If you're getting spine surgery, wouldn't it be good to have a spine surgeon?

Spine surgery, and there is a lot of it being performed in the United States, should be performed by spine surgeons. And yet, believe it or not, there has been momentum recently to have non-operative pain specialists perform spinal fusions.  It's reached a point where the leading spine organizations in the world had to draft a statement.

This isn't safe for patients.  It's not what I would want for a family member.  And it's bad policy for the medical system.  It's indirect result of the distance between those who pay for care and those who receive it.

Fusion surgery refers to the healing or joining of two different spine levels (vertebra) together.  This permanently alters the biomechanics of the spinal column.  It has lifelong implications for the patient and, even when performed correctly, increases the chances of needing another surgery in the future.  I focus on complex spine revisions and scoliosis in my practice, and approximately 35% of my practice are patients who have had a previous spine fusion.

Any type of fusion surgery should be performed by a trained surgeon fully capable and aware of all anatomical considerations with the ability to manage and treat complications.  This includes concepts surrounding the spinal cord, the spine joints, the spine disc space, and the spine's relationship with the pelvis.  Any neurosurgeon who has completed a residency or an orthopedic surgeon who has graduated from a spine fellowship has completed the proper pathway for performing spine fusion surgery.  These respective surgeons spend years studying scrubbing and studying for surgery.  They have dedicated their lives to surgery.

Non-operative specialists such as pain anesthesiologists and pain medicine physicians are not trained to perform spinal fusions.  They have not completed a residency in surgery.  They do not undergo significant repetitive measured and indexed competency training in the surgical instrumentation of the spine.  Yet some of them are starting to perform surgeries in ambulatory surgical centers or even in their offices. 

Why?

Minimally invasive techniques have made spine fusion surgery more available to the general public and in certain ways safer.  This can include percutaneous or small skin incisions as opposed to traditional open surgery.  There is an obvious financial push and incentive for non-surgeons to perform these surgeries, especially in situations where there are ancillary income streams like ambulatory surgical centers or physician offices.

Also, in theory, the companies designing these products would also benefit from as many doctors using them as "safely" as possible.  There are only approximately 3,600 active neurosurgeons in the United States.  There are approximately 5,700 pain management physicians.  The overwhelming majority of physicians just want to help the patient sitting in front of them, and these new devices are another tool in the toolbox.  Give more physicians a hammer, and they will find a nail.

For the patient, I just don't think this is a safe idea.  The American Association of Neurosurgeons, The American Academy of Orthopedic Surgeons, Congress of Neurological Surgeons, Cervical Spine Research Society, Lumbar Spine Research Society, Scoliosis Research Society, and the International Society for the Advancement of Spine surgery agree

For the health system, this is the wrong direction.  Dramatic increases in spinal fusions occur in the United States annually.  This is multi-factorial and layered, but whatever the background is, it's expensive.  I think the taxpayers, CMS, and otherwise should demand accountability regarding who actually performs spine surgery.  The taxpayer are fronting the bill.

If system had less distance among those who provided care, those who received it, and those who paid for it, there be more conscious consumers and providers.  This is the moral hazard of health care.

I want to be very clear that we have some absolutely outstanding pain medicine and non-operative spine colleagues.  They are invaluable members of a team-based approach to treating spinal pathology.  And they provide many non-operative interventions such as epidural steroid injections and radiofrequency ablations.  Thankfully, most patients with degenerative spine conditions will never need surgery.  We, the surgeons, would not be able to do what we do without their assistance.

Just as a complex spine cancer pain would not want a surgeon to manage his lifelong complex opioid pathway, a spine patient should have a spine surgeon performing his spine surgery.

Richard Menger, M.D., MPA is an assistant professor of neurosurgery and an assistant professor of political science at the University of South Alabama.  He is the lead editor for the textbook The Business, Policy and Economics of Neurosurgery.

Image: Lparis22 via Wikimedia Commons, CC BY-SA 3.0 (cropped).

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