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The death of spine surgery as we know it today
The Death of Spine Surgery as We Know It Today
magine these events happening. The Secretary of Health receives a report that the cost of spine surgeries has doubled or tripled in the past 10 years. Furthermore, the Secretary learns that more people are being operated on than in 1990, and the costs per patient have escalated. The Secretary asks if there are good reasons for these increases in governmental costs. He is told that the rising cost of spine surgeries is caused by the use of instrumentation to stabilize the spine. The Secretary then asks if there is a good scientific basis for the use of this equipment? He is told that there are no good scientific studies on treatments for spine disease or even on the use of instrumentation for the treatment of many spine diseases like cervical or lumbar disc. He also learns that the medical supply industry is receiving large revenues from their implants. The companies are finding ways to encourage physicians to utilize their equipment. He is also told that there are many people who are being operated who do not need the surgery. In communities across the country, patients with back pain are going to physicians who do not examine the patient, who look at the imaging studies and the report, and who then perform epidural injections. Some patients even seek acupuncture to relieve pain. I recently saw a patient who had a paraparesis from an epidural injection. Neither the doctor nor the patient was aware of what happened except that the patient could not walk well. Everyone thinks these treatments are benign. How much money is being spent on these types of treatments? What would you do if you were in his position? He immediately orders several large-scale randomized studies of various spine treatments and calls a halt to the surgery, the use of the instrumentation, and other treatments now being used. Surgery being paid for with government (public) funds will have to be justified by calling a quality assurance operator. Other insurers do the same. I have recently attended two national meetings with special sessions on practice economics; both
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© 2004 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
neurosurgeons and administrators were present. There was a tremendous interest in developing spine centers. Why? Of course, to capitalize on the opportunity to make money. Wait a minute! Where will this momentum lead? Read the newspaper headlines of tomorrow: “Doctors Conspire with Industry to Use Unnecessary Treatments.” “Patients Receiving Unnecessary Treatments from Neurosurgeons, Orthopedists, and Pain Doctors.” “Healthcare Costs Escalated by Doctors and Industry.” “Congress Calls for More Controls on Physicians.” If you do not see where this is headed, you are in denial. The patient is coming to see you because of back pain or neck pain. Those are the symptoms. Why? That is the question you should be asking. This question should be asked before any test is done. In older patients, the MR of the spine is abnormal. So what? Does that mean that surgery is indicated? Is the patient complaining of pain because of an organic or psychological problem? If you are interested in a spine center, a better idea is to decide to treat the whole patient. Have all the patients screened first by psychologists. A nurse can be trained to gather the important historical information to save you some time. Then you can see the patients who have real organic pathology or see all of them more efficiently and knowledgeably. In those you operate, you should do some scientific study that contributes information about spine disease and pain. A better idea is to combine your experience with a colleague and do a better study. In this way we can advance our knowledge, help our patients, and use the scarce healthcare funds wisely. Besides, the headlines will read much better, and you will feel like the doctor you were trained to be. James I. Ausman, M.D., Ph.D. Editor 0090-3019/04/$–see front matter doi:10.1016/j.surneu.2004.08.003
magine these events happening. The Secretary of Health receives a report that the cost of spine surgeries has doubled or tripled in the past 10 years. Furthermore, the Secretary learns that more people are being operated on than in 1990, and the costs per patient have escalated. The Secretary asks if there are good reasons for these increases in governmental costs. He is told that the rising cost of spine surgeries is caused by the use of instrumentation to stabilize the spine. The Secretary then asks if there is a good scientific basis for the use of this equipment? He is told that there are no good scientific studies on treatments for spine disease or even on the use of instrumentation for the treatment of many spine diseases like cervical or lumbar disc. He also learns that the medical supply industry is receiving large revenues from their implants. The companies are finding ways to encourage physicians to utilize their equipment. He is also told that there are many people who are being operated who do not need the surgery. In communities across the country, patients with back pain are going to physicians who do not examine the patient, who look at the imaging studies and the report, and who then perform epidural injections. Some patients even seek acupuncture to relieve pain. I recently saw a patient who had a paraparesis from an epidural injection. Neither the doctor nor the patient was aware of what happened except that the patient could not walk well. Everyone thinks these treatments are benign. How much money is being spent on these types of treatments? What would you do if you were in his position? He immediately orders several large-scale randomized studies of various spine treatments and calls a halt to the surgery, the use of the instrumentation, and other treatments now being used. Surgery being paid for with government (public) funds will have to be justified by calling a quality assurance operator. Other insurers do the same. I have recently attended two national meetings with special sessions on practice economics; both
I
© 2004 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
neurosurgeons and administrators were present. There was a tremendous interest in developing spine centers. Why? Of course, to capitalize on the opportunity to make money. Wait a minute! Where will this momentum lead? Read the newspaper headlines of tomorrow: “Doctors Conspire with Industry to Use Unnecessary Treatments.” “Patients Receiving Unnecessary Treatments from Neurosurgeons, Orthopedists, and Pain Doctors.” “Healthcare Costs Escalated by Doctors and Industry.” “Congress Calls for More Controls on Physicians.” If you do not see where this is headed, you are in denial. The patient is coming to see you because of back pain or neck pain. Those are the symptoms. Why? That is the question you should be asking. This question should be asked before any test is done. In older patients, the MR of the spine is abnormal. So what? Does that mean that surgery is indicated? Is the patient complaining of pain because of an organic or psychological problem? If you are interested in a spine center, a better idea is to decide to treat the whole patient. Have all the patients screened first by psychologists. A nurse can be trained to gather the important historical information to save you some time. Then you can see the patients who have real organic pathology or see all of them more efficiently and knowledgeably. In those you operate, you should do some scientific study that contributes information about spine disease and pain. A better idea is to combine your experience with a colleague and do a better study. In this way we can advance our knowledge, help our patients, and use the scarce healthcare funds wisely. Besides, the headlines will read much better, and you will feel like the doctor you were trained to be. James I. Ausman, M.D., Ph.D. Editor 0090-3019/04/$–see front matter doi:10.1016/j.surneu.2004.08.003