L

ike most conscientious physicians, we try our best to practice “evidence-based medicine.” As spine surgeons, that isn’t always easy to do, given the beating operations such as spinal fusion have received in the press.

Let us tell you about Anne Williams, a patient of ours who has given us permission to describe her story. An administrator at a community college in Hickory, N.C., Anne developed severe back and leg pain at age 60. Here’s what she had to say about it:

“The pain got so bad that I ended up sleeping on the floor of my bedroom for eight months. Lying in bed was too painful. When I had to walk, which I tried to avoid at all costs, the pain in my back and legs made me bend over and lean on a walking stick. The grocery store was about the only place I went outside of work, because I could lean over the shopping cart.”

advertisement

An MRI showed stenosis — the arthritic narrowing of Anne’s spinal canal. It also showed that one of the bones (vertebra) in her spine was slipping on top of another. She tried everything: physical therapy, steroid injections into her spinal canal, and pain medications. Nothing worked. Months later, desperate and nearly defeated, she thought about surgery. We recommended removing bone and ligament that were clamping down on her nerves. To do it the right way, screws and rods would have to be used to stop the abnormal movements of her “slipped” vertebrae. In other words, a spinal fusion.

Here’s where the issue of evidence comes to the fore.

The effectiveness of surgical procedures for back pain, especially spinal fusion, has come under fire in the media. A systematic review of spinal fusion, published in 2007, was interpreted by New York Times reporter Gina Kolata as concluding that the procedure is “no better than alternative treatments.” There has been a quiet campaign among medical experts over the past few years to rein in the use of the procedure.

But let’s take a close look at that evidence. The 2007 review included just four trials of spinal fusion. In one trial, fusion was superior to conservative options like exercise or talk therapy. Two of the other trials weren’t large enough to detect a difference in pain between the fusion and non-fusion groups. The fourth was plagued with poor follow-up, making it difficult to interpret the results. That’s not exactly a resounding dismissal of spinal fusion. You wouldn’t know that, though, from Kolata’s recent New York Times story headlined “Why ‘Useless’ Surgery Is Still Popular.”

How spine surgeons think

Different medical problems pose different diagnostic and treatment challenges. If you develop appendicitis with a ruptured appendix, the diagnosis and treatment are as clear as the task facing a firefighter standing in front of a burning house.

Spinal disease is different. It’s more like taking your car to a mechanic for a clanking sound. The mechanic must pop the hood, examine various parts of the engine and exhaust, and run some tests. Sometimes it’s easy to tell what’s causing the noise and a simple tune-up will fix it. Other times there’s more testing involved, and the car may have to stay in the shop for days as the mechanic tries different solutions.

Newsletters

Sign up for our First Opinion newsletter

Please enter a valid email address.

In a similar spirit, spine surgeons see patients with symptoms such as back pain and leg pain. This puts into motion an investigation designed to establish where the pain is coming from and why it is occurring. Only then is it possible to create a rational treatment plan. As a general rule, surgeons don’t see patients with low back pain and immediately think, “Let me do a spinal fusion.” Instead, they map out treatment options that range from less invasive to more invasive over time.

And here is the crux of the matter: Non-surgical treatments simply don’t do the job for patients like Anne Williams.

“My first night at home [after the surgery] I slept in my own bed. You have no idea how wonderful that felt. And the pain in my back and legs went away. It’s been almost a year since the surgery and I stand straight, pain-free. I’ll always be grateful for my surgery and rehab.”

In clinical practice, we don’t put conservative options and spinal fusions into a cage match as soon as a diagnosis is made, as was done in the randomized trials mentioned earlier. Instead, treatments are offered one after the other, ideally starting with the least invasive option, like exercise therapy. The goal is to find the best therapy for the individual. This raises a question for opponents of spinal fusion: Do they expect individuals who have not gotten relief from conservative treatments to continue them ad nauseam because some experts have described spinal fusion as “next to useless,” as the Times did?

The question of whether spinal fusion improves all back pain, at its onset, is somewhat meaningless. Back pain is a broad symptom, not a diagnosis. The real question is whether spinal fusion helps people with specific diagnoses once conservative options fail. The evidence for that is encouraging.

The Spine Patient Outcomes Research Trial (SPORT), published in 2007 (but not included in the systematic review mentioned earlier) demonstrated that surgery, including fusion, was better than “usual care” (active physical therapy, education about exercising at home, and the use of nonsteroidal anti-inflammatory agents) for patients with spinal narrowing and slipped vertebrae. In another randomized trial published this year, fusion surgery improved overall health-related quality of life better than non-fusion surgery among patients with minor slippage of their vertebrae.

Looking at how well surgery works in large groups of patients may actually become outdated. In this new age of precision medicine and personalized health care, what matters most is not whether a group of patients with a particular diagnosis did better, on average, when offered a treatment like spinal fusion. What truly matters is whether a specific patient who hasn’t been helped by conservative treatments, with his or her unique blend of risk factors and goals, would stand to benefit from spinal fusion and be satisfied with the result.

Clinical “big data” registries, which record the details and outcomes of real-world care, can pave the way for patient-centered and personalized care. Two studies based on a large-scale national registry covering 26 US states show remarkable improvements in quality of life for patients undergoing low-back fusions after getting little relief from conservative treatments.

To be sure, an alarming fraction of American health care is unnecessary — upwards of $850 billion spent each year has been deemed “waste.” Spine surgeons clearly need to be mindful of overutilization and focus on delivering high-value therapies. However, sweeping condemnations in the media run the risk of scaring away patients from therapies that have real value when applied to the right person, at the right time, in the right way.

Anne Williams is an example of the value of this approach.

Ahilan Sivaganesan, MD, is a clinical research and spine fellow at Vanderbilt University. Matthew McGirt, MD, is a neurosurgeon in Charlotte, N.C. Andrew Sumich, MD, is a physical medicine and rehabilitation physician in Charlotte, N.C. Clinton Devin, MD, is an orthopedic spine surgeon in Nashville, Tenn. (Sivaganesan reports no conflicts of interest; McGirt is a consultant for Stryker; Sumich is on a study advisory board for Mesoblast; Devin is a consultant for Pacira, a defense expert witness, and has a research grant from the Lumbar Spine Research Society. McGirt, Sumach, and Devin have all received payments from various orthopedic device manufacturers.)

Leave a Comment

Please enter your name.
Please enter a comment.

  • If the pain is bad enough, and it is in an area that a doctor will go, fusion is almost perfect for me. It fixed one of four bulged disc in my neck. But, I have broken my lower back on two occasions. A cast with rehabilitation, got me going the first time. Since, I was the sole provider for six kids and my wife that has unpredictable seizures, I worked with my lower back broke for 3 months. This time, it was a 40% compression fracture, with 6 facet effusions, arthritis,etc. I finally, had to go to the doctor, and was refused surgery. I was given pain meds and than the laws complicated things. The more confused that I became, the more questions I was asked. I finally, just gave up and quit the pain meds, to get a break from the doctors and all of those same questions for the refills. They thought that they owned me and that I would jump through the hoops for the pain meds. I showed them. Now, I have accepted pain,that sometimes is so unbearable. My lower back is worse. Radio Frequency Ablation, helped the facets, but I am now a member of the sciatica club on the right side and a cyst on the left. Plus, there are a lot of long words wrong with me,like spondylosthesis,antriolosthesis,spondylosis,the curve back name,stenosis,hundreds of benign tumors on my lungs,and many more problems. But, life is full of pain. That is still better than a death of no pain. Right ?

  • I had my first fusion in 1992 just before my 22nd birthday. I barely made it through my fourth year at college because I was in so much chronic pain due to Spondillolysthesis (which I still can’t spell) diagnosed during Winter break of my Sophomore at college. I tried everything else including PT, injections, and a custom made brace that made me feel like I was wearing body armor. I was fairly active on the Martial Arts team, though in a non sparring capacity in the year leading up to the surgery with the result being that I was in the best shape of my life when I had the procedure. The doctor fused L-4, L-5, and S1 using what was state of the art hardware at the time that ultimately had to be removed 7 years later but not replaced. I remember feeling like I had gotten my life back, but I also remember the doctor stating that this problem could reoccur which it did over the course of more that 20 years. In 2015, I had fusion at L-2 through L-5 and while I’m not pain free, the difference is just amazing. I can actually get on the floor with my 6 year old without worrying about getting up. I hope someone actually reads this because it’s important to see what a difference this procedure can make in terms of quality of life.

  • I had debilitating pain three years ago from a slipped disk in my neck. One neurosurgeon told me to wait eight weeks and see if it got better on its own; 2/3 to 3/4 of cases resolve themselves. The other surgeon wanted to operate immediately. I waited the eight weeks. I got better on my own. The neurosurgeon told me that his hospital wanted him to do more surgery, because that’s how they get paid. But, he put his patients first and recommended conservative treatment. The other surgeon just wanted to cut. There’s no financial incentive not to. The neurosurgeon told me he could not believe that I did not get surgery, because I was in such horrific pain. But why would I trust my neck to a potential quack who could wind up crippling me? I trusted myself to recover instead. It worked out for me.

  • Why would I be sent this 2007 report in 2016. It would seem it is no longer relive to current literature. I would include that several surgeons had differant opinions as to how many fusions and which method to use. It’s all suspect to me which leaves me with no confidence in any of the spinal surgeons. I just don,t trust their words of outcomes after spine surgery. I guess that’s why they call the profession a practice, I which they would become professional.

  • I’ve been in pair for over 30 years, with spinal stenosis, and “alternative/conservative” treatments haven’t worked. But some orthopedists wanted to operate, while others told me I wasn’t a good candidate for surgery. They had all been looking at the same scans. My conclusion is that this is voodoo, not science. Also this editorial fails to mention the people who were made worse by surgery. This is not a balanced article; it’s an opinion piece by doctors who have an obvious self-interest: their income is at stake. The more surgeries, the more they earn.

  • After trying all the conservative treatments for my radiating low back pain, I was eventually referred to a neurosurgeon who specialized in spinal surgery. I had surgery on L4 L5 in 2007 which yielded some mild but temporary relief. Reading the description of Anne William’s symptoms felt as though she were describing my current pain with the profound decrease in quality of life.

    My question, however, deals with whether or not I should have been considered as a surgical candidate. I have read that active smokers such as I should not be considered for spinal surgery. My surgeon was aware of my smoking history before the operation. I presume this is a possible/probable reason for my poor outcome.

    • I had spinal fusion surgery (L5/S1) 12 years ago to correct spondylolisthesis, which caused pain for years. I’m grateful for the results and find it horrifying that this surgery is considered “useless”.

Sign up for our Morning Rounds newsletter

Your daily dose of news in health and medicine.

X