Deciding whether to have back surgery after a motor vehicle accident or another type of accident is a decision our clients often have to make. It is usually not an easy decision. No doctor in his or her right mind will guarantee the results of a back surgery to the contrary, in making sure not to do so, many doctors scare their patients when rightfully advising them that they may feel worse after the surgery.
More than one client who had back surgery have lamented that they wish they never had the surgery, especially when spinal fusion has been performed. Their concerns have been confirmed in a just released study that shows that invasive fusion procedures are associated with a higher risk of life threatening complications.
The study was published in today’s issue of the Journal of The American Medical Association (JAMA), by lead researcher Richard A. Deyo, MD, of the Oregon Health and Science University, Trends, Major Medical Complications, and Charges Associated With Surgery for Lumbar Spinal Stenosis in Older Adults. The study analyzed Medicare claims for 2002-2007, focusing on 2007 to assess complications and resource use in US hospitals.
Back pain can be treated in one of the numerous ways, in order of increasing complexity: rest and physical therapy, surgery to remove the bony growths that can push on nerves, fusing two vertebrae together, or fusing many vertebrae together. Several recent studies have failed to show a big advantage for back surgery especially for complex surgery. The JAMA study noted that the fastest growth in lumbar surgery in recent decades occurred in older patients with spinal stenosis.
Although trials indicate that for selected patients, decompressive surgery offers an advantage over nonoperative treatment, surgeons often recommend more invasive fusion procedures. Surgical rates declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold. Life-threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. In 2007, compared with decompression, simple fusion and complex fusion were associated with increased risk of major complications, 30-day mortality, and resource use.
So why, if decompression surgery is more effective and safe than a spinal fusion, are surgeons performing more fusions than decompressions? As noted in an editorial accompanying the JAMA study, it seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just 6 years. Some plausible explanations include the introduction and marketing of new surgical devices; the influence of key opinion leaders to stimulate more invasive surgery even in the absence of new indications; beliefs by surgeons that more aggressive intervention produces better outcomes; improvements in surgical technique, anesthetic technique, and supportive care may make more invasive surgery feasible when risks formerly would have been prohibitive; financial incentives to hospitals and surgeons for more complex procedures; and desires of surgeons to be local innovators.
With respect to complications, major medical complications were reported in 3.1% of patients overall and wound complications in 1.2%. Mortality was 0.4% within 30 days of discharge. Major medical complications included procedure codes for cardiopulmonary resuscitation or repeat postoperative endotracheal intubation and mechanical ventilation. They included diagnosis codes for cardiorespiratory arrest, acute myocardial infarction, respiratory failure, pulmonary embolism, bacterial pneumonia, aspiration pneumonia, pneumonia with an unknown organism, and stroke, excluding late effects. Wound complications included hemorrhage, hematoma, or seroma complicating a procedure; disruption of operation wound; nonhealing surgical wound; postoperative infection; and other infection.
Also included were patients with a procedure code for “excisional debridement of wound, infection or burn,” or a diagnosis related group code for wound debridement and skin graft. The new health law will likely have ramifications affecting spinal surgery. The new health overhaul law sets up a new institute that would do studies like Deyo’s, comparing the risks and benefits of various treatments for various conditions. The general tendency noted in the study that many patients and doctors think more medical care always better runs contrary to many concepts expected to be implemented by the new health overhaul law.
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