As patients cycle through injections, ablations and other conservative treatments, some spine surgeons have said delays in specialist evaluation can come at a cost. Nine spine surgeons discussed where the referral system breaks down and how earlier surgical evaluation could help patients receive the right treatment at the right time.
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Editor’s note: Responses were lightly edited for clarity and length.
Question: Patients often spend years in injections and ablations before they reach a surgeon. What is that delay costing them, and where does the referral system break down?
Bryce Basques, MD. Spine Surgeon and Director, Minimally Invasive and Endoscopic Spine Surgery, Brown University (Providence, R.I.): Nonoperative care is critical and plenty of patients should never end up in front of me. The problem is when a third, fifth or tenth procedure happens without consulting a surgeon. By the time some patients reach me, they have lost years of work, have been on chronic pain medication and sometimes have lost neurologic function they can’t get back even with a surgery. I think referring physicians have been trained to see a surgeon as the last stop rather than a place to get an opinion. I would much rather see people early and send most of them back to conservative care with a clearer plan than meet them five years in.
Marco Burkhard, MD. Attending Spine Surgeon at Hospital for Special Surgery (New York City): Many patients spend years cycling through injections and ablations despite having structural pathology that is unlikely to improve without surgery. While conservative treatment absolutely has an important role, prolonged delays can result in progressive neurologic deficits, muscle deconditioning and diminished quality of life. The goal should not be earlier surgery for everyone, but earlier evaluation by a spine specialist so that the right patients receive the right treatment at the right time.
Peter Derman, MD. Endoscopic & Minimally Invasive Spine Surgeon and Founder of Peter B. Derman, MD (Dallas): Spine surgery sounds terrible. Most patients associate it with long, painful recoveries, the need for narcotic pain medications, unpredictable results and a likelihood of tipping off a domino effect of future issues. It is therefore not surprising that most are willing to try almost anything and delay as long as possible before submitting to such an operation. So they limp along, tolerating pain, diminished quality of life and medical bills for potentially ineffective treatments. Can you blame them? I don’t know many spine surgeons who would jump at the opportunity to undergo a multilevel fusion. But this highlights where the referral system breaks down: Patients and referral sources often view surgery as a last-resort nuclear option, unaware of how the field has evolved.
Today, minimally invasive, motion preserving and especially endoscopic techniques can frequently be employed in a targeted fashion to address the source of pain without the trauma of a larger operation. This flips the calculus, making the choice to endure years of chronic pain a needless sacrifice. It is still important to attempt conservative care before considering elective surgery, but if symptoms persist, relief might just be waiting on the other side of a tiny incision.
Brian Gantwerker, MD. Neurosurgeon and President of The Craniospinal Center of Los Angeles: The nonoperative management of patients should always be part of our programs. Things like weight loss, exercise, physical therapy, pool therapy and, of course, injections and ablations are all part and parcel of that. The question comes up for how long and who calls for the next step. The answer is the surgeon. I argue that the surgeon should be involved from the jump off, be directing the care, remain steady handed and not heavy handed and know when to operate. If your patient is getting better with the other stuff, hold off. But if they have motor weakness or aren’t getting better, it’s time.
Jeremy Smith, MD. Orthopedic Spine Surgeon and Division Chief of Spine Surgery at Hoag Orthopedic Institute (Irvine, Calif.): In my practice, we pursue conservative management: physical therapy, injections and ablation, before surgery, unless the patient risks permanent neurologic or functional disability. Some pathologies do poorly with prolonged non-operative care once a neurologic deficit is present, and time spent cycling through injections before reaching a surgeon can negatively influence the long-term outcome.
The breakdown isn’t one specialty failing the patient, it’s a communication gap. Pain management colleagues sometimes don’t catch the point where a progressive deficit needs surgical evaluation. The reverse happens too: patients who’d do just as well with conservative care get pushed to surgery. Patient preference factors in too, some avoid surgery even when indicated. What’s missing is a shared, data-driven triage framework both sides of the referral chain actually use, rather than each provider defaulting to what they’re most comfortable offering.
Issada Thongtrangan, MD. Endoscopic and Minimally Invasive Spine Surgeon at MicroSpine (Scottsdale, Ariz.): The cost is not simply more procedures. It is lost function, time away from work and family, deconditioning, prolonged pain, and sometimes, increasing reliance on medications while a potentially treatable structural problem progresses.
Injections and ablations can be appropriate for carefully selected patients, but they should not become an endless loop when symptoms, neurologic findings and imaging point to a surgical diagnosis. The referral system often breaks down because there is no clear triage point: patients are sent down a treatment pathway rather than being reassessed after a reasonable response, or lack of response.
We need earlier, diagnosis-driven spine evaluation for patients with persistent radiculopathy, neurogenic claudication, progressive neurologic deficit or function-limiting pain despite appropriate conservative care. Structured spine triage pathways have been shown to shorten MRI and surgical-assessment wait times while improving identification of patients most likely to benefit from surgery.
Kushagra Verma, MD. Spine Surgeon at DISC Marina del Rey (Calif.) and DISC Newport Beach (Calif.): Patients often try to avoid surgery, which is understandable, but it’s important they have an appropriate diagnosis before pursuing nonsurgical treatment. Certain problems are managed well with injections and ablations, specifically mild pathology like facet joint arthritis or mild compression of the nerves. However, when the pathology is more severe, patients spending years on injections and ablations often sacrifice a higher quality of life. It also adds a significant expense to the cost of spine surgery because these treatments ultimately fail.
In our opinion, patients should undergo a proper workup, including an X-ray and an MRI of the area of the spine causing them pain and disability. Typically, this involves an AP lateral flexion-extension X-ray and an MRI. And once a proper diagnosis is made, if the problem is truly surgical, it is probably best to pursue a couple of months of conservative treatment and then reconsider surgical intervention. If the problem is not surgical, treating the patient with injections and ablations may be better.
As clinicians, we often see surgical problems managed for years with injections and ablations, which is likely inappropriate. These patients would do better if they had a minimally invasive, outpatient spine surgery and more permanently correct the problem, which would ultimately reduce their expense and provide a higher quality of life after the procedure.
Jacky Yeung, MD. Neurosurgeon at Yale Medicine (New Haven, Conn.): I don’t think the problem is that injections, ablations or surgery are being overused or underused, it’s that patients can spend too long in a single treatment pathway without reassessing their options. That delay can mean years of persistent pain, functional decline and reduced quality of life.
The solution is greater collaboration and community outreach across specialties. Neurosurgeons should have a better understanding of the expanding role of neuromodulation and interventional pain procedures, while pain specialists, physiatrists and referring providers should be aware of advances in minimally invasive spine surgery, including endoscopic techniques that may offer effective treatment with less tissue disruption and faster recovery. More cross-talk between disciplines helps ensure patients receive the right treatment at the right time, rather than simply the treatment that’s most familiar to the provider they happen to see first.
Christian Zimmerman, MD. Spinal Neurosurgeon at St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Undeniably, a pernicious continuance of potentially correctable symptoms. For chronic lower back pain, especially facet joint pain, radiofrequency ablation can be effective in providing symptomatic relief for months, but applying these procedures and outcomes to all patients is arguably distorted and excessive.
The unfortunate circumstance is the application of conventional treatments and the habitual nature of imposing conservative treatments upon all patients. Granted, there are those who will improve, but a number of neurologically compromised patients will eventually require specialist evaluation and surgical intervention.
Unfortunately, delays result in increased emergency room visits, additional modalities and levels of frustration that seem to define the delivery of healthcare. The breakdown seems to occur at the regulatory level of primary care, with imposed evaluations and steerage based on preconceived notions of care and exaggerated restrictions.
Urgent avenues of evaluation will ensure eventual specialist approval, as long as criteria are satisfactorily met.
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