Spine-related health problems continually represent the single greatest inefficiency in the American health care system. Present therapies are often expensive and limited in efficacy and often create more problems than those being solved, but are also “big business” for the spine medical device industry. Total yearly revenues generated by this industry have been estimated at 2.5 billion dollars in the United States alone [10].
It is commonly known that 80% of the population has had at least one episode of disabling back pain during their lifetime. The national survey commissioned by the North American Spine Society during the late summer of 2004 has opened some eyes by its report that 1 (16%) in 6 American adults had back pain every single day during the month before being queried [4].
In the year 2002, there were more than 1 million spinal procedures performed with more than 600,000 uninstrumented cases and 400,000 instrumented cases [1], [13] in the United States alone. The recent observation that “Spinal medicine is producing patients with failed back surgery syndrome at an alarming rate” [12] has great importance as a reality check and wake-up call, particularly in regard to the instrumented cases.
In 2003, it was estimated that Medicare spent US$750 million on spinal fusions and that “A quarter of a million procedures, in which metal rods are screwed into the spine to weld it in place, were performed this year in the United States, 3 times as many as a decade ago” [2]. If it is pointed out that the great majority of pedicle screw and rod instrumented fusions are performed for the treatment of back pain, rather than progressive neurological deficit, it becomes clear that, by these criteria, 16% of the American population would potentially qualify for this surgery.
It is truly unfortunate that a mind-set advocating rigid instrumented fusion as an indication of treatment “success” (regardless of clinical outcome) has permeated the spine surgery profession. Although this philosophy has had success in the management of scoliosis and deformity, it has been a disaster in regard to the management of multilevel degenerative disk disease.
Respected neurosurgeons and orthopedists are now speaking out about the present spine surgery situation. In the April issue of Surgical Neurology [3], editor and neurosurgeon, James Ausman makes clear that we need to get “our priorities straight” regarding the unhealthy state of spine surgery in the United States today, particularly in regard to pedicle screw and rod fusions for the treatment of low back pain unassociated with neurological impairment. Orthopedics Professor Klaus-Peter Schulitz has questioned his own 30-year experience with pedicle screw fixation in the treatment of degenerative spine disease and has expressed his concern regarding its continued use in treating this common disease entity [11].
The fact that other well-established as well as new and innovative spine stabilization procedures having higher success, less complication, and lower cost than multilevel pedicle screw fixation now exist does not appear to be well publicized. Motion-preserving procedures, rather than performing rigid fixation in every case, are clearly a more rational thought processor [5], [6]. The well-established existence of this information and the associated failure of some surgeons to disclose such to patients suggest the existence of another serious problem—that of lack of informed consent before spinal surgery as well as poor understanding of spine ethics [7].
If there is any good news, it is that the phenomenon of spine surgeons frequently performing extensive and expensive instrumented pedicle screw fusions, simply because they know how to, on patients disabled by advanced degenerative disease appears to have now reached its zenith.
Still and yet, there remains a real need today for a rational reexamination of what we believe in regard to noninvasive, minimally invasive, as well as surgical treatment of the ever-increasing numbers of those with incapacitating spinal problems. Clearly, effective alternatives exist at this time. How then do society and the medical profession make some sense of what has been, until this point, a treatment not directed to the patient's best interest? An important means of achieving this productive change is in creating better informed patients. Another asset is the fledgling American Board of Spine Surgery [14] which has now been in existence for 7 years and needs better support from the orthopedic and neurosurgical communities.
The strongest argument regarding the urgent need for change directly relates to the now well-documented increasing failure rates of instrumented pedicle screw spine surgery in the treatment of degenerative disease. It is difficult to believe that this state of affairs would be tolerated in any other surgical specialty. As a contributing author of an interinstitutional (United States and Canada) clinical survey relating to the causes of the “failed back surgery syndrome” published in 1988 [8], I continue to be astonished that, after nearly a quarter of a century after the publication of this study, the same high failure rate continues.
It has been estimated that the greatest advances in medicine in the 21st century will directly relate to an improved understanding of human genetics and associated genomic disease processes. The importance of identifying genomic spine disease was initiated in 1994 [9] and continues to be validated as an important understanding. Over a decade later, it is simply astonishing how few physicians know much about this important subject. There can be little doubt that the early diagnosis of genomic spine disease accompanied by effective preventive care will serve to dramatically decrease future spine-related disability as well as the associated need for surgical interventions. Increased awareness regarding genomic spine disease is clearly an important health care cost-saving enterprise, but this must also be combined with more direct action to discourage ill-advised spine surgery.
An important step, in the right direction, has related to limiting the term “fusion.” “Fusion” implies rigid fixation. In the current American Medical Association CPT coding text, the word “fusion” has been replaced with the term “arthrodesis” (from the Greek: arthro—joint, desis—to bind). Arthrodesis more appropriately covers the spectrum of binding spinal joints (from the flexible to the rigid) and is thus a more accurate description of differing modern more natural biomechanical technologies. Spine surgery needs to recognize that motion-preserving stabilizations may often be a better surgical answer for patients with multilevel degenerative disease (often on a genomic basis) than that of multilevel (often front and back) pedicle screw and rod rigid instrumented “fusions.”
The terms “reconstructive spine surgery” and “arthroplasty” have been advanced to better identify some of these important options. By appropriately applying the basic paradigm of adequate spinal decompression followed by effective and more physiological spine stabilization techniques, patient outcomes can be significantly improved, and failure rates decreased. There is a great need for this. Ill-advised spine surgery which creates more problems for patients than it solves can no longer be tolerated.
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