One man’s recurrent pain taught a surgeon how even the best intentions may sometimes not be enough.

A 70-year-old man was escorted into my clinic with his daughter-in-law. Her lean frame was barely able to support his log-like stiffness. Any attempt to move led to lancinating pain shooting down his lower back and into his leg. “I’ve been in excruciating pain for 6 months. I’ve tried everything and nothing has worked. I’ve been told surgery is the only option, and I’ve come to you as you operated on a relative of mine who is now absolutely fine.”

I explained to him that owing to severe degeneration of his spine, one vertebral body had slipped over another, pinching the nerve badly. The surgical intention would be to put in an interbody cage and realign the spine, fixing it with some screws so that the bones didn’t move and there was no compression on the nerve, leaving him pain free. Not able to comprehend much of the medical jargon I was giving him, he finally said, “You do whatever you think is best for me.”

A few days later, we made two small incisions corresponding to his L45 disc space on either side of his spine and used a series of tubular dilators to position ourselves over the target area. We removed the hypertrophied bone and ligament compressing the nerve, removed the bulging disc, and impacted a nice cage packed with bone graft that snugly fit. “This feels really good,” I told my colleague, referring to the proprioceptive feedback I was getting as I gave one last knock with the hammer. We put in screws to complete the job, and the X-rays we took before we closed looked not only perfect but sublime: impeccable symmetry, incredible alignment. I must confess, I sometimes silently marvel at my own artistry. My colleagues would argue that more often than not, it is not silent.

He was discharged a few days later, feeling “as if my car has been fully serviced!” The family was extremely grateful that months of agony had been reversed in a few days. Until two weeks later, when I got a call from the daughter-in-law. “He can’t get out of bed, the pain in his leg is much worse than what it was even before surgery,” she said. Feeling glum but composing myself, I mentally ran through a checklist of possibilities that could be responsible for this. When patients recover from a surgery of this nature, the post-surgery pain gradually subsides over time, but in his case, he had been completely pain free and was now experiencing a fierce recurrence.

I got a plain X-ray done to see if the hardware was in place, and to my dismay, the cage had backed out into the spinal canal and was pressing on the nerve. Luckily, his motor function was not affected. I explained with empathy the need for a second operation, the intention of which was to reposition the cage. “Try and do something to avoid the operation,” he urged me nervously. “If you want, I’ll stay on bed rest, take some injections, but I don’t want another operation. I won’t be able to tolerate it with my age and diabetes.”

I explained to him in all honesty that I had done several hundreds of these cases, that this was the first time I’d seen this happen with one of my patients, and that according to me, this was the only solution. It was in his best interest to opt for a second surgery, and I would never intend for him to be anything but fully pain free. He joined his hands in front of my face and I held them in mine and pressed them against my chest – to tell him that he was going to be okay.

The next day, we opened up the incision and spotted the cage torturing the nerve. We removed it and put in a larger one to ensure an even snugger fit, reinforcing it with some more screws, knowing that this time we were foolproof. The next day saw him relieved and smiling that this was behind him.

Why do good intentions not always end in good outcomes, I thought. I had done what needed to be done even during the first surgery, and an outcome like this should not have happened. I could blame his bone strength and quality or the shape of the cage. I could condemn him for not following proper postoperative instructions and chide him for not taking care of his posture as I’d advised. I could fault his karma, my karma, and the hospital’s karma. I could bring in the universe, talk about the laws of attraction, and allege the misalignment of frequencies. But the bottom line was that this was my responsibility, even if it was not my fault. And sometimes, outcomes are not within your control, even if your intention was good– especially in medicine.

Three weeks later, an X-ray image popped up on my phone from an unknown number. It was the image of a backed-out cage that gave me a sense of déjà vu because it looked so similar. I assumed this to be someone else with the same problem who was seeking my opinion, but when I zoomed in on the name, it was my own patient. The cage had slipped a second time. I dug my palms deep into my eyes. Before I could dive deeper into my anguish, my phone rang. “He is in terrible pain once again, the same kind of pain he had the last time.”

“He will need another operation,” I said, gutted. The family said that there’s no way he would be willing for that. “This time we’ll just remove the cage,” I tried to rationalize, “and put in some bone graft.” I was pretty sure they were not able to understand why this was happening. I wasn’t sure myself, so how could I expect them to be? I suggested that they could go to someone else for the surgery if they wanted to, but it needed to be done, and urgently. I could sense a helpless reverberation at the other end. They came in the next day, we removed the cage, and he was pain free once again. I got the cage cleaned and sterilized and handed it over to him, telling him to put it in a place of pride at home once he was discharged. I’m a little concerned about how the future will unfold for him.

“Tamhari neeyat ekdum saaf che, nai toh I would never have had three operations,” he told me when he came for a follow up. “And I want some royalty for all the experience you have gained from me!” he laughed. “Happy Parsi New Year to you and your family,” he wished me, handing me over a big box of ‘Meher Pinto’ chocolates as he left my office.

This New Year let us at least start with the right intention; the outcome will be what it will be. Que Sera, Sera.