Surgeons are performing more dangerous, difficult, and expensive spine surgeries involving fusion rather than simpler less expensive decompression procedures, with far more mortality and complications.
Those are the findings by Richard A. Deyo, MD, and colleagues, who looked at adjusted data for all Medicare patients who had the more complex form of the surgery for spinal stenosis and found a 15-fold increase between 2002 and 2007, from 1.3 to 19.9 per 100,000 beneficiaries.
And life-threatening complications increased as well, from 2.3% from those having simpler decompression procedures to 5.6% for those having complex procedures, which also had longer stays and a higher rate of 30-day readmissions. Mortality within 30 days was .6% compared with 3%. Additionally, costs associated with the more costly fusion spine surgery were $80,888, compared with $23,724 for simpler decompression surgery.
Deyo, a researcher at the Oregon Health and Sciences University, and researchers at Dartmouth Medical School and the University of Washington in Seattle published their findings in this week's Journal of the American Medical Association.
"It is unclear why more complex operations are increasing," the researchers wrote. "It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just 6 years. The introduction and marketing of new surgical devices and the influence of key opinion leaders may stimulate more invasive surgery, even in the absence of new indications."
They suggested surgeons may believe more aggressive intervention produces better outcomes. Also, improvements in surgical and anesthetic techniques "may make more invasive surgery feasible when risks formerly would have been prohibitive. Financial incentives to hospitals and surgeons for more complex procedures may play a role as may desires of surgeons to be local innovators," they said.
Spinal stenosis is the painful degeneration of the lower spinal column that decreases mobility and weakens the legs. These operations numbered 37,598 in 2007, at a cost to Medicare of $1.65 billion in 2009 dollars, according to the report.
Interestingly, the number of spine surgeries actually went down slightly between 2002 and 2007, so the number of complex, more dangerous lumbar fusion represent a large portion of the costs.
The researchers also found geographic variations in the rates for spine surgery. "They suggest a poor consensus on indications for surgery or the choice of particular procedures."
Yet, they added "evidence for greater efficacy of more complex procedures is lacking."
The researchers concluded, "in the absence of compelling data showing better pain relief or function with more complex surgery, our results may suggest using the least invasive procedure that accomplishes clinical goals."
In an accompanying editorial, Stanford University orthopedic surgeon Eugene Carragee, MD, said Deyo's findings "do not provide explanations for the increase in complex surgery," which might be explained if patients had more extensive deformities.
"The diagnoses reported, however, do not support this 'ideal' explanation; 50% of these new complex fusion operations were performed in patients with spinal stenosis alone and no deformity."
Such "proliferation of risky and expensive practice beyond reasonable supporting evidence is commonly mentioned as a fundamental failing of medical practice in the United States."
More complex technologies for spine surgery are being used for patients "with little specific indication for the approaches and for whom there is good evidence that simpler methods are highly effective." Additionally, he noted, surgeon compensation for a simple decompression spinal stenosis is approximately $600 to $800, compared with complex fusion, which pays "10-fold greater."
The study by Deyo "demonstrates a definite human cost to this practice in terms of a clear increased risk of surgical mortality, major complications and prolonged morbidity associated with these more complex approaches [and] there is no evidence that these factors have been adequately considered" by surgeons performing the procedures, he wrote.
Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached at cclark@healthleadersmedia.com.