- University of Texas School of Law, Austin, Texas, USA
DOI:10.4103/2152-7806.83392Copyright: © 2011 Watts C. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Watts C. Response to “Unnecessary spinal surgery”. Surg Neurol Int 30-Jul-2011;2:108
How to cite this URL: Watts C. Response to “Unnecessary spinal surgery”. Surg Neurol Int 30-Jul-2011;2:108. Available from: http://sni.wpengine.com/surgicalint_articles/response-to-unnecessary-spinal-surgery/
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,[
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.[
This standard is based primarily upon one study,[
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.
1. Denniston PL.editors. ODG Treatmentin Workers' Comp. Encinitas, CA: Work Loss Data Institute; 2011. p. 1890-
2. Deyo RA, Mirza SK, Martin BJ, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications and charges associated with surgery forlumbar spinal stenosis in older adults. JAMA. 2010. 303: 1259-65
3. Epstein NE, Hood DC. ‘Unnecessary’ spinal surgery: A prospective 1-year study of one surgeon's experience. SurgNeurolInt. 2011. 2: 83-
4. Fritzell P, Hagg O, Wessberg P, Nordwall A; Swedish Lumbar Spine Study Group. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain; a multicenter randomized control trial from the Swedish Lumbar Spine Study Group. Spine. 2001. 26: 2521-34
5. Mincer J. Rate of spine surgery soars. Wall Street J. 2011. 15: D2-
6. Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine, Part 7: Intractable low-back pain without stenosis or spondylolisthesis. J Neurosurg Spine. 2005. 2: 670-72