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Is Multi-Level Spine Fusion
An Acceptable Primary Treatment
For Low Back Pain? |
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Professor Klaus-Peter Schulitz, Orthopaedic
Department, Heinrich-Heine-University, Düsseldorf, Germany in an editorial
published in the MedFak Orthopaedic Journal, March 22, 2004 pointed out that
the continued use of
pedicle screw fixation in the treatment of degenerative disc
disease had to be questioned: |
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Spinal fusion as a treatment for back
pain, as opposed to progressive neurologic deficit,
is clearly an important and highly controversial subject.
Carragee has indicated that, at best, only 50% of such patients
have a high quality outcome (The Role of Surgery
in Low Back Pain, Current Orthopaedics, 2007). Deyo has pointed out
that the small advantage of instrumentation in promoting solid
bony fusion is of little advantage in promoting pain relief or
functional recovery but also is associated with a higher
complication rate (Back Surgery-Who Needs It?, N
Engl J Med, 2007). |
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The graph to the left presents
data from the U.S. Congressional Budget Office.
The number one cost is that due to psychiatric,
psychologic, and drug-related disorders. The
second highest cost relates to back disorders and
back pain. Although the prevalence of back
pain has not changed the number of spinal fusions
surgeries has skyrocketed. The 2007 Back
Letter indicated that complex spinal fusions (i.e.
instrumented circumferential fusions) have risen
from 1.93 per 1,000 back/ spine cases to 49 per
1,000 in 2004. |
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This represents a 2,439% increase in
market utilization. In 1998 the total expenditure for
treating back pain in the U.S. was estimated to be about $26.3
(three times the cost of treating all cancer). The
estimate for 2005 was $86, a 327% increase. Almost
certainly much of this increase is due to ill advised spinal
fusion surgeries for the treatment of low back pain.
80% of the American population experience at least one episode
of disabling back pain during their lifetime and nearly 25% of
Americans suffer from chronic back pain. Many of these
people are being told by spine surgeons that multilevel
instrumented fusion is the answer.
Carragee has indicated that, at best, only 50% of such patients
have a high quality outcome (The Role of Surgery
in Low Back Pain, Current Orthopaedics, 2007) and State
of Washington statistics show that 22% of patients who had
fusions for the treatment of low back pain required further
surgery. Deyo has pointed out
that the small advantage of instrumentation in promoting solid
bony fusion is typically of little value in promoting pain relief or
functional recovery. Multilevel instrumented fusion for
low back pain also begets significantly higher
complication rates (Back Surgery-Who Needs It?, N
Engl J Med, 2007).
These observations are frightening. Unfortunately,
for patients these important disclosures do not appear to have
yet reached grass root levels in America. Illustrated below is one, of
many, case examples in point: |
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This 64 year old retired widow
was seen by a spine surgeon for the treatment of low
back pain of three years duration. At the time
of her first examination, on the basis of her MRI
study he recommended, and then performed, a 4 level 360
degree instrumented
pedicle rod and screw fusion. Relief of back
pain lasted only 9 months and when seen 2 years
following surgery this patient was significantly
more disabled by back pain and had developed
additional problems related to transmitted stress . |
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In the case above the patient was not presented with any
other surgical
options. When asked why she accepted the
recommendation for such extensive surgery she replied: "I'm a
widow, and I'm alone, I just didn't have anyone to ask about
it."
What would motivate a surgeon to make such a recommendation not in the patient's benefit? Clearly there are
strong financial incentives for spine surgeons as indicated by
the exuberant growth of specialty spine clinics in association
with hospitals. There is also evidence
that some "Fellowship Training" Programs promote this
practice. This is well illustrated by the following letter
of inquiry received from a practicing neurosurgeon in the State
of Washington: |
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There exists today a plethora of cases similar to the one
presented above. Some believe that this problem has now
reached the proportions of a true
public health care
concern. Most certainly the great numbers of
such patients now being seen in spine care practice have created
a new category of "failed back surgery" cases which may now
eclipse lateral spinal stenosis
as the most common cause of spine surgery failure. These
cases have also allowed Chronic Pain Rehabilitation Programs to
become big business because of the increasing need for such.
While 1 or 2 level spine stabilizations (many options now exist)
may be reasonable treatment for patients incapacitated by back
pain who have completed the gamut of other non-surgical
therapies in today's world there can not be, in our opinion, any
justification for performing multi-level rigid instrumented
fusions as primary treatment for low back pain. Hopefully,
in the not-too-distant future, all such back pain patients will
be managed by truly minimally invasive restorative spine
procedures performed by interventional radiologists and not
surgeons.
Burton Report is a strong advocate of allowing the patient to be
in the "drivers seat." Burton Report is also a strong
advocate of patients being well informed prior to making
important medical care decisions. |
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