Spinal Fusion: More Evidence (And it's Not Good)

Redirecting Our Enthusiasm

COURTESY OF EVIDENCE IN MOTION

The use of spinal fusion surgery for chronic low back pain has increased dramatically in recent years-despite a lack of consistent evidence that it improves patient outcomes.  During the last several weeks more damning evidence has come out for the Lobotomy of Our Time.

It began with the paper by Trang and colleagues in Spine who compared 725 patients who had spinal fusion surgery with 725 patients who chose other methods to treat their low back pain (such as physical therapy, exercise, etc).  The researchers assessed the final treatment outcomes-including return to work, disability, and use of opioid medications (i.e. oxycontin and the like)-at two years' follow-up.

Almost all categories of outcomes were worse for patients undergoing spinal fusion. Just over one-fourth of spinal fusion patients had returned to work, compared to two-thirds of those treated without surgery. Twenty-seven percent of patients in the spinal fusion group had repeat surgery, while 36 percent experienced some type of complication. 
Eleven percent of the spinal fusion patients had permanent disability, compared with two percent of patients treated without surgery. Most spinal fusion patients continued using opioid drugs after their surgery, with many taking higher doses.

Let me rephrase that "If we do this surgery you have a 1 in 4 chance of a repeat surgery, a 1 in 3 chance of a complication, and 3 in 4 chance of never working again." There were also more deaths in the spinal fusion group.

The geographical variability of this procedure has been repeatedly highlighted in the literature.  How can a high cost, high risk procedure with questionable value continue to be used at increasing frequency?

Bederman et al. just published a paper which explored the concept of what is driving this unacceptable variability. The authors used a cross-sectional population-based study which surveyed orthopedic surgeons, neurosurgeons, family physicians and patients in Ontario, Canada in attempt to determine the influence of the enthusiasm of patients, family physicians, and surgeons for surgery on the regional variation in surgical rates for degenerative diseases of the lumbar spine (spinal stenosis and degenerative spondylolisthesis). Although patients and Family Physicians had variable enthusiasm for surgery, surgeon enthusiasm was the dominant factor influencing surgical rates. Prevalence of disease and community resources were not related to surgical rates. Surgeon enthusiasm for surgery rather than that of referring physicians or patients was the dominant determinant of surgical rates.

As a PT, my enthusiasm is not in the power of my manipulation procedures, exercise programs, or counseling techniques, rather my enthusiasm is in the power of our patients to improve upon their current status.   From the beginnings of our profession we were in the empowerment and change business.  As physical therapists we relish not in the skill of our hands but in the power of our patients to overcome adversity.   When it comes to patient education it is time that we speak loudly against elective procedures that have failed to show benefit and place our patients at risk of significant harm and even death.