In pre-clinical med school at my institution, spine surgery seems to get a bad rap. Lecturers have pointed to studies comparing outcomes of physical therapy for certain ruptured disks vs surgery and implied that physical therapy works about as well.

I also hear a lot about failed back surgery, crazy patients, and general dissatisfaction with spine work (from patients and practitioners). I guess my question comes down to this: how many of your patients come away happy and healthy after your work? Now that is incredibly vague so let me try a more specific approach.

Lets say a private practice neurosurgeon does 10 spine operations in a week, ranging from fusions, lumbar laminectomy and decompression and maybe some X-stop (tm?) or whatever. How many of those patients on a given week are going to be undeniably functioning better after surgery? How many of those 10 will be dissatisfied, and possibly resentful? How many of those patients are going to write you a thank you note every Christmas?

Vague, possibly un answerable, but I’ll take whatever answers I can get.

Spine works great for some, but not for all by a long shot.  One of the reasons that many are so worried that neurosurgeon pay will go down with Obama-style healthcare reform is that there are not good outcomes data for much of what we do in the spine.  My wife is an outcomes researcher who collaborates with AHRQ.  Several years ago that agency, under a different name, wanted to publish reports with evidence that looked bad for the spine surgeons.  There was some big-time fallout amongst spine guys, but since the spine lobby is so well-financed, the report was ultimately withdrawn and the name of the agency changed in the midst of the bru-haha.  After that, my wife was so dead-set against spine surgeons, it is a wonder she ever let me apply for nsurg.

Now, does spine work?  For certain conditions in certain patients, yes, it does.  Are the large numbers of private patients getting spine procedures always those for whom there is good evidence?  Of course not.  It can be difficult to get those studies done well, so it isn’t simply the case that we are all money-grubbing. So one take-home is that in an evidence-based reimbursement scheme as is being proposed by many, we may not fare as well as at present.

I appreciate your response, but I really hope this doesn’t go the route of many threads that attempt to prognosticate the future reimbursement schema and where neuros fit into it. I really just want to know that If I do a specialty where spine is a huge percentage of the work that spine surgery is really helping people.

The money will always be good enough If I do what I love, but I don’t think I could dedicate 70% of my time to something that well, isn’t good for my patients.

My prior point has less to do with prognostication and much more to do with the fact that this is a very difficult realm since politics, money, and data are closely intertwined.  Right now there is very little incentive to study outcomes since insurance is not value-based and there are plenty of patient willing to go under the knife.  With what data we do currently have, outcomes are not great overall.  I suspect that if politics shifts how we are reimbursed, there will be increased interest in establishing credibility for our procedures, but for now the spine companies would rather leave some ambiguity rather than risk cutting their market share.

Guenarius - 15 April 2009 12:04 PM

My prior point has less to do with prognostication and much more to do with the fact that this is a very difficult realm since politics, money, and data are closely intertwined.  Right now there is very little incentive to study outcomes since insurance is not value-based and there are plenty of patient willing to go under the knife.  With what data we do currently have, outcomes are not great overall.  I suspect that if politics shifts how we are reimbursed, there will be increased interest in establishing credibility for our procedures, but for now the spine companies would rather leave some ambiguity rather than risk cutting their market share.

got it, it seems incredible to me that neurosurgeons can spend 70-90% of their time in the community doing something with very little data to support it. I hope/ am guessing somebody believes in this stuff.

I just read up a bit on spine surgery for sub acute back pain here, if anyone has access to up-to-date: http://www.uptodate.com/online/content/topic.do?topicKey=spinaldi/3032&selectedTitle=1~39&source=search_result

and you seem dead on; mostly ambiguous data not really going either way.

So that’s just how it works, in pp, you play surgical chiropractor? I can’t believe that’s the whole story.

If there is a neuro exam finding that correlates well with imaging abnormality, surgery will likely have a good outcome.  If the complaint is pain with normal imaging, surgery is not a good idea.

Spine surgery for some vague disorder like: “I have back pain” probably wont help much. But for an actual disorder that shows up clearly on imaging and has corresponding neurological deficits, I believe spine surgery is quite effective. Problem is, spine surgery for the former is carried out just as often, if not more, as the latter.

That sounds familiar…

BR41N5 - 15 April 2009 02:43 PM

Spine surgery for some vague disorder like: “I have back pain” probably wont help much. But for an actual disorder that shows up clearly on imaging and has corresponding neurological deficits, I believe spine surgery is quite effective. Problem is, spine surgery for the former is carried out just as often, if not more, as the latter.

got it. Could one build a happy and healthy practice treating only those who, you know, need spine surgery (and obviously intracranial stuff)?. Or are you going to lose your scruples trying to screen good patients while paying your immense overhead.

I guess that’s up to the surgeon.

Primary care doctors and internists love making a big fuss about specialists and all people who give them a hard time in the hospital and make more money than them.  It doesn’t help that there are a small number of spine surgeons in the field who operate on any and everything and give the whole specialty a bad wrap.

Having said that, anyone who sees the patients we see and looks at the pathology on scans we see would absolutely tell you spine surgery is a critical and often life saving intervention.  At the end of the day, internists can’t read our scans, and will never be able to distinguish who has unstable fractures and who doesn’t.  Combine that with the fact that there is no minimally invasive alternative, and it’s easy to see that spine surgery isn’t going anywhere.

Our patient’s are often disabled, and in horrible, life-altering pain.  Responsible surgeons try physical therapy and every other alternative prior to operating.  Even after all alternatives, there are still more patients than surgeons have time to operate on.

Perhaps the clinical trial your professor is referring to is the randomized portion of the “SPORTS Trial.” All that study proved is that if you have high cross-over of your randomized groups then intention to treat analysis biases towards the null hypothesis.  The prospective portion of that study was strongly in favor of surgery over “best medical treatment.”

Go ahead and marinate on that for a while......

NRA4LIFE - 15 April 2009 05:28 PM

Perhaps the clinical trial your professor is referring to is the randomized portion of the “SPORTS Trial.” All that study proved is that if you have high cross-over of your randomized groups then intention to treat analysis biases towards the null hypothesis.

that’s right where the bias should pull you when considering surgery as treatment. High cross over in ITT trials is obviously undesirable but a bias towards null is what makes proof so “burdensome” and well, why they use ITT.

Thank you all for posting. I think that’s a great answer: if the complaint matches the image, you probably have a lesion you can correct surgically. Another quick question:

spine patients get a bad rep, care to comment? I wouldn’t shy from a field just because of difficult patients, but I’d still appreciate your thoughts on what it is like to treat people with back pain.

cojifan - 15 April 2009 04:57 PM

BR41N5 - 15 April 2009 02:43 PM

Spine surgery for some vague disorder like: “I have back pain” probably wont help much. But for an actual disorder that shows up clearly on imaging and has corresponding neurological deficits, I believe spine surgery is quite effective. Problem is, spine surgery for the former is carried out just as often, if not more, as the latter.

got it. Could one build a happy and healthy practice treating only those who, you know, need spine surgery (and obviously intracranial stuff)?. Or are you going to lose your scruples trying to screen good patients while paying your immense overhead.

I guess that’s up to the surgeon.

This is pretty much what general neurosurgery is all about. You really should talk to an attending who has been around for a while, they’d know about it first-hand provided they havent super-specialized in any particular area.

BR41N5 - 15 April 2009 05:45 PM

cojifan - 15 April 2009 04:57 PM

BR41N5 - 15 April 2009 02:43 PM

Spine surgery for some vague disorder like: “I have back pain” probably wont help much. But for an actual disorder that shows up clearly on imaging and has corresponding neurological deficits, I believe spine surgery is quite effective. Problem is, spine surgery for the former is carried out just as often, if not more, as the latter.

got it. Could one build a happy and healthy practice treating only those who, you know, need spine surgery (and obviously intracranial stuff)?. Or are you going to lose your scruples trying to screen good patients while paying your immense overhead.

I guess that’s up to the surgeon.

This is pretty much what general neurosurgery is all about. You really should talk to an attending who has been around for a while, they’d know about it first-hand provided they havent super-specialized in any particular area.

will do, I really need to find an approachable pp neurosurgeon to talk to.

Experts feel free to correct me. Here is some of what I have gathered: There are certainly patients whom most reputable neurosurgeons would consider poor surgical candidates, and some patients that most would agree need surgery quite urgently. In between there are many patients with lots of pain, and even some mild deficits that correlate with imaging findings (eg ruptured disk). A good number of those patients may improve on their own over the next year or so, and in many countries, including Canada, would likely not receive surgery for quite a while, in the hopes that their symptoms would improve. I think the same patient in the US is much more likely to receive surgical treatment relatively early, and if properly selected, will likely obtain prompt and dramatic benefit, though in 3 years, be no different than the patient who had no surgery. Whether surgery was the correct course of action in a patient who may have eventually improved without treatment is a difficult question. If the surgery was paid for by insurance, the patient will probably love you for so effectively taking away their pain. If they had to pay out of pocket, they may have been willing to hold off longer to see if they could improve without treatment, to save their home from foreclosure. Sometimes surgery at one level, eg fusion, can put greater strain on adjacent levels increasing the likelihood of need for additional surgery in the future. Exactly how to decide who will ultimately obtain more benefit than risk from any given procedure is probably currently more of an art than a science. However, even if you are responsible and ethical, when you are the one getting paid for each procedure, the possibility of an additional future procedure may not be as adverse to you as it might if you were the patient, particularly one paying out of pocket. At the end of the day:
1. probably the best predictor of “success” as a spine surgeon (as measured by happy patients, not necessarily by income) is your skill in patient selection.
2. In some cases, the most evidence-based (assuming long-term outcome measures) and most economical course of action, may eventually be to let patients put up with a bit more pain for a bit longer. However, if they don’t have to, why should they?

this has quickly turned into an incredibly informative thread. Thanks all.