On December 30, 2010 journalists Peter Waldman and David Armstrong of the Bloomberg news organization published: “Doctors Getting Rich With Fusion Surgery Debunked by Studies”.  This investigative report documented that the number of spinal fusions in U.S. hospitals rose to 413,000 a year between 2002 and 2008 and that the cost of these procedures was now at least $150 billion a year.  

For some spine surgeons preferential financial support from hospitals and medical device manufactures appears to have allowed this unique group of individuals a continued opportunity of convincing their patients into having ill-advised surgical procedures not in their best interest.  This opportunity of being able to achieve a financial bonanza has been described by some social observers a  “irresistible” temptation.

The city of Minneapolis appears to have achieved the dubious distinction of being the primary site for the most multi-level instrumented spinal fusions in the U.S.  How this came to be has reflected the pioneering work of Orthopedic  Scoliosis/ Deformity surgeons John Moe, Robert Winter, and David Bradford in rebuilding the spines of patients disabled by severe scoliosis, polio, and other malformations.  Their accomplishments, often provided free for their patients, has reflected the highest ideals of medical practice.

Unfortunately, things then began to change (not for the better).  The opportunity of utilizing these surgical skills for the treatment of back pain due to disc degeneration was subsequently seized upon as a unique occupational opportunity by some of their trainees.
 

Observations on the Bloomberg News Article

David W. Florence, M.D.

After reading both the Bloomberg News Report on Spine Fusion Surgery and the subsequent response by the International Society for the Advancement of Spine Surgery (ISASS), I felt that something, from my point of view, was needed.

I would like it to be known that I trained under, and practiced with Joseph Barr, Sr., considered by some to be the first spine surgeon to perform disc surgery in the world, at the Massachusetts General Hospital, until I entered the Armed Forces at the beginning of the Vietnam War.  My entire career has been associated with either direct or indirect involvement in spine care.  At present, I am pleased to be one of the most senior spine specialists in America today.

The Bloomberg News Report reflected considerable investigation.  My understanding of the article is that it ‘debunks’ excessive fusions, especially for the treatment of back pain associated with degenerative disc disease, something well substantiated in the current spine literature.

As both a physician and husband, I have the most profound respect for appropriate spine fusions, as I have a severely impaired wife who is ambulatory, only due to the benefit of multiple spine surgeries resulting her being presently fused from the 6^th thoracic vertebra to the sacrum.  This must represent the epitome of spine fusion success from any perspective.

Alternatively, over the last five plus years, I have reviewed and examined hundreds of spine cases, both pre and post operative, for insurance companies, law offices, and governmental bodies.  The results have been consistently alarming.  Quality indicators for spine surgery have become almost non-existent.  Economics is now the obvious incentive for a few, but yet formidable, spine surgery groups in the United States.  In 1981, I published an article relating to the dismal effect of inappropriate spine surgery on patients with significant psychological issues, or extrinsic factors such as workers’ compensation or personal injury.  Those conclusions continue to well substantiated in the peer reviewed literature, especially during the last year.

So where does the issue surface?  The single most profound problem in spine care today is the inability of the spine specialist to discern physical from psychological illness and treat the patient more appropriately.  In my opinion the many evident red flags are often ignored by surgeons crusading to promote multi-level fusion as a effective means of eliminating pain, even when the psycho-social factors or addiction are obvious and “failed” back surgery is the result.  The current literature expresses great concern regarding the performing of spine surgery on depressed patients who have also been on opioid medications on a long term basis, and yet this is a red flag which is often also ignored.  Without question, spine surgery on psychologically impaired individuals is uniformly unsuccessful over the long term (the scale that really counts).  Workers’ compensation and personal injury cases are bedfellows.

Good mechanisms to discern the level of psychological involvement and impairment exist and they need to be better employed.  Pain and /or distress in neurologically intact patients do not represent acceptable indications for spinal surgery.  The patient who ‘demands’ surgery represents a major contradiction to such an endeavor in and of itself.

Contrary to the content of the ISASS response, there are many magic wands available in medical practice to sort out all the complex factors, but the spine specialist needs to learn how to pick up these wands, and more profoundly how to wave them in the right direction (not a self-interest economic direction).

My own observations over the last five plus years suggest that neither providers nor manufacturers will change or even alter their direction until external forces convince them to do so.  Past abuse has been such that it is clear that we will experience, in the not very distant future, an all pervasive backlash dramatically limiting physician treatment choice as dramatic as surgical amputation or the well appreciated consequence of the guillotine.

Unfortunately, American medicine has typically been reactive and not proactive.  In its present form, the spine surgery industry will continue to attempt to escalate its marketing of fusion surgery until it self-implodes because spine surgery in its present form defies reason, logic, as well as the actual needs of the patient.  I defy you to prove me wrong on this.

Dr. Florence can be reached at: dflorence@sentinel-med.org