Lumbar stenosis surgery: Spine surgeons not insurance companies should decide when enough is better than too much
- Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, and Chief of Neurosurgical Spine and Eduction, NYU Winthrop Hospital, Mineola, New York, USA
Nancy E. Epstein
Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, and Chief of Neurosurgical Spine and Eduction, NYU Winthrop Hospital, Mineola, New York, USA
DOI:10.4103/sni.sni_300_17Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 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: Nancy E. Epstein. Lumbar stenosis surgery: Spine surgeons not insurance companies should decide when enough is better than too much. 10-Oct-2017;8:247
How to cite this URL: Nancy E. Epstein. Lumbar stenosis surgery: Spine surgeons not insurance companies should decide when enough is better than too much. 10-Oct-2017;8:247. Available from: http://surgicalneurologyint.com/surgicalint-articles/lumbar-stenosis-surgery-spine-surgeons-not-insurance-companies-should-decide-when-enough-is-better-than-too-much/
Background:Lumbar surgery for spinal stenosis is the most common spine operation being performed in older patients. Nevertheless, every time we want to schedule surgery, we confront the insurance industry. More often than not they demand patients first undergo epidural steroid injections (ESI); clearly they are not aware of ESI's lack of long-term efficacy. Who put these insurance companies in charge anyway? We did. How? Through performing too many unnecessary or overly extensive spinal operations (e.g., interbody fusions and instrumented fusions) without sufficient clinical and/or radiographic indications.
Methods:Patients with lumbar spinal stenosis with/without degenerative spondylolisthesis (DS) are being offered decompressions alone and/or unnecessarily extensive interbody and/or instrumented fusions. Furthermore, a cursory review of the literature largely demonstrates comparable outcomes for decompressions alone vs. decompressions/in situ fusions vs. interbody/instrumented fusions.
Results:Too many older patients are being subjected to unnecessary lumbar spine surgery, some with additional interbody/non instrumented or instrumented fusions, without adequate clinical/neurodiagnostic indications.
Conclusions:The decision to perform spine surgery for lumbar stenosis/DS, including decompression alone, decompression with non instrumented or instrumented fusion should be in the hands of competent spinal surgeons with their patients’ best outcomes in mind. Presently, insurance companies have stepped into the “void” left by spinal surgeons’ failing to regulate when, what type, and why spinal surgery is being offered to patients with spinal stenosis. Clearly, spine surgeons need to establish guidelines to maximize patient safety and outcomes for lumbar stenosis surgery. We need to remove insurance companies from their present roles as the “spinal police.”
Keywords: Decision makers, decompression, insurance companies, laminectomy, spinal stenosis, surgery, unnecessary fusion
Lumbar surgery for spinal stenosis with/without degenerative spondylolisthesis (DS) is one of the most common spine operations presently performed in older patients. Nevertheless, every time we want to schedule surgery, we confront the insurance industry. More often than not, misinformed about the disease, the insurance companies demoand patients first undergo epidural steroid injections (ESI) despite their lack of long-term efficacy, and significant risks/complications. But who put the insurance companies in charge anyway? We did. How? By performing unnecessary or overly extensive surgery for lumbar stenosis with/without DS. This includes allowing too many lumbar decompressions to include interbody, and/or instrumented fusions without sufficient clinical and/or radiographic indications. Our main question now is how can we right this wrong?
The death of spine surgery
In 2003, Ausman wrote about “the death of spine surgery.”[
Notation of unnecessary spine surgery: The value of second opinions
In 2013, Epstein prospectively evaluated 183 patients who came in for second opinions where first opinion spine surgeons offered spinal surgery.[
Similar outcomes for lumbar stenosis/DS with laminectomy alone vs. laminectomy with in situ or instrumented fusion
Insurance companies should grant permission for lumbar stenosis/DS surgery where adequate clinical/neurodiagnostic criteria are met. We assume our spinal surgical colleagues would not be asking for such permission unless certain “surgical” inclusion criteria were satisfied. Nevertheless, this is not always the case and there is an increasing lack of spinal surgeons “policing themselves.” Furthermore, if the permission requested is for unwarranted surgery, and/or for surgery that is unnecessarily extensive, then the insurance companies may actually be doing patients a favor. Certainly, some of the best literature shows laminectomy vs. laminectomy/fusion for lumbar spinal stenosis/DS have similar outcomes. Furthermore, those not undergoing fusions have reduced operative time, blood loss, length of stay (LOS), a reduced need for postoperative acute rehabilitation, and less cost.
In 2016, Epstein reviewed Weinstein's randomized controlled SPORT trial data from 13 sites involving 2,500 patients with disc disease, DS, and stenosis.[
In 2016, Forsth et al. presented convincing data that patients with lumbar stenosis (with/without DS) demonstrated comparable outcomes with/without attendant fusion.[
Higher Medicare costs for fusions
In 2014, Schoenfeld et al. looked at 185,954 Medicare patients (2005–2007) having spine operations for disc disease, stenosis, and spondylolisthesis.[
Different rates of spinal fusion linked to reimbursement strategies
Two recent studies indicate that the decisions to perform fusions for lumbar stenosis may be determined by multiple “social” rather than “ surgical factors”. In 2016, Jancuska et al. utilized the New York Statewide Planning and Research Cooperative System (SPARCS) database to evaluate 228,882 patients undergoing lumbar spine operations.[
In another study in 2017, Schoenfeld et al. evaluated whether spine surgeons opted for more expensive/extensive/invasive spine surgery/treatment options for treating lumbar discs, stenosis, and DS in those with private vs. public insurance.[
How to take surgical decision-making away from insurance companies: Utilize pain centers
Will we as spinal surgeons ever monitor ourselves? If the likely answer is “no”, how else can we take the surgical decision-making power out of the hands of insurance companies? Some have suggested utilizing pain centers, with their different specialists, including neurologists, physiatrists, and psychologists along with spinal surgeons to offer a “team evaluation”. Thus, we would maximally utilize conservative measures, and limit unnecessary and/or overly extensive surgical alternatives.
As long as spine surgeons offer unnecessary and/or overly extensive operations for lumbar stenosis/DS without insufficient indications, we will continue to be policed by insurance companies. To reverse this, we must better regulate ourselves and work to maximize patient safety and outcomes. The decision to perform laminectomy alone vs. laminectomy/fusion should be solely based upon clinical criteria. Being swayed by other factors is a very “slippery slope”, and unfortunately offers insurance companies the opportunity to intervene.
1. Ausman JI. The death of spine surgery as we know it. Surg Neurol. 2003. 60: 469-
2. Ausman JI. The death of spine surgery, sequel - 2014. Surg Neurol Int. 2014. 5: 169-
3. Epstein NE. Are recommended spine operations either unnecessary or too complex. Evidence from second opinions?. Surg Neurol Int. 2013. 4: S353-8
4. Epstein NE. Commentary on: The role of surgery for treatment of low back pain: Insights from the randomized controlled SPORT trials. Surg Neurol Int. 2016. 7: S648-51
5. Epstein NE. Commentary on: A randomized controlled trial of fusion surgery for lumbar spinal stenosis (Forsth P, Olafsson G, Carlsson T, Frost A, Borgstrom F, Fritzell P, et al. N Eng J Med 2016;374:1414-23). Surg Neurol Int. 2016. 7: S641-3
6. Försth P, Ólafsson G, Carlsson T, Frost A, Borgström F, Fritzell P. A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. N Engl J Med. 2016. 374: 1413-23
7. Jancuska JM, Hutzler L, Protopsaltis TS, Bendo JA, Bosco J. Utilization of Lumbar Spinal Fusion in New York State: Trends and Disparities. Spine (Phila Pa 1976). 2016. 41: 1508-14
8. Schoenfeld AJ, Harris MB, Liu H3, Birkmeyer JD. Variations in Medicare payments for episodes of spine surgery. Spine J. 2014. 14: 2793-8
9. Schoenfeld AJ, Makanji H, Jiang W, Koehlmoos T, Bono CM, Haider AH. Is There Variation in Procedural Utilization for Lumbar Spine Disorders Between a Fee-for-Service and Salaried Healthcare System. Clin Orthop Relat Res. 2017. p.
Emeritus Editor in Chief: Surgical Neurology InternationalJames I. Ausman
I think the editorial is fine. One of the reasons I suggested a team evaluation is that by its design, it regulates excess surgery, and also encompasses all the patients with back pain who would be evaluated. Thus, neurosurgeons, if smart, would capture all the market and yet blunt the criticism of the insurers as their system would ensure a comprehensive evaluation of the patients. So, I still favor that approach although I think it is not highly likely that neurosurgeons would do this. It is done in epilepsy and Parkinsonism. There is no reason why it cannot be done in spine surgery. So, I agree with what Dr Epstein wrote, but self-policing is not going to happen. Only when further restrictions on spine surgery are instituted will neurosurgeons have to change their approach. They must be driven into back pain clinics.