With more years in practice, spine surgeons say their threshold for recommending surgery has evolved toward discernment.
Variables such as advances in outpatient techniques and anesthesia have shortened recoveries and expanded surgical options are also changing how these decisions are made. Five spine surgeons discuss their approaches.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker’s invites all spine surgeon and specialist responses.
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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CDT Tuesday, Feb. 10.
Editor’s note: Responses were lightly edited for clarity.
Question: How has your threshold for recommending surgery changed over the last five years?
Jeffrey Carlson, MD. Coastal Virginia Surgery Center (Newport News): Certainly, with more experience in patient care, making a confident diagnosis and treatment plan, my surgical recommendations have expanded. New graduate spine surgeons may not have the boldness to recommend surgery early in the treatment course but with experience comes confidence in your surgical outcomes. Although, nothing provides more humility than long-term follow-up. As surgical and anesthetic techniques have improved, the patient’s surgical experience and recovery have significantly shortened over the decades. Outpatient surgery and optimized recovery times have made surgery a more viable choice for patients and families. Now, patients have more resources to explore and find the best treatment options, which for many, surgery becomes the quickest road to normalcy. As physicians we thrive on relieving pain. When insurers insist on putting patients through impractical treatments, it can be very difficult for the patient and the mature surgeon. The senior surgeon has read the ending to that story.
Noam Stadlan, MD. Endeavor Health Neurosciences Institute (Skokie and Highland Park, Ill.): The recommendation for surgery usually should be highly individualized. There are some situations such as severe cord compression with severe myelopathy where the recommendation is obvious except if the patient is too medically ill for the procedure. Most spine procedures are for pain or limited neurological deficit. In that situation, one must assess the likelihood of success versus the risks. The likelihood of success depends on how well the symptoms fit with the imaging pathology, as well as an assessment of the patient’s capacity for improvement. The capacity for improvement depends both on the absence of preexisting permanent nerve injury, as well as the patient’s capacity to appreciate the improvement and for that improvement to eliminate a significant portion of their pain burden. The risks include obvious medical risks and pain from the surgery. Better techniques and technology can improve the assessed likelihood of success, as well as lessen the risks of failure to improve or appreciate improvement; so, in that sense my threshold for recommending surgery has changed. But I would hope that the threshold for all spine surgeons would be where the likelihood of benefit to the patient outweighs the risks.
Yu Po Lee, MD. UCI Health (Orange, Calif.): My threshold for recommending surgery has not changed dramatically over the past five years. My indications for surgical have been to perform a decompression when there is spinal stenosis. Fusion when there is instability due to trauma, scoliosis, tumor, or iatrogenic when a wide decompression is needed or if there is a spondylolisthesis. The literature has shown that adhering to these principles generally results in favorable outcomes.
The biggest changes have been in options for patient optimization. Innovations in osteoporosis treatment have led me to wait on patients with osteoporosis and refer them to endocrinology and for treatment prior to surgery. I have also begun to refer patients who are obese to endocrinology for treatment with GLP-1 medications prior to surgery. Challenges that I am facing are operating on patients who are on anticoagulation therapy because there is very little in terms of a consensus on what is the best anticoagulation strategy for these patients. I have a higher threshold in operating on these patients. The age of my surgical patients also seems to be rising because patients are living longer and patients are staying healthy and active longer. These does create challenges, and it does require increased coordination with primary care physicians and requires a multidisciplinary approach when scheduling surgery. But this will probably be a growing trend as we are dealing with an aging population.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: My threshold has become more conservative because experience has taught me that surgical restraint often serves patients better than intervention. Five years ago, I might have offered surgery to patients with chronic axial back pain if they’d “failed conservative care,” believing I could help. Now I recognize that three months of basic PT doesn’t constitute failure and that surgery might not address underlying factors contributing to their pain. This evolution doesn’t reflect doubt in surgical skill; it reflects deeper understanding of what surgery can and can’t accomplish. I’ve learned to have more honest conversations about surgical equipment and to invest more time helping patients access truly comprehensive conservative care. This shift comes from more than 12 years of following outcomes and recognizing that my job is to both operate skillfully and to help patients make good decisions about whether surgery is right for them. Being a good surgeon sometimes means saying no, and that’s gotten easier as I’ve matured in practice.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): From my perspective and other practicing spinal surgeons in our local area, the process of recommending surgery is unchanged, predominantly predicated on a patient’s worsening signs and symptoms. Yet the approval process, with its labyrinth of exigencies, has definitely slowed through scrutiny and imposed conservative therapy arbitration. Granted, the Pandemic was neither a friend towards provider nor patient; the elective surgical impediments are embedded of late and still plague many markets nationally. What has clearly changed over a five year period is more discernment by patients either through cherry picking the internet and unwillingness to care for the disadvantaged and higher acuity population.
