The most important conversation I have with a patient is not the one where I explain the anatomy of their deformity or describe the surgical technique. It is the one where I try to make sure they understand, as clearly and honestly as I can make it, what they are actually agreeing to — and what they should realistically expect from it.
Most patients arrive at a surgical consultation already having done significant research. They have read condition pages, watched videos, found forums, and compared surgeons. What they have often not found is someone willing to tell them the less comfortable things alongside the encouraging ones. This post is my attempt to write down what I actually say in those conversations.
The Decision to Operate Belongs to You
I can tell you what I see on your imaging. I can tell you what the natural history of your specific condition looks like — what happens to a deformity like yours if it is left alone, what happens if it is treated surgically. I can tell you what surgery would involve, how long recovery takes, and what the realistic range of outcomes looks like in patients like you. That is my job and I will do it as completely and honestly as I can.
What I cannot do is make the decision for you. Surgery of this magnitude — long-segment fusion, deformity correction, revision reconstruction — is not something that should be done because a surgeon recommended it and a patient felt unable to say no. It should be done because a patient understood the tradeoffs and concluded that the expected benefit was worth the real risk and the real recovery. My role is to give you the information you need to reach that conclusion. The conclusion itself is yours.
This means I expect you to ask questions. If something I have said is unclear, ask me to explain it again. If you want to understand why I am recommending a specific approach over an alternative, ask me to walk through my reasoning. If you want to know what another surgeon might say, I will tell you honestly whether I think a second opinion would be valuable in your case, and I will never discourage you from seeking one.
Recovery Takes Longer Than You Expect It To
Every patient who has had major spine surgery and was told recovery takes three to six months will tell you that no one told them it would feel like this at month two.
The first two to four weeks after major spine surgery are difficult. You will have more pain than you expected, less function than you expected, and less ability to care for yourself than you expected. This is normal — it does not mean something has gone wrong. The spine is a load-bearing structure that has just undergone a significant operation, and the early healing phase is demanding regardless of how well the surgery went. Planning for this phase — having help at home, not scheduling obligations, managing expectations with your family and employer — is not optional. It is part of the procedure.
The second half of recovery — months three through twelve, sometimes beyond — is where functional improvement actually happens. The bone is consolidating. The muscles are rebuilding. The neurological function that was compressed or stretched is recovering at the pace that nerve tissue recovers, which is slow and nonlinear. The recovery curve is not a straight line. There will be good weeks and difficult weeks. A difficult week at month four does not mean the surgery failed; it means the body is still healing.
I tell patients this not to discourage them but because I have watched patients panic unnecessarily at month two because no one prepared them for what month two feels like. A patient who understands what normal recovery looks like is a better-equipped patient.
What You Do Before Surgery Matters as Much as What I Do During It
The outcome of major spine surgery depends on the surgeon and the operation — but it also depends heavily on the patient who walks into the operating room. There are modifiable factors that significantly affect surgical outcomes, and I take them seriously enough to delay surgery when they have not been addressed.
Bone density is the most important one for my patient population. Scoliosis correction, flatback correction, and revision surgery all rely on screws that must hold in bone under significant cyclic load. A screw that pulls out of osteoporotic bone produces a complication that requires another operation. For patients with significant untreated osteoporosis, I refer them to a metabolic bone specialist first, begin bone-building therapy, and schedule surgery after bone density has improved to a level where I believe the fixation will hold. This takes time — sometimes three to six months. I understand that patients are anxious to proceed. The delay is the right thing to do.
Nutrition matters more than most patients realize. Low albumin — a marker of protein malnutrition — is associated with significantly higher rates of wound complications and infection after major spine surgery. I check nutritional markers routinely before major cases and address deficiency before proceeding.
Smoking is associated with substantially higher pseudarthrosis rates after spinal fusion — the fusion may not heal, which usually means another operation. I discuss this directly.
Cardiovascular fitness predicts recovery. Patients who are deconditioned before major surgery recover more slowly and have higher complication rates. In patients for whom it is safe and feasible, prehabilitation — physical therapy and conditioning before surgery — improves outcomes on the other side.
I raise these things not to create obstacles but because addressing them genuinely changes outcomes. The time spent optimizing before surgery is not wasted time. It is part of the surgical episode.
Your Surgery Is Planned Specifically for You
I want patients to understand how their surgery is planned, because I think it matters — not as a marketing point, but as something that directly affects what the surgery accomplishes.
Complex spinal deformity surgery is not a standardized operation applied uniformly. The amount of correction a patient needs is not a round number — it is a specific target derived from the patient’s own anatomy: their pelvic incidence, their age, their skeletal proportions. I plan correction targets using normative alignment data from the MEANS study — a large multi-ethnic database of healthy adult spine alignment that I led — which gives me population-specific benchmarks rather than the same arbitrary thresholds applied to everyone. A 45-year-old woman needs a different alignment target than a 65-year-old man, even if their curves look identical on the front view of an X-ray.
When appropriate, the rods used to hold the correction are not pulled from a shelf — they are custom-contoured to the planned correction geometry. The interbody cages that go between the vertebrae, in cases that require them, can be manufactured from the patient’s own CT scan to match the specific geometry of that patient’s disc space. For patients with very abnormal bone anatomy — severe deformity, prior surgery that has altered the bone surfaces, congenital variants — I use Firefly® patient-specific navigation guides, 3D-printed to fit the exact contour of that patient’s spine, to guide screw placement where standard navigation is unreliable. Before closing, I verify screw position with an intraoperative CT scan.
I describe this not because these technologies make me a better surgeon than someone who does not use them, but because they represent a coherent philosophy: surgery that is built around the specific patient in front of me, not adapted from a template. Patients deserve to understand how their procedure is planned. More detail is on the Ultra-Personalized Spine Surgery page.
I Will Tell You What I Cannot Fix
Surgery corrects structural problems. It decompresses nerves that are compressed. It stabilizes segments that are unstable. It restores alignment that has been lost. What it cannot do is undo years of chronic pain sensitization, reverse muscle atrophy that has been progressive for a decade, or reliably eliminate all pain in a patient whose nervous system has been in a pain state for a long time.
I tell patients what I am trying to accomplish surgically — the specific structural problems I am addressing — and I try to be honest about which of their symptoms are most likely to improve and which ones may not. A patient with severe flatback deformity and a 15-cm positive sagittal imbalance who cannot stand for five minutes — that patient’s functional limitation is most likely mechanical, driven by the deformity, and surgery has a strong likelihood of producing meaningful improvement. A patient with a 10-cm imbalance and two years of central sensitization who rates their pain at a 9 out of 10 at rest — the surgical outcome in that patient may be more modest, not because the operation is less well performed but because the nervous system component of their pain will not be addressed by restoring alignment.
I would rather have that conversation before surgery than have a patient ask me afterward why they are still in pain. The answer is always clearer and easier to give when both parties understood it going in.
A Second Opinion Is Always Reasonable
What I do ask is that patients bring their actual imaging — not just radiology reports — to any surgical consultation, including the one with me. Reports are summaries. I review the images themselves. A full-length standing scoliosis X-ray series, if it exists, is the single most important study for deformity evaluation and should come to every consultation.
One More Thing
A patient who has read their reports, done their research, and arrived with a list of questions is a patient who is taking their health seriously. That is exactly the kind of engagement that leads to good outcomes. I find those conversations easier and more satisfying, not more difficult.
The goal of the consultation is for you to leave with a clear picture of your spine, an honest assessment of what surgery can and cannot accomplish for your specific situation, and enough information to make a decision you are confident in. That is what I am trying to provide. If that has not happened by the end of an appointment, the appointment is not over.
Dr. Zeeshan Sardar, MD, MSc, F.R.C.S.C
Co-Chief of Spinal Deformity Surgery • Director, Quality & Patient Safety
Och Spine Hospital at NewYork-Presbyterian / Columbia University • New York, NY
To schedule a consultation, call 212-932-5187 or visit the contact page. Telemedicine consultations available in NY, NJ, CT, FL, PA, MO, CA, and TX. For patients considering revision or complex deformity surgery, the second opinion page describes what a remote evaluation involves.
This post reflects the author’s general approach to patient consultations and does not constitute individualized medical advice for any specific patient or condition.