Response to “Unnecessary spinal surgery”

Dear Sir, In their recent paper on ‘unnecessary’ surgery, Epstein and Hood have performed a notable service by calling attention to the phenomenon of excessive spine surgery being performed in this country,[3] an occurrence that has been documented both in the lay media [4] as well as in the scientific medical literature.[2] They and the seven whose comments were appended to their paper appear to believe that this is due to erroneous decision making by the surgeon, when in fact the reasons are multifaceted. I believe it to be due to a significant liberalization of the indications for surgery, coupled with a rapidly developing complex system of coding for spinal surgery, which is designed to maximize billing and thus collection; in addition, there is also a concerted effort being made to redesign surgical instrumentation so as to make it easier for the surgeon to carry out the operation. I do not have any direct concern with the coding and the instrument design; by all accounts, these can be advantageous for legitimate spinal surgery. My concern is with regard to the changes being introduced in the indications for surgery, and their promotion. In the mid 80s, I was in a position to listen in on board meetings of the American Association of Neurological Surgeons (AANS) and meetings for planning scientific programs for the AANS and, to some extent, the Congress of Neurological Surgeons (CNS). I saw increasing emphasis being placed upon the issue of spinal disorders and on the need to include the art of fusions in their treatment. The political and the educational leadership in the field of neurosurgery made a concerted effort to increase the number of neurosurgeons who could do spinal fusions, especially in the treatment of degenerative joint and disc disease. As editor of a national neurosurgical journal, I saw increasing numbers of papers submitted by neurosurgeons dealing with the technical aspects of spine surgery. These articles were published. There were a number of reasons for this evolution. Neurosurgeons were already performing fusions in traumatic spinal disorders. Also, they observed that the orthopedic surgeons who were performing most of these procedures in the lumbar spine were beginning to extend their interests to the cervical spine, not just the posterior but also to the anterior cervical spine, which had heretofore been the preserve of the neurosurgeon. With this increase in the number of surgeons active in the spine, there had to be an increase in patients and procedures. This was accomplished by relaxing the indications for surgery and increasing the sophistication in coding so as to maximize returns on each procedure. As the equipment became easier to use, more surgeons were encouraged to operate, and each surgeon was able to perform more cases in a finite period of time. These concerns about the changes in the indications for surgery prompt two lines of thought. Over the years I have witnessed a decline in the importance given to history and physical examination, and it is now all too common to see these being almost entirely disregarded, with most of the emphasis being on the imaging findings. I have seen this not only in the hospital but also at the presentation of patients during administrative management conferences and when reviewing records in cases of personal injury and medical liability litigation. I have recently stepped down from a position within a state workers' compensation system. There, I reviewed dozens if not scores of cases, all attesting to the previous observation. The decision to operate is ultimately based on the appearance of the ‘scan,’ regardless of the strength of the history and the physical findings. Most of those I queried about this issue gave me different versions of the same answer – that such notions were for the ‘purist.’ Is this what is now being taught in our medical schools, residencies, and fellowships? Mind you, these observations are not limited to just one spinal specialty. However, of more direct concern is the blatant support for this minimalistic ideology regarding the indications for spinal fusions, which emanates from the AANS standard which states that fusions may be carried out in select patients for chronic back pain alone.[6] This standard reads as follows: Lumbar fusion is recommended as a treatment for carefully selected patients with disabling low back pain due to one- or two-level degenerative disease without stenosis or spondylolisthesis. This standard is based primarily upon one study,[5] a study that has been criticized in many quarters where therapies other than fusion are proposed. It definitely needs to be reviewed because of its apparent open-ended permissiveness, which has caused some established promoters of guidelines to reject it.[1] There is no guidance regarding the phrase ‘carefully selected patients.’ It has been a long time since I have seen a declaration, in or out of medicine, that is so ripe for abuse. What do the directors of neurosurgical residencies and fellowships teach that this phrase means? The cynic would allow that this means ‘any patient the surgeon selects.’ The thoughtful observer of the present scenario would agree. I agree with Epstein and Hood that there is a great deal of unnecessary surgery of the spine taking place. But, a generation of surgeons has developed to believe, apparently, that pain can be excised or at least pampered by a well-performed fusion. This is a serious problem for the educators of neurosurgeons, the principle target of this communication, but also for all spinal surgeons. With the increasing public awareness about costs and processes there will be attempts to dispose of this financial drain. I am concerned as to what else will be removed at the same time.