Fusion surgeries often unnecessary in workers' comp, physician says
As the medical director and CEO of Comprehensive Pain Medicine in Florida, Dr. Sanford M. Silverman has seen his share of patients with failed back surgeries. By the time they get to his facility, these patients have just about lost all hope.
"They can't work; they are stressed, anxious; they become a real mess," Silverman says. "They are dependent on large amounts of opioids."
Many of his patients have had spinal fusion surgeries. In fact, he says the number and costs of those particular procedures has increased in recent years despite recent research showing mixed results.
"We don't know the cost effectiveness," Silverman says. "There haven't been a lot of studies. Medical directors may say it doesn't work at all or has really poor outcomes."
About spinal fusions. According to the Mayo Clinic, a spinal fusion "permanently connects two or more vertebrae in your spine to improve stability, correct a deformity or reduce pain." It was first described a century ago to treat patients with tuberculosis of the spine called Pott's disease.
"It will collapse your spine," Silverman says. "It doesn't happen much today."
As Silverman explains, in patients with Pott's disease, the spine is snapped in half, crushing the bone and hurting the spinal cord. Spinal fusions were developed to stabilize the spine.
"They put hardware in, fix it like a fracture, and take pressure off the spinal cord," he said. "Typically [it is done] with screws and cages."
The procedure can be especially helpful in certain situations such as a burst comprehension fracture where a vertebra breaks and pieces of it may penetrate surrounding tissues and the spinal column.
"A guy falls off a roof and crushes his vertebra," Silverman says. "It usually requires emergency surgery. You've got to take pressure off the spinal cord. That's what a spinal fusion is."
But the procedure is increasingly being used to treat age-related spine problems. Disks, for example, act as shock absorbers and protect the nerve root. As we age, disks can begin to impinge on the nerve root. "Those degenerative changes with alleged instablity are the apparent rationale for a fusion," Silverman says.
The controversy. Research indicates the U.S. has a much higher rate of spinal fusion surgeries compared to other countries. Studies done in the 1990s showed the U.S. had a rate twice that of Canada and Norway and five times the rate in the U.K.
"From 1990 to 2001 there was an increase of 220 percent," Silverman says. "Medicare data from 2002 to 2007 shows the instrumented fusion rate increased fifteenfold from 1.3 to 19.9 per 100,000 beneficiaries."
Instrumented fusions involve metal implants secured to the vertebrae to hold them together while simple fusions use bone to bridge adjacent spinal bones.
Silverman says recent studies raise questions about the wisdom of such procedures.
"What we saw was a return-to-work study done in 2012 on evidence-based spinal care," Silverman says. It compared patients who had simple vs. those who had spinal instrumented fusion surgeries. "The RTW was equal in both groups by six months, but the fusion group took longer to get back to work."
The 2012 study, led by researcher Vincent C. Traynelis, said the disk patients were more likely than the fusion patients to be working six weeks after surgery.
A Cochrane Review -- systematic reviews of primary research in health care and health policy that are internationally recognized as the highest standard in evidence-based health care -- compared conservative medical care with spinal fusion surgeries. "They said there was a higher fusion rate but no pain reduction or improvement in quality of life," Silverman said.
Silverman also points to research by Dr. Richard Deyo, an internist and researcher at Oregon Health and Science University, that suggests more complex forms of surgery are associated with higher risks of life-threatening complications and higher costs. Deyo has said that surgical fees for simple decompressions run about $600 to $1,000, whereas fusions can be up to 10 times more.
"I'd be really concerned about back surgery in general," Silverman says. "Surgery is irreversible."
Spinal cord stimulators, an example of a more simple procedure, have been shown to be superior to fusion, and "they are reversible," he says. "You can't change a fusion. Once you get it, you are done."
By Nancy Grover
Read more at the WorkersComp Forum homepage.
October 21, 2013
Copyright 2013© LRP Publications