The spine “resists” us: the evidence and business behind spinal fusion – mahrgan

In most orthopedic departments, spinal fusion is likely to be one of the most common operations, and one of the most expensive and profitable operations.

Surgery is very useful for people who have suffered trauma, such as car accidents, or people with congenital diseases or even back arthritis and some spondylolisthesis in the spine.

But this surgery may also be one of the most overused and unnecessary, and although the evidence for its effectiveness is unclear, surgeons often recommend it for many situations.

A recent study clearly lacks rigorous clinical trial evidence, which raises the question of why surgeons cut so many backs without knowing whether it is effective, and a healthcare industry that relies on expensive medical equipment Regulatory review is as rigorous as prescription drugs.

For hospital administrators, the expensive procedures and equipment used by doctors seem to be comparable to the curriculum of the American healthcare system. However, the frequency and cost of spinal fusion are rising, which suggests that the orthopedics department may need to be carefully studied. The average cost of spinal fusion is between US$60,000 and US$110,000.

The British Medical Journal’s review of several randomized controlled clinical trials of elective orthopedic surgery found that there is little evidence to support spinal fusion in patients with degenerative disc disease. For the other five orthopedic surgeries (including rotator cuff repair), there is almost no evidence that surgery is better than non-surgical treatment.

Spinal fusion, even a sign that is beyond the focus of the research, is also controversial. At best, there is vague evidence that it should be used to treat a disease called spinal stenosis, which is a severe form of arthritis that mainly affects the elderly.

Due to the lack of experimental data on the effectiveness of spinal fusion in many cases and the medical equipment used in the operation, surgeons can only rely on the sales promotion of self-interested equipment manufacturers-usually with financial relationships with these companies The same company. Doctors-and less reliable observational data.

Surgical treatment usually has two components: decompression and spinal fusion. For the former, the doctor will open the patient’s back and cut off the joint bones, which squeeze the nerves from the back to the legs. For the latter, surgeons use bone grafts to weld the vertebrae together, usually using medical equipment to stabilize the area.

“This procedure may be overused. Studies have shown that it is more expensive, more risky, and more complicated for patients with spinal stenosis. Researchers have shown that although decompression alone is safer and has similar As a result, integration is increasing,” said Dr. Steven Atlas, associate professor of medicine at Harvard Medical School.

More surgeries

Spinal fusion is risky, partly because patients may experience more serious problems than they did at the beginning. This is especially worrying for patients who may not even recommend surgery.

“Over time, fusion-you fuse two bones together, there is no movement between the bones, there was movement in the past-there is evidence that you will increase arthritis changes above and below the fusion,” Ah Truth said. This increases the pressure on the segments below and above the vertebrae, leading to a domino effect, and patients need more fusion to relieve pain.

However, despite the available evidence, spinal fusion has proliferated over time.

According to a study by the Spine Research Foundation, lumbar fusion surgery increased by 142% between 1998 and 2008. A review of medical insurance claims revealed that more complicated versions of surgery involving more vertebral surfaces increased by 38% from 2004 to 2007, indicating a shift to more complicated and more expensive surgery. By 2015, more than 40% of spinal fusions performed in the United States were for indications for which there is little evidence of clinical applicability.

“If there weren’t some plagues that caused the spine to begin to dissolve-the spine of the elderly was not much different from the past 50 to 60 years. Dr. Eugene Karaji, a professor of orthopedics at Stanford University School of Medicine and a former professor of orthopedics, said: “Reported disease Physiology and the need for surgery have increased dramatically. This is not a smoking gun, but there must be something that smells rotten, that’s for sure. “Director of Spine Surgery.

For indications that are generally believed to benefit from the surgery, a recent study of Norwegian spinal surgery by the New England Journal of Medicine found that patients who underwent decompression surgery alone had the same pain relief effect as patients who underwent spinal fusion surgery at the same time.

The meta-analysis of the British Medical Journal relies entirely on randomized controlled clinical trials, which are the gold standard for research. But the lack of other forms of information, such as observational research and real-world case studies, is a limitation. This article also does not consider the experience and medical judgment of surgeons.

Doctors will not arbitrarily perform operations that they know are useless. But they do not necessarily consider the clinical evidence when deciding what to recommend, and they are unlikely to have any contact with the patient several years after the recovery period, unless there are complications. So they may not really understand what is effective and what is ineffective.

“They wake up in the morning and think,’What can I do for my patients? I don’t need (randomized controlled trials). I have seen the benefits in my patients, and they have become better,” Dartmouth Said Jonathan Skinner, a professor at the Dartmouth Institute who studies the relationship between innovation and the increase in health care costs.

“But once the operation is complete, the surgeon will never see the patient again unless there is a problem,” Skinner said. “Any surgeon is very difficult to evaluate, and there is a prejudice that considers success while ignoring unsuccess.”

The advantage of randomized controlled trials is that they provide conclusive evidence on whether medical interventions are effective, what complications may occur, and how to explain the placebo effect. This kind of research provides the best evidence, allowing clinicians and patients to perform risk-benefit calculations.

“If, on average, this thing doesn’t work, then you have a responsibility to tell me why it works for this particular patient, not just an argument based on faith,” said Dr. Vikas Saini, who is The chairman of the organization. The Lown Institute is a non-partisan think tank and research organization that focuses on unnecessary care and other health care issues. “Some suspicions are justified and not enough to shut down these operations, but enough to say, let us be careful.”

Spinal fusion does have risks. According to a study published this year by the Lawn Institute in collaboration with Australian scholars, there is no strong evidence to support spinal fusion for stenosis and other diseases that are associated with adverse outcomes. Their review of medical insurance claims from 2016 to 2018 found that among the seven low-value surgeries, inpatient spinal fusion had the greatest association with hospital-acquired diseases, adverse patient safety indicators, and accidental admissions after outpatient surgery.

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