The death of spine surgery, sequel - 2014.

Abstract

Clark Watts has published an outstanding paper on the shift of the American Association of Neurological Surgeons (AANS) from an educational association to a trade association in 2003.[10] In simple terms, its effects were to change neurosurgery from an organization dedicated to the welfare of the patient to one dedicated to the benefit of the neurosurgeon as a business person and to the society that promotes the interests of the neurosurgeon. In this paper he describes what influence this change may have had on the practice of neurosurgery and the neurosurgeon–patient relationship. He cites data that spine surgery represents 70-100% of what a neurosurgeon does now. He quotes evidence that the fusions being done for spinal stenosis have increased 15× from 2002 to 2007 without an increase in disease complexity. In addition, the costs for the procedures tripled and the complications also increased. He cites that Consumer Reports rates spine surgery as the most over-used treatment in Medicine. He also reports that the reimbursement for a simple decompressive laminectomy has decreased by 33% and for complex procedures with fusions by 20%.[10] Nancy Epstein and others have reported in Surgical Neurology International (SNI) that 50% of spine surgery being done is unnecessary.[5,6,8] In addition, she reported a literature review in 2013 that indicated that the risks of epidural steroid injections for spinal stenosis and back root pain had higher risks than benefits.[4] A recent paper in the New England Journal of Medicine (NEJM) indicated that after 6 weeks, the benefit from epidural steroid injections compared with local anesthetic agents was no different.[7] There were reports of neurosurgeons receiving high compensation as consultants to industry producing spine technology[2] and misuse of products designed by some neurosurgeons or spine surgeons for their own benefit.[9] Watts wonders if these results are related to the change from Neurosurgery from a patient care to a trade organization.[10] I have seen these changes in spine surgery occurring all over the world as the desire for more compensation incentivizes neurosurgeons and spine surgeons to do more complex procedures for greater financial reward. It is not a phenomenon restricted to the USA. In 2003, I wrote an Editorial on “The Death of Spine Surgery”,[1] which was received with denial by spine surgeons and still is today. If I were the Secretary on Health in any government concerned about costs for healthcare and I was informed about the 15× increase in complex surgery, 3× higher costs with no increase in the disease process, my first question to my assistant would be, “Where is the evidence to justify these costs? The answer would be “There is no scientific justification”. In fact there is evidence that too much surgery is being done at too great a cost. The first action I would take, as would any 6th grader, would be to stop payments for the complex procedures until justification was established. With the coming economic problems of the economies worldwide because of the huge expansion in worldwide debt backed by the printing of money that is not backed by gold and thus has no value, governments will be forced to make decisions to restrict expenses. The ultimate effect on neurosurgeons, spine surgeons, pain management specialists, and hospitals will be a drastic reduction in reimbursement for spine surgery. These events will have a huge impact on spine specialists incomes. Epstein has suggested how economies can be made in widely used procedures.[3] What I have advised for years is that Multidisciplinary Spine Centers be developed that would include Psychologists, Occupational therapists, Physical Therapists, Drug Addiction Specialists, Chiropractors, and Neurosurgeons or Spine surgeons who together would diagnose and treat neck and back pain. Thus, regardless of what happens economically in your country, the patient would always be under the control of the “Back and Neck Pain Center”. With the multidisciplinary evaluation of each patient, the proper treatment could be administered and justified. Private practicing internists and general practitioners are flooded with patients from Orthopedists and Neurosurgeons who do not want to see those with continued postoperative pain or drug addiction. There should be plenty of patients for those whose Back and Neck Pain Center did a reasonable job in evaluating patients and restoring those to work. Industry is interested in this kind of assessment but cannot find places where this type of work is done. The alternative is to keep doing what you are doing and deny reality with the eventual crash of your income and specialty. Clark Watts has eloquently stated for National Associations what they must do given this impending crisis. You decide, or someone else will.