In spine and orthopedic surgery, an abnormal MRI is not a surgical indication. But patients arrive convinced it is, and sorting through that disconnect is the most consequential part of the job, according to many surgeons.
The question of when not to operate sits at the intersection of clinical judgment, patient expectations and financial pressure that runs in multiple directions: patients who want relief now, employers who want workers back and payers who view spine surgery primarily as a cost.
The pressure to operate rarely comes from insurers — more often it comes from the patient. Ten orthopedic and spine surgeons describe the frameworks they use to navigate that moment.
Editor’s note: Responses have been edited for clarity and length.
Question: What is your personal rule for when not to operate, and how do you hold that line when a patient, payer or employer pushes you?
Kasra Ahmadinia, MD. Spine Surgeon at Advanced Orthopedics of Oklahoma (Tulsa): My rule is pretty straightforward: If this were my family member, would I want them to have the surgery?
Being able to perform an operation does not necessarily mean that you should. I need to believe that the potential improvement is significant enough to justify the risks we are asking the patient to accept.I often make this tangible by asking patients, “On a scale from zero to 100, with 100 being the best quality of life you can imagine, where are you today?” If they say 80 and are hoping surgery will get them to 100, I tell them we have relatively little to gain and potentially a lot to lose. But if they tell me they are at 20, the equation is very different. There is substantially more room for surgery to make a meaningful difference in their life.
I’ve turned down many surgeries for exactly that reason. If I don’t think I can offer enough benefit to outweigh the risk, I won’t operate. Putting it in these terms also helps patients understand that saying “no” to surgery isn’t doing nothing. Sometimes it is the most important decision a surgeon can make.
Ernest Braxton, Jr., MD. Partner and Neurosurgeon at Vail (Colo.) Summit Orthopaedics & Neurosurgery: Our ASC would realistically take on the newly added procedures that have predictable recovery, low complication risk and a clear same-day or overnight pathway, including many spine and musculoskeletal cases we already perform safely in appropriately selected patients. Where we would decline, or at least hesitate, is implant-driven surgery such as multilevel fusions and complex reconstructions, where the cost of interbody devices, screws, plates and biologics can approach or exceed the entire ASC payment. Adding a code to the covered list does not make it viable if the facility loses money every time the case is scheduled.
For that to shift, CMS needs to assign device-intensive procedure designation to the implant-related procedures it is adding, so the device portion of the payment reflects actual implant cost, ideally on par with how hospital outpatient departments are reimbursed for the same devices. Without that, patients who are excellent candidates for ambulatory surgery will continue to be directed to the hospital.
Eric Cohen, MD. Orthopedic Surgeon at University Orthopedics (East Providence, R.I.): My personal rule is simple. I will not operate if I believe surgery is not indicated and won’t improve the patient’s outcome regardless of pressure from the patient, employer, insurer or referring colleagues. Doing no harm remains paramount. Surgery carries inherent risks and complications even in ideal cases, making unnecessary procedures simply not worth the risk.
David Langer, MD. Chairman, Department of Neurosurgery at Lenox Hill Hospital (New York City): Whenever I meet with a patient considering surgery, I often explain that there are four kinds of surgery:
- Surgery you don’t need.
- Surgery you can have.
- Surgery you should have.
- Surgery you must have.
In general, the decision to proceed with surgery is relatively straightforward when it falls into the categories of should have or must have. In these situations, the patient’s life or quality of life is likely to be significantly affected without surgical intervention. The benefits of surgery are often clear, making the decision to proceed considerably easier.
The more difficult decisions — and the ones most vulnerable to error — arise when patients are offered surgery they can have or, worse, surgery they don’t need. This challenge is particularly common in spine surgery, where patients frequently present with symptoms alongside abnormal radiographic findings. The critical question is whether those findings actually explain the patient’s symptoms. Both the symptoms and the imaging may be abnormal, yet they may be entirely unrelated.
The surgeon’s responsibility is to establish, with as much certainty as possible, a meaningful correlation between the patient’s symptoms, clinical signs and radiographic findings. This is often where surgical decision-making becomes most challenging. Patients frequently arrive convinced that an abnormal MRI is proof that surgery is necessary, even when their symptoms have little or no relationship to the imaging findings. In these circumstances, I often find the decision not to recommend surgery relatively easy. The greater challenge is helping patients understand why an operation is unlikely to benefit them. There are also patients for whom surgery is clearly unnecessary, particularly when the disconnect between their symptoms and imaging findings is even more pronounced.
Importantly, I cannot recall a situation in which an insurer or payer pressured me to operate on a patient. I have occasionally experienced pressure from the legal community to recommend surgery, but such circumstances have been relatively rare.
Ultimately, the decision to operate must be grounded in a clear and clinically meaningful relationship between the patient’s symptoms, physical findings and imaging. Poor outcomes are more likely when these elements are misaligned, particularly when surgery is performed to address an imaging abnormality rather than the true source of a patient’s symptoms.
Perhaps one of the most important responsibilities of a surgeon is recognizing that the ability to perform an operation does not, in itself, justify doing so. Patients and their families deserve just as much thoughtful explanation and education about why surgery should not be performed as they do about why it should. Knowing when not to operate is every bit as important as knowing how to operate.
Emeka Nwodim, MD. Orthopedic Spine Surgeon and Managing Partner of Centers for Advanced Orthopaedics, Bay Area Orthopaedics & Sports Medicine Division (Hanover, Md.): When determining whether surgery is appropriate, several factors must be considered. These include establishing sound surgical indications, confirming that an appropriate procedure exists to address the underlying pathology and determining whether that procedure is likely to provide meaningful benefit to the patient. Equally important are appropriate patient selection, thorough patient education — particularly regarding the risks of surgery — and the establishment of realistic expectations for outcomes. I am often inclined to recommend against surgery when any of these essential elements are lacking or when they are not appropriately aligned.
Regarding pressure from patients, I have found that establishing a strong, trusting physician-patient relationship well before surgery is considered helps minimize pressure in either direction and facilitates a more informed, collaborative decision-making process. With respect to external pressures from payers or employers, I am fortunate that these entities have minimal influence over the treatment decisions I make in partnership with my patients.
Ultimately, my goal is to ensure that the decision to proceed with surgery — or to recommend against it — is guided by sound clinical judgment, the patient’s best interests, and a shared understanding of the potential risks and benefits.
Lali Sekhon, MD, PhD. Spine Surgeon at Reno (Nev.) Orthopedic Center: I don’t offer surgery if the risk outweighs the benefit. Examples are patients with numbness and no deficits or pain. Patients deemed high risk for general medical health for elective surgery. Patients with back or neck pain in the absence of myelopathy or radiculopathy. It’s simpler when I stick to the guidelines.
Vladimir Sinkov, MD. Founder and CEO of Sinkov Spine Center (Las Vegas): First of all, there must be a clear indication to perform a spine surgery with a clear anatomic problem that could be addressed relatively safely with a surgical intervention. The patient needs to display a clear understanding of what the surgery involves, what are the risks and alternatives, and what will be required of them to optimize postoperative healing and recovery. The patient also needs to be healthy enough from a medical and psychologic standpoint in order to heal and rehabilitate after the surgery and ensure the best possible outcome with a reasonable amount of risk.
Insurers and employers almost never “push” for the surgery. They typically see spine surgery only as a significant expense to them and do not want to consider the benefits of the surgery for the patient. The patients, on the other hand, sometimes insist on a surgical intervention as soon as possible because of their bothersome symptoms and poor quality of life, even when there is no clear indication for the surgery or before they tried all reasonable nonsurgical treatments. In such cases I have lengthy discussions with them to explain my treatment plan and why it is in their best interest.
A more common scenario where I have to hold off from performing the surgery despite external pressures is when a patient had a clear indication for surgery and has already tried all reasonable nonsurgical treatment options but is not medically optimized for the best possible post-operative outcome (such as poorly controlled diabetes or continued exposure to nicotine through smoking or other means).
In such cases I often feel pressure from the patient, who desires relief of pain and return to normal function as soon as possible, from the payer, who wants to close the claim as soon as possible, and from the employer, who wants their worker back as soon as possible. In such cases I have to clearly communicate my reasons not to operate to all involved parties and explain why it is in the patient’s best interest.
Michael Swords, DO. Orthopedic Surgeon at Michigan Orthopedic Center (Lansing): My personal rule for when “not to operate” is layered.
1. Does the patient have a clinical problem that the literature and experience demonstrate that the surgery will result in an improved outcome?
2. Does the general health of the patient support the risk and recovery without major complications making the clinical scenario worse? Will they tolerate the procedure and recovery without significant risk of adverse medical complications?
3. Does the patient have the ability as an individual, or with resources, to meet the demands required of the post operative care?
These criteria are essential in decision making regarding surgery. I have never had an employer or payer push me to operate. Patients will sometimes apply pressure and that is where education and communication become vital. At the end of the day, they will seek care elsewhere if there is not alignment in the plan of care.
Mark Wang, MD. Orthopedic Spine Surgeon at Desert Institute for Spine Care (Phoenix): The simplest answer to this question is the most honest one. Surgeons don’t operate on images, we operate on people. It matters if the imaging, the symptoms and the exam all correlate with what the patient feels impairs them the most.
There are times when the situation dictates that surgery is the best option such as when we are confronted with trauma, severe spinal deformity and/or neurological dysfunction, but the truth is that the vast majority of our patients suffer from pain as the predominant factor limiting their quality of life. It’s up to us to build a relationship with our patients and form a bond of trust in our care. With each interaction, we must pledge to ourselves and to our patients that we will do our best to remedy their symptoms within our power. This may or may not include surgical intervention as the treatment of choice.
There is little place for payers or employers to wield influence in the sanctity of this relationship. This is what I believe makes one a good doctor and not just a good surgeon.
Christian Zimmerman, MD. Spinal Neurosurgeon at Saint Alphonsus Health System (Boise, Idaho): Personal rules or determinations for surgical recommendations and complex spinal delivery are predicated upon but not exclusive to presenting substance; symptoms/modality correlates, persistence, degree and magnitude of those infirmities, and the inimically opposed conventions of periodic therapies.
Deficiencies in laterality or radiation, coupled with any obscurity, render further investigation and nonsurgical treatment options. Rarely, (especially in our current insurer condition), are surgical demands expounded by payer or employer, while patient exigencies are managed in their rare, unpropitious fashion.
Compromise or palliative circumstances are usually extenuating and directed with a comprehensive oversight and consensual agreement. The slightest disregard for evidence-based (procedural) progression constitutes a potentially ineffectual result to both patients and the system.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
