents and advanced directives in case anything happens, a strange sleep, lasting questions of whether the procedure actually worked. This ambivalence and cognitive dissonance are completely normal feelings when it comes to surgery, and my guess would be that they are incredibly common experiences when patients are deciding. Even with my psychology training, excellent medical care, and social support, I was still so terribly anxious about my surgery. I had negative thoughts and emotions, uncontrollable pain, irritation, fear. I felt hopeless and disappointed often. I was uncharacteristically avoidant and unwilling to hear others’ ideas and opinions. I was inflexible and very hard to be around at different points (just ask my wife). And yet, in the right hands of a trusted team, I also felt comfortable with my decision in the end and see the benefits this choice has provided me. I am more active. I have more patience and a better mood. And, I have a new perspective on the complexities of what my patients often struggle with prior to medical procedures. Whatever the treatment goals are, remember make room for the mixed emotions that come with this process of electing for surgery—it is a difficult decision to make and how one navigates this ambivalence and the counseling and comfort one receives makes all the difference for these emotional aspects of the patient experience.