The last two decades have shown such a tremendous growth in the rate of spinal surgeries that even spinal surgeons have called for a reevaluation of the criteria for these ultimate interventions. You may have also heard in the news that the number of people on disability in America is unreasonably high at nearly 50,000,000.
I referred to surgery as an “ultimate” because surgery should always be a last resort, never a first resort. You might be shocked at the number of times I find out that patients were referred to surgeons without first being referred to in a conservative option to see if the problem can be resolved nonsurgically. The “surgery first” approach is a violation of the standard of care, if not a violation of the patients themselves.
A self-insured system in Portland, Oregon, Legacy Health, recognized this problem in 2012. This system now requires employees and family members who consider elective spinal surgery to go through an elaborate presurgical consultation that includes a psychologist and physical therapist. This was an attempt to cut the number of unsuccessful outcomes post-surgery. Now that the program has been in place for a while, but officials say that it is not an attempt to cut down on the number of surgeries, per se, but to make sure patients get the “right surgery.”
The most common spinal surgery today (about 87% of spinal procedures in 2013) is a spinal fusion, in which vertebrae are mechanically fused so that the joints between them no longer move. As of 2011, there were 465,000 fusions done in the US compared to 252,400 ten years earlier at a cost just under $13 billion. Hospitalization alone averages just under $30,000 per case, while the total cost per case can easily hit six figures.
Most surgical experts agree that spinal fusion should not be routinely performed for disc herniations, spinal stenosis, or degenerative disc disease in the absence of spinal instability or deformity. A 2006 Medicare panel found that spinal fusion could not reasonably be expected to provide long-term benefit for patients suffering from degenerative disc disease, but this finding did not express itself in Medicare policy.
In my own practice, the vast majority of the disc injuries that we treat conservatively improved to the point that people can return to work and normal function. We use both manual and mechanical spinal decompression, active exercise, and physiotherapy with very positive effects.
There are times, however, when we see patients who have waited so long to seek care that their conditions have deteriorated such that conservative care does not have its best chance to turn their situations around. There are also some patients with complications (not all of which are physical) that make them less than ideal candidates for conservative care.
A number of criteria are factored into my decision for surgical referral. For example, there are people who are unlikely to be compliant with a conservative care approach. Because they are likely to fail, I may get a surgical opinion earlier in those cases. Anyone who has neurological complications, such as muscle weakness, will get a surgical opinion quickly. If there are medical or congenital conditions that complicate care, such as advanced joint disease or malformed structures that prevent healing, I am likely to get a surgical opinion early. If I have a patient who does not respond with at least 50% subjective and objective improvement after four weeks of conservative care, I will get more imaging or a surgical opinion or both. As you can see, there are many factors involved, so each case must be evaluated individually with the patient’s best outcome in mind.
Any such decision is made with the patient. It is, after all, completely the patient’s decision about which care they seek or whether to seek any at all. My task is to provide an array of options with information so that each patient can make the best possible informed decision.
When either surgery or a surgical opinion is needed, I do not hesitate to pull the trigger. I have worked hard to develop relationships with surgical colleagues, and there are some I use with great confidence due to their skill, positive outcomes, and perceptions on the part of patients that they care. As the occasion arises, we arrange those referrals quickly and conveniently for our patients.
One case recently involved a senior gentleman whose back and sciatic pain did not respond to decompression. I obtained an MRI that explained why: the disc had actually fractured, and a piece was wedged against a nerve. Here is a case that needed a surgical intervention, but there was a complication. This man had saved his money to take his wife (of several decades) on the trip of their dreams, a cruise, that was scheduled only 3 ½ weeks away. We had to do something to save his trip as well as the function of his right leg.
I called one of the surgeons that I like to use the next business day, which was a Monday. Upon hearing of the situation, including the cruise, the surgeon saw that patient three hours later. Two days after that, the surgery was completed. This man was able to heal sufficiently to take his cruise and enjoy the trip of a lifetime with his bride. Yes, I like that whole situation.
So, there are times when surgery is necessary. The rule of thumb is conservative care first, medication if necessary, and surgery as a last resort. All health care decisions should be made by patients armed with the best possible information. It is also true that the outcomes are better when all of their providers communicate and cooperate.