Spinal Fusion Surgery is Ineffective, Costly

By John Henry Dreyfuss, MDalert.com staff.

Save to PDF OrthopedicsEvidence-Based MedicinePerformance-Based Medicine By
  • Spinal fusion surgery is no more effective for pain resulting from degenerative disk disease than are exercise, education, and physical therapy.
  • Rates of a variety of spinal surgeries have soared in recent years in the U.S.
  • Published studies have repeatedly shown that spine surgery is often ineffective and dangerous.

Spinal fusion surgery (Figure 1) is often ineffective and unnecessarily expensive according to the results of a large review study published recently in The Spine Journal. The study found that 2 types of spinal fusion surgery were no more effective than supervised exercise or physical therapy in patients with degenerative disk disease (DDD; Figure 2). Spinal fusion surgery was also significantly more costly than nonsurgical alternatives. Despite these findings, rates of spinal fusion surgery continue to increase in the U.S.

These surgical approaches were called “useless” in a report published in The New York Times.

 

Figure 1. Spinal fusion.
(Sources: Flickr/By warrenski/Creative Commons.)

The Spine Journal 2016

The article published in The Spine Journal noted that “a total of 380,305 patients underwent surgical treatment for lumbar DDD between 2000 and 2009. Population adjusted incidence increased 2.4-fold from 2000 to 2009. Among the procedures, APLF [anterior and posterior lumbar fusion] increased 3.0-fold and PLIF/PLF [posterior lumbar interbody fusion/posterolateral lumbar fusion] increased 2.8-fold.”

“Anterior lumbar interbody fusion was performed in 16.8% of patients, PLIF/PLF in 67.9%, APLF in 13.6%, and TDR [total disc replacement] in 1.8%.”

“Surgical treatment for lumbar DDD was 1.8 times more common in the Midwest region and 1.7 times more common in the South region than in the Northeast region. Total disc replacement was more common in younger patients and in the Northeast region. Posterior lumbar interbody fusion/PLF was more common in older patients and in the South region.”

However, in its findings, this study concluded that this variety of spinal surgeries is no more effective for the pain related to DDD than are exercise, education, and physical therapy. Americans and their insurers are paying for these surgeries in escalating and there are no data to support this therapeutic approach.

This trend is due in part to way that therapies are approved for use in the U.S. Before a pharmaceutical agent is indicated for a given use and marketed for use in patients it must be approved by the FDA. While this is not a foolproof process and both dangerous and ineffective drugs have been brought to market, the bar for proof of efficacy is much higher for drugs and devices and it is for surgical approached.

In fact, as physicians know well, surgical approaches do not need to be reviewed or approved by the FDA. In fact, any surgeon in the U.S. can devise a surgical approach based on his or her medical intuition and simply begin practicing it on patients. It may not be until years later – if ever – that the surgical approach is studied in a controlled manner and data are constructed to indicate the efficacy or inefficacy of the approach.

The New England Journal of Medicine 2009

In 2009, a series of trials was published in The New England Journal of Medicine which compared vertebroplasty with a sham procedure in a randomized trial. The investigators found similar results between the intervention group and the control group. There was no benefit to the surgery. Sadly, rates of vertebroplasty and other invasive spinal surgeries have continued to increase. Surgeons may benefit from these procedures but neither patients nor payors reap any benefit.

“Improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in a control group,” the investigators concluded.

“Spinal fusion rates continued to soar in the United States until 2012, shortly after Blue Cross of North Carolina said it would no longer pay and some other insurers followed suit,” according to The New York Times report.

 

Figure 2. T1 weighted sagittal cervical spine MRI showing degenerative disc disease,
osteophytes, and osteoarthritis of C5-C6.
(Sources: Wikipedia/By Stillwaterising/GNU Free via Wikimedia Commons/
Creative Commons CC BY-SA 3.0.)

Forbes

A review of the findings of the study published in The Spine Journal was also published in Forbes.

The Forbes article concluded that the findings “should put the fear of God in anyone who wants to get a fusion operation for low back pain blamed on worn-out spinal discs.”

The article, “Why You Should Never Get Fusion Surgery For Plain Back Pain,” was authored by Forbes staff writer Robert Langreth. Mr. Langreth wrote the article in The Spine Journal “has several great examples of what can happen when the operation goes wrong. It somehow manages to put much of the best stuff at the end, so I will summarize some it for you. There is one patient in the story who was still in such pain after the operation he ended up dying of a painkiller overdose at age 41. Another125 patient study touted as having positive results for fusion is missing followup data from a full 45 patients. In another study more than 5% of people who got complex fusion operations had life-threatening complications. I’ll add another detail: the theory behind this operation is poor, as there is no surefire way to pinpoint the pain to the degenerated discs being operated on.

“Another amazing fact: Even if the doctor performs the operation properly, you may still end up paralyzed from the waist down:

“In 2004, [Minnesota surgeon Manuel] Pinto was seeing Jean Kingsley, 57, a patient who had had two previous fusion surgeries and was still suffering back pain. Pinto told her, according to a hospital report he wrote, that more ‘surgical treatment could provide her with some relief of her pain’ if her symptoms ‘were extremely severe, unrelenting’ and had ‘failed extensive conservative care,” which “appeared to be the case.”

“Her third operation, a daylong procedure by Pinto in September of that year, fused 13 vertebrae along her entire spine and was a disaster. Kingsley, of Milaca, Minnesota, returned home paralyzed from the waist down, according to hospital records in a lawsuit she brought against Pinto. A jury in Minnesota state court found earlier this year that Pinto was not negligent in the case.”


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