Gross Overutilization of Spinal Injections and Surgery
The following are excerpts from the invaluable highly referenced 2009 online medical journal article "Overtreating Chronic Back Pain: Time to Back Off?" The authors include Richard A. Deyo, MD, MPH; Sohail K. Mirza, MD, MPH; Judith A. Turner, PhD; Brook I. Martin, MPH. The link to the full article is http://www.medscape.com/viewarticle/58695. This study documents gross overutilization of invasive, highly expensive epidural injections and spinal surgeries. In most cases, inexpensive and relatively safe chiropractic procedures would make far more sense.
Chronic back pain is among the most common patient complaints. Its prevalence and impact have spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for indications that are not well validated, leading to uncertainty about efficacy and safety, increasing complication rates, and marketing abuses. Recent studies document a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates. We suggest a need for a better understanding of the basic science of pain mechanisms, more rigorous and independent trials of many treatments, a stronger regulatory stance toward approval and post-marketing surveillance of new drugs and devices for chronic pain, and a chronic disease model for managing chronic back pain.
The efficacy of spinal injections is limited. Epidural corticosteroid injections may offer temporary relief of sciatica, but both European and American guidelines, based on systematic reviews, conclude they do not reduce the rate of subsequent surgery.[57,58] This conclusion is based on multiple randomized trials comparing epidural steroid injections with placebo injections, and monitoring of subsequent surgery rates.[59-62] Facet joint injections with corticosteroids seem no more effective than saline injections.[57,63]
Despite the limited benefit of epidural injections, Medicare claims showed a 271% increase during a recent 7-year interval (Figure 1C). Facet joint injections increased 231%. Earlier Medicare claims analyses also demonstrated rapid increases in spinal injection rates.[12,64] For patients with axial back pain without sciatica there is no evidence of benefit from spinal injections; however, many injections given to patients in the Medicare population seemed to be for axial back pain alone.
Charges per injection rose 100% during the past decade (after inflation), and the combination of increasing rates and charges resulted in a 629% increase in fees for spinal injections. During this time, the Medicare population increased by only 12%.
Although spine fusion surgery has a well-established role in treating fractures and deformities, 4 randomized trials indicate that its benefit is more limited when treating degenerative discs with back pain alone (no sciatica). Despite no specific concurrent reports of clarified indications or improved efficacy, there was a 220% increase in the rate of lumbar spine fusion surgery from 1990 to 2001 in the United States (Figure 1D). The rise accelerated after 1996 when the fusion cage, a new type of surgical implant, was approved. Their promotion may have contributed to both the rise in fusion rates and increased use of implants. In the last 5 years of the 1990s, Medicare claims demonstrated a 40% increase in spine surgery rates, a 70% increase in fusion surgery rates, and a 100% increase in use of implants.
Higher spine surgery rates are sometimes associated with worse outcomes. In the state of Maine, the best surgical outcomes occurred where surgery rates were lowest; the worst results occurred in areas where rates were highest. Multiple randomized trials suggest that adding surgical implants to bone grafting slightly improves rates of solid bone fusion but may not improve pain or function.[68-70] Implants increase the risk of nerve injury, blood loss, overall complications, operative time, and repeat surgery.[68,69] In a large study of injured workers, the rapid increase in the use of intervertebral fusion cages after 1996 was associated with increased complications but not with improved disability or reoperation rates. We recently found that reoperation rates after initial spine surgery were higher in the late 1990s than earlier in the decade, despite greater use of fusion procedures and implants.
The link to the full article is http://www.medscape.com/viewarticle/58695.
Special investigative article on back surgery by Harvard Medical School Professor and writer for The New Yorker, Jerome Groopman, M.D., from April 8, 2002:
Surgeons have often touted procedures that ultimately proved to be disappointing. In the nineteen-fifties, many patients with angina and coronary-artery disease had an operation that involved tying off an artery that runs under the sternum. The idea was that it would increase the flow of blood to a heart that was being starved of its normal supply. Then, at the end of the decade, a clinical trial demonstrated that patients who underwent a sham operation did just as well as those who had the real one; the placebo effect apparently accounted for the fact that so many patients felt better afterward.
The radical mastectomy, pioneered a century ago, used to be routinely performed, too. Physicians believed that breast cancer spread in a contiguous, stepwise fashion from the primary tumor, and that the only way to eradicate the disease was to remove the entire breast and the underlying muscles. By the nineteen-eighties, it had become clear that tumor cells could spread throughout the body early in the disease, through lymph channels and blood vessels. A lumpectomy, followed by local radiation, proved as effective as a radical mastectomy in treating the cancer, and was far less traumatic to the patient.
Last year, approximately a hundred and fifty thousand lower-lumbar spinal fusions were performed in the United States. The operation, which involves removing lumbar disks and mechanically bracing the vertebrae, is of tremendous benefit to patients with fractured spines or spinal cancers; more frequently, however, it is performed to alleviate chronic lower-back pain. But how effective is it? That’s a question that many of the doctors who perform the fusions, and the insurers who pay for them, appear reluctant to ask.