In the MedFak Orthopaedic Journal, March 22, 2004 Professor Klaus-Peter Schulitz, Orthopaedic Department, Heinrich-Heine-University, Düsseldorf, Germany pointed out in an editorial that the continued use of pedicle screw fixation for the treatment of degenerative disc disease had to be questioned:
Multi-level complex spinal fusion as a treatment for axial back pain has become the single most controversial subject in the U.S. health care system.
Carragee has pointed out 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 stated 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). Researchers at the Dartmouth Medical School have noted that thousands of Americans have opted for these types of fusions “when the evidence for surgical success is virtually nonexistent.”
The August, 2010 issue of the BackLetter reports on a survey of Orthopedic Surgeons attending the Annual Meeting of the American Orthopedic Association in Boca Raton Florida which indicated that of 100 respondents only one indicated that they would undergo fusion to treat their axial low back pain.
How then do unsuspecting patients get talked into this? The answer has to do with their being told that their pain is “discogenic” in nature and that fusion will give them a 70-80% chance of pain relief
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. If they are non-smokers the great majority of these patients will self-heal with non-surgical conservative therapy.
Illustrated below is one, of many, case examples in point:
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 reviewing 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.
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 and now well-documented conflicts of interest among well compensated spine professional surgeons. 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 hospital Credentialing Committee in the State of Washington:
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 overuse epidemic. The term “overuse” is defined as providing a treatment whose risk of harm to a patient exceeds it’s potential benefit.
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.
Discogenic Pain and Discography
Shown to the left is a needle being placed in a disc prior to the injection of dye or other substances The procedure is referred to as a “discogram.” Although this test is used to evaluate internal disc disruption it has been frequently used as a excuse for recommending fusion as a treatment for low back pain.
Evidence-based medicine has clearly documented that discography can cannot reliably differentiate an asymptomatic degenerated disc and that the procure itself can cause permanent disc damage. The diagnosis of “discogenic pain”, often used to justify spinal fusion, has come under ever increasing scrutiny as not even being a major cause of low back pain when compared to other musculo-ligamentous and facet related issues.
In 2009 the American Pain Society indicated that there was no evidence that discography was even a valid diagnostic test. The overly aggressive marketing of discography as an objective means of justifying spinal fusion has created a significant backlash. In the state of Washington, at the present time, discography is
not a covered service.
While multi-level spine fusions may be reasonable treatment for patients incapacitated by back pain from trauma, spinal instability, deformity or tumors there can not be, in our opinion, any justification for performing multi-level rigid instrumented fusions as primary treatment for axial low back pain due to degenerated discs. Hopefully, in the not-too-distant future, all such back pain patients will be managed by promoting non-smoking, good nutrition, non-opioid medications, physical and manipulative therapies, regular exercise, and minimally invasive restorative spine procedures performed by qualified interventional specialists.