When surgery isn’t the best immediate option for spine patients, interventions can range from physical therapy to spinal injections and over-the-counter NSAIDS.
Spine surgeons discuss the underutilized interventions they personally rely upon.
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, May 18.
Question: What’s the most underutilized non-surgical intervention you routinely recommend before considering the OR? Why does it remain that way?
Michael Burdi, MD. DISC Newport Beach (Calif.): From my perspective, physical therapy and interventional treatments such as epidural steroid injections are still underutilized before recommending surgery. Unless there is an urgency, trying nonoperative options first gives those who ultimately need surgery more clarity while keeping marginal cases nonoperative if the other modalities help, at least for the short run.
Jeffrey Carlson, MD. Orthopaedic & Spine Center (Newport News, Va.): The most underutilized non-surgical intervention I use is OTC NSAIDS. I see many patients that come for surgical consultation after many months of waiting to see a physician who have not had any NSAIDS. It seems patients are conditioned to consider narcotics or surgical intervention, without starting with the easy advice. Simple home exercises and OTC NSAIDS have successfully treated innumerable patients to a point that they are not considering surgery.
Kamran Khan, MD. Endeavor Health Neurosciences Institute (Naperville, Ill.): I have found acupuncture to be a great nonoperative tool in aiding patients. I tend to use it more postoperatively for persistent isolated neck or back pain. We have an integrative medicine clinic within our organization that has been instrumental in supporting our patients and offering another method to manage symptoms.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Structured, progressive physical therapy and specifically the kind that emphasizes active rehabilitation, movement confidence, and pain neuroscience education. I say this as a spine surgeon: the evidence for exercise-based rehabilitation in axial low back pain, and even in many radiculopathy presentations, is as strong as or stronger than the evidence for the surgical and interventional procedures we perform far more readily. That asymmetry should trouble us.
Why does it remain underutilized? A few honest reasons. First, not all physical therapy is equivalent — high-quality, individualized, progressive rehab is hard to find and harder to ensure. Prescribing PT is easy; ensuring the patient receives good PT is not. Second, the system doesn’t incentivize it. A surgeon who recommends six weeks of PT before a follow-up visit generates no revenue in that interval. The patient may improve and never return. That’s the right outcome for the patient and a structural disincentive for a fee-for-service practice. Third, patients have often already been told their pain is structural, and it’s genuinely difficult to redirect their expectations toward rehabilitation when they’re holding a film that appears to explain everything.
I’ve built my practice around this tension. The most important thing I do for most patients I see is not operate on them. That requires both clinical conviction and a system designed to support non-surgical pathways. We need more of both.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Stringent mandates and their endless reporting have shaped most spinal surgeons’ routine presurgical care, which in the insurance world, equates to or supersedes the presuppositions of surgical care. In many circumstances, participation barriers either expense or capability inherently prevail, exempting some folks from a supplementary furthering of care. Albeit, arrival at a particular place of spinal health, (usually more fit than not), most imposed strengthening components of physical medicine, disqualify one from proposed surgical interventions. Advancing a patient’s stamina through aerobic or meditative exercise, (which has contemporaneously become quite popular and requested by many patients as an adjunct to rehabilitation) parallels with Physical Medicine and turned out to be altogether beneficial.
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