The Post story looks at the large number of fusions done by a Florida neurosurgeon, Federico C. Vinas. There are suggestions that many of these procedures were not medically necessary, and Vinas did them just for profit (he makes $2 million a year). Spinal fusion is not cheap: in the United States it costs on average of $111,000.
Spinal fusion, like almost everything in American medicine, is overpriced. Based on outcomes from countries similar to the United States, the costs of medical procedures are artificially high: probably five to ten times what they should be (which is obvious from the fact that even within the United States they vary that much).
The Post talked to several patients who did not benefit from the surgery, some of whom are in severe pain and unable to walk. Others are now leading normal lives. These newspaper anecdotes are compelling, but don't really address the efficacy of spinal fusions. The problem is that there is no real consensus on the efficacy of fusion for treating nonspecific low back pain.
The Post story isn't the first on this topic: Bloomberg examined the same issue in 2010. The Bloomberg story is interesting because it's about the Twin Cities Spine Center and Ensor Transfeldt, a surgeon who examined me 20 years ago. Several years ago I had a minimally invasive cervical laminoforaminotomy by a different Twin Cities Spine surgeon. I passed on proposals by other surgeons for a fusion or a disc replacement: the Terminator-like spine model with the titanium ball-bearing design really creeped me out.
Limitations of Spinal Fusion
By its very nature spinal fusion reduces the patient's flexibility by bolting together two or three vertebrae with bone transplanted from the patient's hip or a cadaver. The fusion prevents rotation of the spine at those levels, putting stress on other parts of the spine, which can cause serious damage and pain, and potentially limits the patient's activities. It's therefore not something you should consider lightly. Other surgical procedures, such as disc replacement, still have serious limitations.
I'm therefore inclined to agree with the thrust of the Post and Bloomberg's reporting: some doctors are doing too many fusions.
Playing Golf and Tennis
The increase in the number of fusions is by no means motivated solely by profit: many people are simply not willing to suffer excruciating pain, become dependent on narcotic painkillers, or become invalids, and they look to surgery to make them mobile (from the Post):
“Patients want to be able to play tennis and golf and go surfing at much higher ages than they did in the past,” said Gunnar Andersson, chairman emeritus of the department of orthopedic surgery at Rush University Medical Center in Chicago and president-elect of the International Society for the Advancement of Spine Surgery, a professional group. “They are more likely to seek out treatment and more likely to accept surgery as an option.”This echoes a popular refrain: "Baby Boomers don't want to age gracefully." This attitude is dead wrong.
Keeping People Active and Healthy
Ask any doctor how to prevent diabetes and heart disease, and the top two answers go hand in hand: weight control and exercise.
If you can't walk, you can't run, and you can't do any serious exercise. If you don't exercise you gain weight and your heart and lung function decline. You get diabetes, heart disease, high blood pressure, and are at increased risk of stroke and even cancer. You lose your sense of proprioception, which is essential to avoiding falls. You experience bone loss, which makes serious fractures from even minor falls likely. In particular, hip fractures are a major factor in the decline and death of the elderly ("ma was doing great until she fell and broke her hip").
In strictly monetary terms, the question is: Are the long-term costs of treating chronic organic problems like diabetes, hypertension and heart disease caused by being sedentary greater than the costs of correcting orthopedic conditions that exacerbate those organic problems?
The cheapest solution is to keep people active and healthy, and off expensive painkillers (with their addictive and debilitating side effects), and diabetes and blood pressure meds for as long as possible.
No Responsibility for Patient Healing
The motivation shouldn't be for surgeons to do spinal fusions because they make more money. The only motivation should be to restore good health and function to the patient.
The problem with our health care system is that it's so fragmented: no one entity is responsible for healing the patient; they're all focused on their own particular specialties. That pits caregivers in different specialty areas against each other as they try to sell their own solutions to patients. There's usually no neutral arbiter with sufficient medical expertise to help a patient decide on the best solution. Patients have to decide for themselves, with only the advice of the specialists with a vested interest to go on. Often the best salesman -- not the best solution -- will win.
Practices at the Mayo Clinic and the Cleveland Clinic try to resolve that issue, but they're initially expensive and geographically limited.
The Health Care Cost Spiral
Ultimately, the question of spinal fusions cannot be simply characterized as "doctors are money grubbers" and "baby boomers are getting fusions so they can play tennis." Our health care system is not focused on healing people, but on making money. The profit motive distorts medical care.
On the other side, patients want to be able to work, pick up their grandchildren, use their hands and arms, walk on their own two feet, get themselves out of bed and into the bathroom and bathe themselves. Most people would pay anything to do that.
Whenever someone talks about fixing the first problem someone yells, "Free Market!" and whenever someone talks about fixing the second problem someone yells, "Death Panels!"
Hence the problem of ever-spiraling health-care costs.
Given all the fretting about the number of nursing assistants we'll need as baby boomers age, it will probably be cheaper in the long run to to fix orthopedic problems -- back, knee and hip -- by whatever means necessary to keep an aging population mobile, healthy and self-sufficient as long as possible.
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