On August 3, 2016 the New York Times published an essay called “Why ‘Useless’ Surgery Is Still Popular”. In the essay the author decries the continued use of medical procedures “despite clinical trials that cast doubt on their effectiveness.” One of the procedures discussed in the essay, the spinal fusion, is a procedure that I routinely perform on my patients, almost uniformly with great success. Unfortunately, this essay irresponsibly cites only one review article about spinal fusions and thus unfairly describes the procedure as ineffective and “useless”. On a professional level I am disappointed in this essay because I think it is misleading to the public and may prevent delivery of a potentially very effective therapy. Not only may a patient be scared away from getting a spinal fusion after reading the essay, insurers are starting to take notice and have pounced on the opportunity to not have to pay for their patients to have fusions, deeming them “medically unnecessary”. On a deeper, more personal level, articles like this really burn me up (and I really have to bite my tongue to remain professional there.) I work tirelessly to provide the best possible care for my patients and spinal fusions comprise a large part of my practice. You can imagine how I feel when articles like this in the mass media attempt to discredit what I do to help so many people.
Like any surgical procedure, the key to a desirable outcome is to only perform spinal fusions on patients with the proper indications for the procedure. The “useless” author cites a review article by Mirza et al in 2007 that compiled data from 4 randomized trials of lumbar spinal fusion for discogenic back pain. These trials found that spinal fusions were no better than physical and cognitive therapy for treating chronic low back pain. The issue here, as it usually is whenever a surgery fails, is the poor indication for surgery. First of all, any reputable spine surgeon knows that you should never offer surgery to a patient with only back pain. There must be a corresponding structural cause of the patient’s pain that is amenable to surgery and the patient’s physical exam findings must correlate with these structural problems. A degenerating disc causing so-called discogenic pain is NOT a structural cause of back pain!! We’re not even certain that a degenerating intervertebral disc (IVD) can cause pain. The thought is that by removing the degenerated and thus painful disc and fusing the adjacent vertebral bodies you will relieve the patient’s pain. Unfortunately, so called “black disc surgery” (because the discs get darker as they degenerate) usually doesn’t work. In my opinion this is the softest indication for spinal fusion and in fact most insurers won’t even approve the procedure for this indication. The vast majority of patients who present to my clinic with chronic discogenic back pain are sent right back out for pain management, physical therapy or other forms of conservative management.
Spinal fusions are clearly effective in correcting structural problems of the spine such as spondylolisthesis and degenerative scoliosis. That’s not just my anecdotal belief; multiple clinical studies have proven so. For example, in the landmark randomized, controlled SPORT study published in the New England Journal of Medicine in 2007, Weinstein et al looked at spinal fusion versus nonsurgical treatments (i.e. physical therapy, epidural steroid injections, etc.) for the treatement of spondylolisthesis (a painful condition where one vertebral body slips over the one below it.) The study demonstrated clear superiority of spinal fusion over nonsurgical treatments (see figure 1.) The benefits of spinal fusion have been found to persist out to at least 8 years in subsequent analyses. Patients who underwent nonsurgical treatment also got better, just not as rapidly or to the same extent as patients who underwent spinal fusion. Finally, it’s important to note that the benefits of spinal fusion in the SPORT study were seen for fusion techniques that in my opinion are a bit archaic in the age of advanced minimally-invasive techniques. Of course, the “useless” author didn’t discuss seminal studies such as SPORT in her essay.
Figure 1: A successful minimally-invasive spinal fusion done at L4/5 for spondylolisthesis.
Over the next several posts we’ll discuss the indications for spinal fusion as well as the various techniques used to achieve a spinal fusion. Hopefully you’ll learn what I already know: that spinal fusions, when done for proper indications, can dramatically improve a patient’s function and quality of life.
Thanks for reading!
J. Alex Thomas, M.D.
Weinstein, J. N., Lurie, J. D., Tosteson, T. D., Hanscom, B., Tosteson, A. N. a, Blood, E. a, … Hu, S. S. (2007). Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. The SPORT authors. The New England Journal of Medicine, 356(22), 2257–70.