There are marked disparities in the frequency of spinal surgery performed within the United States over time, as well as across different geographic areas.[1
] One study cited a 20% increase in the US hospitalization rate for low back surgery between 1978 and 1985.[2
] Another study, based on the annual national survey of hospitalization from 1979-1985, documented that cervical spine operations increased by 45%, cervical fusions by 70%, lumbar surgery by 33%, and lumbar fusions by 60%.[1
] Utilizing the Utah Medicare database (1984-1990), a 20% greater incidence of laminectomy and disc removal was documented in the state of Utah compared with the national average, with a 50% disparity in surgical rates observed for different geographical areas within Utah itself.[3
] Similarly, variations were observed in the number of patients undergoing surgery for lower back pain in different geographical areas in Iowa.[2
One possible source of these disparities is the criteria for spine surgery. For example, while some surgeons will operate on a patient with pain alone, [i.e. without neurological or radiographic abnormalities], other surgeons consider such surgery “unnecessary”. To get a better understanding of this population, this prospective study was performed.
Of the 274 patients seen in consultation in a single year, 45 were scheduled for “unnecessary surgery”, [i.e. based upon pain alone]. While these 45 patients experienced pain, they exhibited no neurological deficits, and, based upon review of the X-ray, MR, and/or CT studies showed no significant abnormal radiographic findings. Therefore, there was no clear surgical procedure that would benefit the patient. Nevertheless, spinal surgery, often quite extensive was recommended. Furthermore, an additional 2 patients were scheduled for unnecessary lumbar operations, when in fact they needed cervical surgery.
Three of the 45 patients with only pain had other disease entities that may have caused their pain e.g. multiple sclerosis, fibromyalgia, and lupus. In addition, 29 of these patients had overlapping comorbidities, many major, which would have increased the risks associated with “unnecessary” spinal surgery.
Some surgeons will argue that pain alone, particularly in patients who have exhausted conservative treatment modalities [e.g. anti-inflammatories, physical therapy, epidural steroids] over a 3-6 month period, justifies spinal surgery. Even if we accept this argument, which we do not, it does not justify the wrong operation, or extensive multi-level procedures. Furthermore, how do you justify operating on a patient with pain alone, when there are major, overlapping, potentially life-threatening co-morbidities? For example, three of the patients in this study had cardiac stents and were on both aspirin and Plavix. Why would you risk a fatal myocardial infarction for an operation on these patients?
In summary, one cannot use these numbers to get a regional, much less national, estimate of the frequency of recommended “unnecessary” spinal surgery. In this study, 47 out of 274, or 17.2%, of the total number of patients seen in a single year were scheduled for unnecessary surgery. This is an underestimate of the percentage of unnecessary surgeries as the 274 patients include those coming for first opinions. If we only considered the patients coming for second opinions, then the percentage of unnecessary operations would have been considerably larger. Unfortunately, we did not keep track of the total number of consults for whom surgery was recommended. In any case, it is clear that it is rather common. Many spine surgeons would agree with the senior author that none of the 47 patients seen in a single year should undergo the surgery proposed. Many would also agree that “unnecessary” surgical procedures are uncalled for in the presence of serious comorbidities. In the interest of our patients, as well as in the interest of reducing medical costs, a better understanding of frequency of “unnecessary” spinal surgery is needed.