Patient centered care and collaborative efforts between providers may yet prove to be the best approach:

Back Pain?

Are spinal fusion surgeries being performed needlessly?

By Robert D. Argyelan, DC

A recent article published in Newsweek by its science contributor, Sharon Begley, (http://www.thedailybeast.com/newsweek/2011/08/14/some-medical-tests-procedures-do-more-harm-than-good.html) indicated that perhaps spinal surgeries are being performed needlessly because expensive common tests and procedures may lead to medical interventions for a problem that may have eventually resolved on its own.  “From PSA tests for prostate cancer (which more than 20 million U.S. men undergo every year) to surgery for chronic back pain to simple antibiotics for sinus infection, a remarkable number and variety of tests and treatments are now proving either harmful or only as helpful as a placebo” writes Begley.

According to Begley, the problem stems more from too much testing combined with drawing the wrong conclusions about what must be done in response to positive test findings.

“Just as cardiac CT makes sense in principle, so does getting a high-resolution image of the spine if someone is suffering lower back pain with no clear cause. An MRI typically costs about $3,000 and is designed to spot everything from bulging discs to hairline fractures. Find any of those things, the logic goes, and you can treat the problem surgically. But there’s a fundamental flaw: clinical trials have shown that back surgery, including vertebroplasty (putting special cement on a tiny spinal fracture) and spinal fusion, is no more effective at alleviating ordinary pain than plain-old rest and mild exercise. But like any surgery, it carries risks. Last year the American College of Physicians warned that “routine imaging [for low back pain] is not associated with clinically meaningful benefits but can lead to harms.” That’s because the “abnormalities” seen in an MRI often have nothing to do with the back pain (people without pain have them, too), but seeing something on a scan makes a physician feel compelled to get rid of it,” writes Begley.

“There is a longstanding fallacy among physicians that if you find something different from what you perceive to be ‘normal,’ then it must be the cause of the patient’s problem,” says UNC’s Hadler.

Begley’s concerns aren’t just with spinal surgeries being an unnecessary outcome from findings found on expensive tests, but sees cardiovascular surgery in the same light.   “At least five large, randomized controlled studies have analyzed treatments for stable heart patients who have nothing worse than mild chest pain. The studies compared invasive procedures including angioplasty, in which a surgeon mechanically widens a blocked blood vessel by crushing the fatty deposits called plaques; stenting, or propping open a vessel with wire mesh; and bypass surgery, grafting a new blood vessel onto a blocked one. Every study found that the surgical procedures didn’t improve survival rates or quality of life more than noninvasive treatments including drugs (beta blockers, cholesterol-lowering statins, and aspirin), exercise, and a healthy diet. They were, however, far more expensive: stenting costs Medicare more than $1.6 billion a year.”

It is understandable that a physician would want to relieve a patient’s complaint of pain and, in the case of back pain, the complaint can be debilitating while adversely affecting the patient’s quality of life.  Acute low back pain will affect 80% of the population at least once according to numerous articles, with 35% of the population being affected at any one given time.  Statistically, traditional posterior entry for low back surgery to perform spinal fusions does not have a high success rate and, while some symptoms might be alleviated, complications from the development of scar tissue, adhesions, or the resulting onset of more rapid deterioration of the vertebral joint above the surgical fusion is often noted.

Begley’s opinion, and others including Peter Ullrich, MD as written in Spine-Health, seem to indicate that needless surgeries are being performed because of wrong conclusions being drawn from diagnostic testing.  Ullrich writes, “By far the number one reason back surgeries are not effective and some patients experience continued pain after surgery is because the lesion that was operated on is not in fact the cause of the patient’s pain.”

Does that mean surgeries should not be performed or that diagnostic tests shouldn’t be taken?  Certainly not.  Perhaps though, it might signal for a different approach to be taken in the management of patient care.  It may be more sensible for a patient management system to include conservative practitioners of spinal treatment, such as chiropractors, to work alongside orthopedists and neurosurgeons to better determine if and when surgery should be considered.  Spinal manipulative therapy, as performed by doctors of chiropractic, has been established to be effective in the treatment of acute back pain.  Ongoing research in its use in treating chronic low back pain is showing promise.  An article published in Medscape Today  (http://www.medscape.com/viewarticle/748147?src=emailthis) by Pauline Anderson says that there are few differences between acute and chronic lower back pain.

Conservative care approach should be the initial course of treatment for patients expressing acute low back pain and, as evidence is proving, warranted for chronic complaints as well.  However, not all patients respond to spinal manipulative therapy or other conservative approaches and when neurological symptoms persist, appropriate diagnostic tests should be ordered and consultation with the orthopedic or neurological surgeons may be a responsible course of care to pursue.  Too, not all surgical procedures are equal and it would be well advised for patients to secure surgeons who are up to date and qualified in delivering the newest, most effective procedures with the most effective equipment and tools that are available.  Simple posterior surgery is no longer the only option as minimally invasive procedures now allow for lateral entry for fusion surgeries.

Begley’s contention is that physicians need to avoid performing useless surgeries that do not provide a medical benefit or outcome while only serving to generate revenues. “Medicare pays them more than $100 million a year for screening colonoscopies; some 40 percent are for people in whom they will almost certainly harm more than help.”  The physician’s credo remains, “First, do no harm.”