“Evidence of Overuse of Medical Services Around the World” By Brownlee et al., Lancet, 2017: Does This Apply to Transforaminal Lumbar Interbody Fusions (TLIF)?
- Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, New York, and Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop NeuroScience/Neurosurgery, Mineola, New York 11501, United States.
DOI:10.25259/SNI_386_2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Epstein NE. “Evidence of Overuse of Medical Services Around the World” By Brownlee et al., Lancet, 2017: Does This Apply to Transforaminal Lumbar Interbody Fusions (TLIF)?. Surg Neurol Int 02-Aug-2019;10:154
How to cite this URL: Epstein NE. “Evidence of Overuse of Medical Services Around the World” By Brownlee et al., Lancet, 2017: Does This Apply to Transforaminal Lumbar Interbody Fusions (TLIF)?. Surg Neurol Int 02-Aug-2019;10:154. Available from: http://surgicalneurologyint.com/surgicalint-articles/9553/
In 2017, Brownlee et al. published a paper in Lancet entitled: “Evidence for overuse of medical services around the world.” In this article they discussed the overdiagnosis of “disease,” the overuse of medical devices, and resultant unnecessary treatments being performed in medicine/surgery. Here we reviewed Brownlee’s key points, and offer direct parallels to the present overuse of transforaminal lumbar interbody fusion (TLIF) to treat degenerative lumbar disc disease and stenosis with/without degenerative spondylolisthesis.
Over Diagnosis, Overuse, and Overmedicalization of Medical Devices/Services
Brownlee described overdiagnosis as the “…diagnostic labeling of abnormalities or symptoms that are indolent, nonprogressive or regressive, and that if left untreated or treated later will not cause significant distress or shorten the person’s life.”[
Brownlee et al. (2017) defined: “…overuse in the form of aggressive treatment of clinically insignificant findings.”[
Through a personal communication, Dr. Koo Van OverBeeke made the following comments regarding the overuse of spine instrumentation. He stated “We all know this is a money driven overuse. In the Netherlands the use of spinal instrumentation is restricted by rules from the insurance companies. Patients are not allowed to pay more by themselves; we do not have private practices for these surgeries. In other countries, such rules are known. Spinal instrumentation is much more common. Is it really necessary? It is something that we always wanted to know, but we are afraid to ask.” He also stated: “Because of the enormous rise of medical costs in the Netherlands, the ministry of health asked for a survey in order to see what is useful in the daily practice of all doctors working in Dutch hospitals. The preliminary result was that 50% of medical care was not proven to be of any effect compared with no medical treatment. Of course, medical treatment should be tailored to any individual patient , which means that a medical treatment can be useful for one patient and not for the other”.
Overmedicalization, according to Brownlee et al. consisted of: “…disease or abnormality…leading to populations previously considered “normal” or health being labeled as diseased.”[
Application of Browlnee et al. Overuse, Overdiagnosis, and Overmedicalization As It Could Be Applied to TLIF (Transforaminal Lumbar Interbody Fusion)
Certainly, overuse, overdiagnosis, and overmedicalization would apply to many of the transforaminal lumbar interbody fusions (TLIF) vs. decompression alone performed to treat lumbar disc disease, stenosis, with/without degenerative spondylolisthesis (DS). In 2018, Epstein reviewed the outcomes/complications of performing laminectomy alone for patients with 2-3 level (58 patients; stenosis/disc disease) and 4-6 level lumbar disease (79-disc disease/ stenosis/26 DS).[
SPORT Trial Documented Efficacy of Laminectomy (With or Without Fusion) For Lumbar Degenerative Spondylolisthesis (DS)
Abdu et al. in their 2018 randomized controlled Spine Patient Outcomes Research Trial (SPORT) evaluated the 8-year outcomes for patients from 13 centers treated for DS utilizing “decompressive laminectomy (with or without fusion) versus standard nonoperative care.”[
Failure of Industry-Supported Studies to Report Complications of TLIF/MI TLIF
In 2011, the Carraggee et al. article “A Critical Review of Recombinant Human Bone Morphogenetic Protein-2 Trials in Spinal Surgery” reviewed the results of 13 Medtronic- funded studies in which they found skewed results favoring the product rhBMP-2.[
As so aptly described by Brownlee et al. (2017), today’s practice of spine surgery, particularly as it concerns TLIF/ MI TLIF, is overshadowed by the overdiagnosis, overuse, and performance of unnecessary operations.[
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management.
1. Abdu WA, Sacks OA, Tosteson ANA, Zhao W, Tosteson TD, Morgan TS. Long-Term Results of Surgery Compared with Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis in the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2018. 43: 1619-1630
2. Brownlee S, Chaikidou K, Doust J, Elshaug AG, Glasziou P, Heath I. Evidence for overuse of medical services around the world. Lancet. 2017. 390: 156-168
3. Carragee EJ1, Hurwitz EL, Weiner BK. A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned. Spine J. 2011. 11: 471-91
4. Epstein NE. Lower complication and reoperation rates for laminectomy rather than MI TLIF/other fusions for degenerative lumbar disease/spondylolisthesis: A review. Surg Neurol Int. 2018. 9: 55-