• Is the prevalence of lumbar spine surgery ,particularly fusions, increasing and why?

    28 September at 05:03 from atlas

    26 October 2017

    There is ample evidence that the prevalence of lumbar spine surgery(LSS) is increasing every years,particularly in the US and Australia.Spine surgery has increased among patients with non-radicular , non-malignant/septic/neurocompressive/unstable lower back pain (i.e. 'lumbago')-LOW BACK PAIN.Is there a valid explanation for this increases which is real i.e. adjusted per capita and per patient/surgeon ratio?

    Possible explanations  proposed by many authors and senior surgeons include: more spinal surgeons per capita(examined and not the case), appearance /availability of advanced neuro-imaging identifying 'black' discs more frequently? Other possibilities are: increase in the prevalence of reported LBP, improvements in spinal surgical training, better surgical outcomes after surgery for LBP and  perhaps in very rare cases financial incentives.

    Studies have examined the REGIONAL variation in the prevalence of LSS to try and identify an explanation. McIntosh G et al (1998) in Canada looked at the 5 provinces over a 12 month period totalling 12,329 procedures.The incidence was NOT uniform across Canada ,and it was less than in the USA.The authors looked at many variables and concluded that they could NOT explain the increase satisfactorily.More recent studies in Spine looked at Ontario and found that "surgeon enthusiasm' was the dominant potentially modifiable factor influencing surgical rates. Further, they found that the supply of spinal surgeons nor the prevalence of LBP reporting were significantly related to LSS rates(Spine Volume 36, No.6, pages 481-489).

    Herkowitz HN and SidhuKS (Jnl of American Academy of Orthopaedic Surgeons) found that most  patients codidered for lumbar fusions can be successfully non-surgically treated.They also found such sugary to be "controversial".They advised that fusion("arthrodesis") was indicated as an adjunct to decompression for patients with spinal stenosis associated with a spondylolisthesis (or for progressive post-laminectomy slip i.e. iatrogenic).These authors cautioned that arthrodesis (fusion) has a poor success rate when used to treat " back pain associated with multi-level disc degeneration seen on MRI images" and that arthrodesis should be reserved until" after secondary gain issues e.g. workmen's compensation , have been adequately resolved."

    Weinstein JN et al (Spine 2006.31(23):2707-2714)looked at trends and variations in LSS between 1992 and 2003 in 306 hospital referral regions.Lumbar fusion rates rose steadily since 1992 (0.3 per 1,000 in 1992 to 1.1 per 1,000 enrollees in 2003).They noted a very large inter-regional variation for discectomy (8 fold) and for fusions (20 fold).They could not identify a medically scientific basis  for this extreme regional variability in LSS.They considered a lack of scientific support for/against surgery, financial incentives, new technology, differences in training and professional opinion.The authors were very critical of the lack of evidence-based decisions of the" most variable "procedure - lumbar surgical fusion(lumbar arthrodesis).They found that this procedure had "enjoyed the most rapid increase in use over then past 10 years" with particularly weak evidence based support for its use.They concluded that the scientific evaluation of outcomes for spine surgery had NOT kept up with the changes in operative techniques.They also noted that recent reviews of the quality of clinical evidence supporting LSS undertaken by the Cochrane Collaboration "illustrated the serious weaknesses in the clinical science".They sagely cautioned that major surgery is often carried out without an adequate scientific basis for making a reasonably accurate estimate of likely outcomes.

    It is clear that the role of lumbar fusion surgery (arthrodesis) and disc replacement type surgery (arthroplasty has NOT been adequately defined, yet both are escalating somewhat alarmingly in frequency.For procedures that have been cautioned about in the peer-reviewed literature for decades ,the increase in performance is concerning to most senior spinal surgeons.The cost to the health care budget (and insurers) for this type of surgery is intruding into the cancer care, heart disease etc budget.The role (including indications, success rates, risks and long term outcomes) for the more conventional lumbar decompression for neural compression causing painful radiculopathy (stenosis and focal nuclear herniation) HAS been extensively defined and validated.Outcomes amongst this group of patients with experienced and skilled surgeons are excellent.

    I suggest that there is one obvious solution-surgeons MUST talk to their patients and tell them pre-operatively the expected risks and  outcomes. patients should be advised the uncertain role for fusion (except in a case also presenting with severe symptomatic painful or advanced deficit from significant  radiculopathy and spondylolisthesis, developmental or iatrogenic, as per Hekowitz & Sidhu).Similar advice applies for arthroplasty(disc replacements and motion limiting procedures).Without this clear discussion the patient cannot give informed consent(material risk includes failure in these procedures compared with decompression and discectomy).

    With time the role for arthroplasty and arthrodesis may well become better defined. Presently there exists a high rate of so called Failed Back Surgery Syndrome ( FBSS) arising out of arthroplasty and arthrodesis procedures. The occurrence of so called FBSS is much less as a result of the more established , and peer reviewed multi-centre long term evaluated decompression and discectomy for sciatica(painful lumbar radiculopathy) .The current position of uncertainty of success and significant risk, I believe MUST be conveyed to patients BEFORE not AFTER arthroplasty/arthrodesis (as well as in all other spine sugary) , including FAILURE and other RISKS , otherwise informed consent has NOT taken place.(see High Court recent examination of Informed consent in Wallace v Kam 2013).

    There have been a number of recent published studies ( including Dr Ian Harris, Dr L Atkinson etc)  pointing to a defined incidence of poor outcomes in subgroups undergoing spinal surgery for predominant non malignant non septic axial back pain in the absence of significant spondylolisthesis and a number of jurisdictions have abandoned  lumbar 'fusion' procedures for back pain.

    Please always follow your doctor's advice.

    All opinions are those solely of the author.

    Dr Michael Coroneos is a senior Brisbane neurosurgeon who graduated with 1st Class Honours UQ MB BS in 1980. He holds 6 Fellowships in surgery and was  honoured to be elevated to Master CIME status by the American Board of Independent medical Examiners (ABIME) after training and  3 examinations 2012 to 2017 in May 2017.He is a clinical OSCE examiner RACS, Mortality Assessor QASM for RACS, Honorary Adjunct Clinical Assistant Professor and Examiner, Chairman MAC Sunnybank Private Hospital ) Healthscope and has a number of other advisory and administrative positions in the health industry.