NASS’ Empty Response to the Post’s Article

On October 27, Peter Whoriskey and Dan Keating wrote an article for The Washington Post newspaper about spine fusion surgery and used the example of a single patient and a single surgeon to make a case that spine fusion surgery may be over used.

The North American Spine Society (NASS) took exception to Whoriskey/Keating’s article and wrote a letter.

The letter, which we reproduce at the end of this article, said that the “issue of unnecessary surgery is of paramount interest to NASS” and a “serious issue” but that it was “inappropriate to roundly condemn the concept of fusion, per se.”

Per se.

NASS went on to say that “Spinal fusion is currently undergoing rigorous scrutiny; the indications for spinal fusion are being evaluated and re-evaluated constantly”.

All of which is well and good but we could not help but notice that, for some reason, NASS couldn’t come up with a single study to cite which would offer support for spine fusion surgery.

In fact, the NASS letter was really a string of opinions and assertions with no supporting data.

Too Much Fusion Surgery?

The Post article emphasized the point that there may be too many spine fusion surgeries. The authors quoted Gunnar Andersson, M.D., chairman emeritus of the department of orthopedic surgery at Rush University Medical Center in Chicago as saying the “critics of spine fusion surgery, who believe spinal fusions are being performed too frequently, are “’not wrong.’”

As a general proposition, most surgeons would agree that some of their colleagues over use spinal fusion while other colleagues, conversely, under use spinal fusion. This is, in other words, not a new topic.

When is spine fusion indicated? Would it be for instability, degenerative disc disease, stenosis, burst fractures, all of the above or none of the above? For which patients? Anterior, posterior or lateral access? Biologics? Patient psychology? Many, interrelated factors determine whether spinal fusion surgery is the treatment of choice for any particular patient.

How do physicians answer such questions?

Most spine surgeons, we would argue, augment their training and experience by doing studies, tracking outcomes and presenting, listening, reading and debating at peer meetings like, well, NASS’s annual meeting.

NASS’ role, it seems to us, is to foster non-partisan study, debate and education for surgeons. Evidence Based Medicine, in other words. And when, for example, spine fusion surgery is challenged, we would expect NASS to respond with evidence.

The Post’s Story Outline

According to the Post story, the incidence of spine fusion surgery has increased dramatically in the last decade. Surgeons, hospitals and suppliers of spine fusion implants have benefited financially during this period. And, said the Post’s two authors, many of these spine fusion surgeries may have been unnecessary and performed to financially benefit surgeons and hospitals. Furthermore, many spine fusion patients ended up worse off for the surgery. One patient in the story, a 62-year-old former pipefitter, was diagnosed with “lumbar stenosis and degenerative problems.” But, wrote the Post’s authors, “instead of curing him, the surgery has all but crippled him.”

SPORT Studies

In fact, hundreds of clinical studies exist at NASS and from a large number of peer-reviewed journals which offer comprehensive data for the efficacy of spine fusion surgery. But NASS’ letter didn’t go there. In fact, in response to the Post’s assertion that spine fusion doesn’t work consistently, NASS said that a review and scrutiny of spine fusion surgery is currently in process. Perhaps NASS believes that spine fusion is unsettled science?

Certainly the most famous study which explicitly compared surgical intervention to non-surgical treatment of spine disorders is Dartmouth’s SPORT (Spine Patient Outcomes Research Trial) study. This study was discussed and reviewed extensively at more than one NASS annual meeting.

The SPORT study was organized by Dartmouth University about ten years ago and was funded in part by The National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Office of Research on Women’s Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention.

As designed by Dartmouth (which has been a critic of the volume of spine surgery since the 1980s) the studies covered 2, 500 patients, randomized them to either a surgery arm or a non-operative arm and followed them for five years. Thirteen sites participated.

Here is a summary of the results:

• Intervertebral disc herniation, published in JAMA, November, 2006
  • While both groups improved substantially after treatment, the improvement from standard surgery was more rapid. Patients who had surgery also reported better results in physical function and satisfaction one and two years after the operation.
• Degenerative spondylolisthesis, published in The New England Journal of Medicine, May, 2007
  • Patients with spinal stenosis accompanied by degenerative spondylolisthesis who were treated surgically showed substantially greater improvement in pain and function through two years follow-up compared to patients treated non-surgically.
• Spinal stenosis, published in The New England Journal of Medicine, February 21, 2008
  • Patients with spinal stenosis who were treated surgically showed significantly greater improvement in pain, function and disability through two years follow-up compared to patients treated non-surgically. Because patients in the randomized cohort “crossed over” either from the non-operative arm to have surgery or from the surgery arm to remain non-operative, the analyses were non-randomized, as-treated comparisons with careful control for potentially confounding baseline factors.

Carragee: “No Complications”

Eugene Carragee, M.D., is still the editor-in-chief of NASS’ peer-reviewed journal, The Spine Journal (TSJ).

The Washington Post authors asked Dr. Carragee to comment on the single patient’s case which, in their view, was a case study for debate over when spinal fusion surgeries were necessary. The patient suffered from compression of the spine and degenerative discs.

The Post authors wrote that Carragee had “said that a simpler procedure known as a decompression often offers patients, without complications, as much benefit as a fusion and poses fewer risks.”

We could not help but chuckle at Carragee’s comment that decompression surgery is without complication. If memory serves, he has engaged in a scorched earth campaign against his colleagues who’d mentioned that there were no complications in Infuse studies from a couple decades ago.

Decompression surgery—which has a strong success record and a comparatively low complication rate—does most certainly have a risk of complication, as has been amply documented in the pages of the journal Carragee edits.

Carragee may occasionally be wrong but never in doubt.

NASS’s Response Letter

Here is what the NASS Executive Committee had to say about The Washington Post article:

“The Executive Committee of the North American Spine Society (NASS) read the October 28, 2013 Washington Post story on spinal fusion (“Spinal fusions serve as case study for debate over when certain surgeries are necessary”) with great interest and concern.

The issue of unnecessary surgery is of paramount interest to NASS, from many perspectives, including humanitarian, ethical, scientific and economic. Recognizing that the issue of unnecessary or poorly or marginally-indicated surgery is, indeed, a serious issue, it is nonetheless inappropriate to roundly condemn the concept of fusion, per se.

Fusion of the spine is an invaluable tool in the surgeon’s armamentarium to alleviate intractable pain and return patients to healthy, productive lives. As in ALL surgical procedures, the key is the surgical indication for the individual patient. Overuse or underuse are both bad medicine and do the patient a disservice. There is universal support for spinal fusion in cases of instability, fracture, tumor, infection, deformity. Simpler and safer treatments, if available, should always be pursued first. And, before proceeding with surgery, the potential risks and chances of success must be completely understood.

Pain in the lower back is the #1 cause of disability in the United States and worldwide. Neck pain is #4! Together they cause more than 5 million years of disability in the US alone—enough for every person to be disabled by a spine condition for more than six days each year. Patients are demanding access to effective, thoughtful therapies that allow them to remain active and maintain their quality of life.

NASS is collaborating with Medicare and private insurance carriers to develop evidence-based guidelines for surgical intervention and to define conditions that are best treated without surgery. Spinal fusion is currently undergoing rigorous scrutiny; the indications for spinal fusion are being evaluated and re-evaluated constantly in an effort to develop the optimal indications to serve the best interests of the patient.”

NASS’ Role

In many ways the popular press, the insurance carriers, patients and NASS’ membership are asking for more evidence-based information with which to navigate the cross currents of healthcare. NASS and the other surgeon societies are natural sources for evidence-based information.

In this instance, unfortunately, NASS appears to have punted a valuable opportunity to educate and inform. It’s time NASS figured out its role as a facilitator and disseminator of objective, non-partisan information and education.