Back PainSurgical procedures

Back Surgery Unnecessary for One in Six Patients Referred

Researchers in New York published a report earlier 2011 year claiming that between one in five and one in six patients scheduled to undergo back surgery may not in fact need an operation at all. Unnecessary back surgery costs patients time and money, as well as putting them at risk of surgical complications from anaesthetics, infection, and haemorrhage. In a wider sense, unnecessary surgery also raises health insurance premiums for everyone, increases healthcare spending and taxes, and reduces productivity as more people remain out of work for longer. This tendency for patients to be referred for back surgery when other treatments may be more appropriate is, perhaps, a sign of the different criteria for surgical selection in individual practices, hospitals, and geographical areas (Epstein and Hood, 2011).

An editorial published 2010 year in the Journal of the American Medical Association, also questioned the motives of surgeons and the way the medical system, as it is currently set up, allows new technology and procedures to be introduced at a rapid rate (Carragee, 2010). Although the rates of some back surgeries have gone down, there has been a dramatic increase in the rate of complex spinal surgery, procedures which increase the risks of patient morbidity over more traditional surgical procedures. As it stands, the burden of proof is on those researchers looking to show that what a surgeon wants to do does not work, rather than the surgeon demonstrating safety and efficacy.

Dr. Fred J. Epstein

The lead author of the new study, Dr. Epstein, a neurosurgeon, looked at the rate of referral by other surgeons for 274 patients seen for cervical and lumbar spinal issues. The neurosurgeon placed any patient referred by another surgeon for a spinal operation in the ‘unnecessary surgery’ group when they had pain alone, with no neurological deficits, and no significant abnormal findings on radiological examination. Forty-five patients fell into this category, and an additional two patients were recommended to undergo lumbar spinal surgery despite having indications that cervical spinal surgery was required. There were more patients referred for unnecessary back surgery who had cervical spinal complaints than those with lumbar spinal complaints (23.1% compared to 14.2%).

Unnecessary Spinal Fusion

Some of the back surgeries scheduled for these patients involved discectomy and fusion, and posterior lumbar interbody fusions (some at three or four levels). These are invasive operations that have the potential to lead to Failed Back Surgery Syndrome (FBSS), causing more severe problems than those bringing the patient to seek medical help in the first place. Spinal fusion can develop into adjacent segment syndrome and escalate any degeneration in the regions of the spine above and below the area fused. Patients without existing need for back surgery may then face another spinal procedure as a result of their unnecessary surgery compromising the health of the spine. The neurosurgeon and co-author of this study cited a rate of 17.2% of patients scheduled for ‘unnecessary surgery’, a figure which may shock some and simply confirm the suspicions of others.

How to Improve Referral for Back Surgery

An Ottawa-based study into waiting times for spinal surgery looked at how decisions were made about referrals for patients with back or neck pain, alongside those with leg pain due to spinal problems. The researchers developed a questionnaire designed to identify patients with leg-dominant or back-dominant pain with the intention of cutting the waiting time for patients to see a pain specialist and be referred for back surgery. Simon (et al, 2009) found that the survey they administered was as sensitive and specific, if not more so, than diagnostic imaging and assessment by a pain specialist for patients with back or leg pain and had the potential to decrease unnecessary referrals for spinal surgery. The simplicity of the questionnaire allows it to be used as an effective triage tactic to prevent patients waiting for weeks or months to see a surgeon only to discover they are not likely to benefit from spinal surgery. It may also reduce the number of unnecessary surgeons by avoiding the raising of expectations in patients that they will need back surgery and resulting in disappointment when this is denied them. Instead, patients would more swiftly be referred for physical therapy and pain management to help them control and relieve their symptoms of back pain, and have less stress and anxiety associated with lengthy waiting times for referrals.

Patients who did need surgery would also have shorter waiting times as there would be fewer being referred for further assessment. Waiting times to see a spinal surgeon in Canada are extremely lengthy and these researchers in Ottawa are hopeful that a triage system such as they suggest could radically cut such waiting times and reduce patient morbidity from unnecessary waits and unnecessary surgery.

happy surgeons holding x-ray report

Spinal Surgeons Choose Back Surgery Less than Family Physicians!

Another group of researchers, working out of California but looking at patients in Ontario, consulted orthopaedic and neurosurgeons, family physicians, and patients themselves to assess the preference of all groups for lumbar spinal surgery. Bederman (et al, 2010) found that most family physicians had a poor understanding of the factors that make a patient a good surgical candidate thus contributing to the wide variance in referral rates across patient groups. There were six clinical factors identified by the researchers as influencing the decision for surgical referral: walking tolerance, pain duration, severity, neurologic symptoms, typical onset, and dominant location of pain. Contrary to what may be presumed regarding spinal surgeons’ enthusiasm for their field of medicine, it was actually the family physicians who were found more likely to prefer surgery, with surgeons the least likely group to choose this option. Patients who were older were more likely to opt for surgery, as were those who had previous surgical consultations.

These researchers suggest that family physicians may improve their method of referrals by taking note of surgeons’ emphasis on the location of pain, as well as acknowledging that for patients it is the quality of life that is of utmost importance. Appreciating the different factors at play in the process of referral for spinal surgery, and having improved faith in the health professionals making such decisions, could help patients accept a treatment plan whether or not it includes back surgery. With nearly one in five patients apparently referred for unnecessary back surgery, there is a clear need to improve referral procedures before overall patient care can be enhanced.

Epstein NE, Hood DC., “Unnecessary” spinal surgery: A prospective 1-year study of one surgeon’s experience. Surg Neurol Int. 2011;2:83. Epub 2011 Jun 21.Simon D, Coyle M, Dagenais S, O’Neil J, Wai EK., Potential triaging of referrals for lumbar spinal surgery consultation: a comparison of referral accuracy from pain specialists, findings from advanced imaging and a 3-item questionnaire. Can J Surg. 2009 Dec;52(6):473-80.Bederman SS, Mahomed NN, Kreder HJ, McIsaac WJ, Coyte PC, Wright JG, In the eye of the beholder: preferences of patients, family physicians, and surgeons for lumbar spinal surgery. Spine (Phila Pa 1976). 2010 Jan 1;35(1):108-15.Carragee, E.J., The Increasing Morbidity of Elective Spinal Stenosis Surgery: Is It Necessary? JAMA. 2010;303(13):1309-1310.

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