The evidence base for spinal fusion has not collapsed, but the assumptions around it have.
Motion-preserving procedures have matured enough that surgeons now have real alternatives for patients who once would have gone straight to fusion. Artificial disc replacement, cervical laminoplasty and minimally invasive decompression are no longer workarounds; for the right patient, they can be the better call.
Payers have noticed. So have patients. Four surgeons describe how they’re managing that pressure and why the best answer isn’t resisting it, but building a clinical framework that gets to the right procedure before anyone asks.
Ask Orthopedic Surgeons is a series of questions posed to orthopedic surgeons and leaders around the country about clinical, business and policy issues affecting orthopedic care. Becker’s invites all orthopedic surgeons and specialists to respond.
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Please send responses to Cameron Cortigiano at ccortigiano@beckershealthcare.com by 5 p.m. Central time on Nov. 9.
Note: Responses were lightly edited for clarity and length.
Question: How are you navigating the tension between spinal fusion as a default and the growing clinical and payer pressure to use it less?
Milad Alam, MD. Orthopedic Spine Surgeon at DISC Palm Beach (Calif.): There are certain diagnoses where motion preservation may not be an option. However, that is always going to be our first attempt. This could mean avoiding a fusion surgery by a simple decompression or considering artificial disc replacement. Over the past decade, advances in artificial disc replacement in both the cervical and lumbar spine have allowed us to treat many spinal pathologies without fusion surgery. I believe it is vital for all of our spine surgeons to consider minimally invasive decompression or motion-preserving procedures prior to recommending a fusion surgery.
Having said that, there are certain instances where fusion surgery is still the gold standard and the most definitive recommendation. I think it is important to educate our patients about their pathologies and the exact reason why fusion surgery might be indicated. In those cases, performing the fusion surgery with a minimally invasive approach is most ideal for minimizing postoperative complications. Minimally invasive approaches reduce the risk of adjacent segment disease and the potential risk of requiring further surgery down the road.
Jeffrey Carlson, MD. Orthopedic Spine Surgeon and President of Orthopaedic & Spine Center (Newport News, Va.): My practice has had little tension with insurance companies over the use of fusion recently. This may be due to patient selection when proceeding with fusion surgery. The indications for fusion surgery in those patients with instability, fracture, infection or tumor have long been recognized, so we have no trouble getting these surgeries approved. In patients with back pain only as the predominant indication for treatment, we spend more time and resources to determine the appropriateness of the surgery prior to ever getting this in front of the insurance company. The patients will have to fail multiple efforts at conservative care prior to being offered the surgery. There are patients that come to the office requesting surgery that have not been through our algorithm for back pain and can get frustrated with the procedures, but most patients are reluctant to proceed with surgery as a first step. This process has been successful and beneficial for patients and surgeons to have the correct patient for the surgery.
Amit Jain, MD. Spine Surgeon and Vice President of Care Transformation at Johns Hopkins Medicine (Baltimore): I navigate this by aligning strict, multidisciplinary indications with evidence-based risk stratification to ensure better outcomes. Decompressions and motion-preserving strategies (such as laminoplasty over laminectomy and fusion) must be prioritized where appropriate, reserving fusion for deformity, documented instability or revision surgery.
Siamak Yasmeh, MD. Orthopedic Spine Surgeon at DISC Tarzana (Calif.): I think the key is to move away from the mindset that fusion is the default solution for every degenerative spine problem. My philosophy has always been to preserve as much natural spinal motion as possible, and I think that is ultimately better for patients when it can be accomplished without compromising the surgical outcome.
I approach this in a few ways. First, I believe in exhausting appropriate conservative treatment before recommending surgery. Second, when surgery is necessary, I look carefully at whether I can address the underlying pathology without sacrificing motion. For example, I have a particular interest in cervical laminoplasty, which allows us to decompress the spinal cord in patients with multilevel cervical stenosis and myelopathy without performing a fusion. Similarly, artificial disc replacement can be an excellent alternative to fusion in appropriately selected patients. Minimally invasive decompression and microdiscectomy are other ways to address pathology without unnecessarily destabilizing the spine.
That said, fusion is often necessary. There are absolutely patients with instability, deformity or other structural problems where fusion is the right operation. I don’t think we should avoid fusion just to satisfy payer pressure any more than we should perform it out of habit.
Ultimately, I think we need to ask a more fundamental question: Does this patient actually need a fusion to solve their problem? If I can achieve the same clinical objective while preserving motion, I would much rather do that. I think it’s better for long-term mobility, potentially reduces adjacent-segment stress and often avoids the additional morbidity and cost associated with fusion.
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