Back pain is an extremely common issue, with up to 84% of adults experiencing it at some point in their lives. For some, the pain becomes chronic and debilitating, severely impacting their quality of life. When conservative treatments like physical therapy, medication, injections, and lifestyle modifications fail to provide adequate relief, back surgery may be recommended. However, there is concern among medical experts and patients alike that many back operations are unnecessary and ineffective. In this article, we will explore the following questions:
- How common is back surgery?
- What are the different types of back surgery?
- What percentage of back surgeries are considered unnecessary?
- What factors contribute to unnecessary back surgeries?
- What are the risks and costs associated with unnecessary back surgery?
- How can patients protect themselves and improve back surgery outcomes?
How common is back surgery?
Back surgery rates have increased dramatically over the past 20-30 years. According to the Healthcare Cost and Utilization Project (HCUP), spinal fusion surgeries increased 3.4 fold from 1998 to 2008. Here are some key statistics on the frequency of back surgeries in the U.S.:
- Over 1 million spinal surgeries are performed each year.
- Back surgery is one of the most common surgical procedures, with over 600,000 lumbar discectomies and 500,000 spinal fusions annually.
- Back surgery accounts for $12 to $15 billion in healthcare expenditures per year.
- The rate of complex fusion procedures increased 15-fold from 2002 to 2007.
The growth in back surgeries has been attributed to several factors, including:
- An aging population with higher rates of degenerative spine conditions.
- Advances in medical imaging and surgical techniques making more back conditions appear operable.
- Financial incentives for surgeons and hospitals.
- Broader insurance coverage for certain procedures.
- Increased patient demand.
The high volume of back surgeries being performed makes the appropriateness of these procedures an important public health concern.
What are the different types of back surgery?
There are various back surgery procedures that aim to alleviate pain and improve function. The main types of back surgery include:
Decompression Surgery
Decompression surgery removes structures causing nerve compression. Common decompression procedures are:
- Laminectomy: Removal of the lamina to access the spinal canal.
- Foraminotomy: Widening of the neural foramen opening where nerves exit the spine.
- Discectomy: Removal of a herniated disc pressing on nerves.
Spinal Fusion
Spinal fusion joins two or more vertebrae together using bone grafts and implants. Goals include stabilizing the spine and preventing further degeneration. Types of spinal fusion include:
- Posterior lumbar interbody fusion (PLIF)
- Transforaminal lumbar interbody fusion (TLIF)
- Anterior lumbar interbody fusion (ALIF)
- Lateral lumbar interbody fusion (LLIF)
- Cervical fusion
Disc Replacement
Artificial discs can be implanted to replace degenerated intervertebral discs. The devices aim to maintain motion and reduce adjacent segment disease.
Other Procedures
Additional back surgeries include scoliosis correction, laminoplasty, corpectomy, kyphoplasty for spinal fractures, and spinal stenosis surgery. The type of operation depends on the specific spinal pathology being treated.
What percentage of back surgeries are considered unnecessary?
Estimates on the percentage of unnecessary spine operations vary widely in the medical literature:
- A Dartmouth study found that 1 in 3 spinal fusions for lumbar stenosis and 42% for degenerative disc disease were inappropriate.
- A separate Dartmouth analysis deemed 60% of spinal fusions for chronic back pain to be unnecessary.
- A Spine Journal review reported an average of 24% of lumbar fusion procedures (range of 11-61%) were inappropriate or had questionable indication based on 9 studies.
- A Washington state study deemed one-fifth of spinal fusion surgeries unnecessary using the Rand Appropriateness Method criteria.
- Analysis of the National Inpatient Sample database estimated unnecessary hospital admissions for spinal fusion at 2.9-4.3%.
Based on these studies, a reasonable estimate is that between 15-40% of back operations, particularly fusions for degenerative conditions, may be considered unnecessary or inappropriate. This amounts to at least 150,000 to 600,000 potentially avoidable spine procedures each year.
What factors contribute to unnecessary back surgeries?
Medical experts point to several factors that likely contribute to overly aggressive back surgery rates:
Overreliance on Imaging
X-rays, CT scans, and MRIs often reveal abnormalities in spine anatomy that are not actually the cause of symptoms. Seeing purported problems on imaging leads to unnecessary interventions.
Desire for Quick Fixes
Patients and doctors often want rapid solutions for chronic back pain. Complex surgeries are seen as a quicker option compared to conservative care, despite limited benefits.
Financial Incentives
There are strong financial motivations for ordering excessive imaging and performing back surgeries, which are among the most lucrative procedures.
Industry Marketing
Aggressive marketing campaigns by device manufacturers promote implants and surgical approaches to physicians and patients.
Questionable Indications
Surgeries are often performed for ambiguous diagnoses like degenerative disc disease despite a lack of evidence for long-term benefits compared to non-operative care.
Repeat Operations
Prior spine surgery is a risk factor for undergoing another procedure, often with diminishing returns.
Variations in Care
Up to a 5-fold difference exists in back surgery rates between different regions, suggesting a lack of consensus on appropriate surgical criteria.
What are the risks and costs of unnecessary back surgery?
Subjecting patients to procedures of questionable merit exposes them to numerous risks and burdens:
Surgical Complications
Back surgery can result in nerve damage, paralysis, bleeding, infection, blood clots, heart attack, stroke, and even death in rare cases.
Lack of Improvement
Many patients fail to obtain pain relief from spine surgery. Unnecessary procedures mean subjects incur surgical risks without actual benefits.
Higher Rates of Disability
Those undergoing unnecessary spine operations are more likely to have prolonged disability and take chronic narcotic pain medications.
Costs and Lost Wages
Unneeded back surgeries waste billions in direct medical costs and indirect costs from lost work. Patients also suffer out-of-pocket expenses.
Failed Back Surgery Syndrome
When spine surgery provides no improvement or worsens pain, patients may be left with chronic pain and reduced function, known as failed back surgery syndrome.
Reduced Quality of Life
The combination of persistent pain, disability, and emotional distress can substantially lower patients’ overall well-being after ineffective operations.
Avoiding unnecessary procedures would clearly result in significant benefits for both patients and society.
How can patients protect themselves and improve back surgery outcomes?
Patients facing potential back surgery should take the following steps:
Get a Second Opinion
Consulting with another specialist helps patients make a fully informed decision about risks vs. benefits of an elective operation.
Try All Conservative Treatments First
Exhaust nonsurgical options before considering surgery, including physical therapy, chiropractic, massage, acupuncture, yoga, injections, NSAIDs, etc.
Ask About Less Invasive Options
Inquire whether minimally invasive spine surgery techniques may be appropriate to reduce risks.
Stop Smoking
Smoking severely impairs back surgery outcomes, so quitting 4-8 weeks beforehand provides major benefits.
Reach or Maintain a Healthy Weight
Excess weight increases back problems. Losing weight prior to surgery can help reduce pain and improve results.
Find a High-Quality Surgeon
Research outcomes data for surgeons and surgical centers to find the best back specialists.
Realistically Manage Expectations
Discuss expected benefits but also risks and limitations of surgery so there are no surprises.
Participate in Post-Op Rehab
Closely follow recommended rehabilitation protocols after surgery to achieve the best possible recovery.
Conclusion
Back pain often leads patients down a path towards risky and expensive spine surgery of questionable merit. While appropriate surgical candidates do exist, a disturbing 15% to 40% of back operations are estimated to be unnecessary. By exhausting conservative treatment options, finding top spine specialists, managing expectations, and taking other precautions, patients can avoid becoming a regrettable back surgery statistic. All parties – patients, doctors, and insurers – should be mindful about ensuring spine procedures are truly likely to help, not hurt, those suffering from chronic back problems.