Spine surgeons have to balance surgical care and conservative treatment in their work, and some conditions have tended to be over-operated.
Two surgeons discuss the barriers that make some overtreated cases challenging to push back on.
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.
Next question: What technology investment has delivered the highest return in terms of outcomes, efficiency, costs or surgeon satisfaction?
Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CDT Tuesday, Jan. 13.
Editor’s note: Responses were lightly edited for clarity.
Question: What spine condition do you believe is most commonly overtreated today? Why is it so hard to reverse that trend?
Jeffrey Carlson MD. Orthopedic and Spine Center of Newport News (Va.): As spine surgeons, we are focused on the improvement of our patients lives and so we are constantly evaluating new technologies. Currently, I am seeing the over-treatment for SI joint dysfunction. Patients’ complaints of pain drive us to provide treatment. SI joint pain has been poorly described by patients and physicians, which has led to a multitude of treatment options. We know that the number of treatment options available increases when no particular option is successful and corporations see profitability. As surgeons, we see these patients after having been through a myriad of diagnostic tests, procedures, medications and continuing to struggle in life. That leads to the surgeons best treatment option, surgery. Even if a single community spine surgeon declines to do an SI surgery, there will be another surgeon or pain specialist that will perform an invasive procedure. Those surgeons/proceduralists are doing what they think is best for the patient, hoping for the best outcome from a treatment that the patient has not tried yet. My hope is that there is an honest appraisal of SI dysfunction and it’s treatment.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Degenerative disc disease in the absence of neurologic compromise or mechanical instability is profoundly overtreated — not because surgeons don’t care, but because the system makes it incredibly difficult to do the right thing. Surgeons are trained to fix problems, and when patients arrive desperate for relief after seeing black discs on MRI, our instinct is to help. The challenge is that we operate within systems where comprehensive conservative care is underfunded and fragmented, while surgical pathways are streamlined and reimbursed.
Peer-to-peer review was designed to ensure appropriateness but often becomes a checkbox exercise rather than meaningful clinical dialogue. Most surgeons I know genuinely want to operate only on patients who will benefit, but we need better evidence, stronger conservative care infrastructure, and reimbursement models that support physicians who take time to explain why surgery isn’t the answer. This isn’t about bad actors — it’s about a healthcare system that needs to better support clinicians trying to do right by their patients.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): As pointed out a roughly a year ago, there is an excessive number of spinal surgeries being recommended and completed, raising the inferences of patient safety and cost. Since 1993, an steeply ascendent graph closely approaching 10 times the usage of lumbar fusions have occurred, especially in the aging population, once again implicating physicians with either ‘bricks and mortar’ influences or investiture in biomedical appliances. The over use of spanning, multilevel fusions for training or implicit reasons, remains unnecessary and a reckless danger to patient and community when fashioned for the most subtle of indications. Trends are and will continue to change, as appeals processes rightly scrutinize these debentured requisitions.
