ShareThisIt's an increasingly familiar story in American medicine. Four out of five Americans will suffer from disabling back pain sometime, according to the National Institutes of Health. Spending on back care soared between 1997 and 2005, reaching $86 billion -- just shy of what Americans spent battling cancer.
As those numbers have multiplied, so have questions about the more aggressive forms of back treatment. A 2008 study in the Journal of the American Medical Association, for example, noted that the increase in back-care spending occurred "without evidence of corresponding improvement" in patients' health.
"Intense pain is not necessarily an indication for surgery," said Dr. Richard Deyo, a professor of family medicine at Oregon Health and Science University and one author of the study. "You can't fix everything with a knife."
Perhaps the biggest controversy involves an invasive surgery called spine fusion, which attempts to relieve back pain by permanently connecting (or fusing) several levels of bone. While the overall number of back operations has flattened out in recent years, complex fusion surgeries, which can cost upward of $80,000, continue to proliferate. American surgeons perform twice as many of these operations as their counterparts in most European countries, Australia and New Zealand, and five times more than the United Kingdom, despite similar patient populations.
This debate is likely to intensify under the sweeping new federal health legislation that President Barack Obama signed in March, gradually requiring doctors and hospitals to demonstrate that their services are cost-effective. The New England HealthCare Institute estimates the United States could save $1 billion a year by eliminating unnecessary back surgeries.
Minnesota is likely to be a crucible in this debate. It's home to Medtronic Inc., the world's largest maker of devices used in spine surgery, as well as Abbott Northwestern Hospital, which performs more spine fusion surgeries on Medicare patients than any other U.S. hospital, according to the industry publication Orthopedic Network News.
Fusion surgery has historically been used to correct deformities, fractures and other conditions. Results have been good and largely noncontroversial. But in recent years, more procedures have been used to treat back pain related to aging, prompting several studies to question whether the expensive intervention is worth it.
In 2006, American doctors performed approximately 343,000 spine fusion operations, up 82 percent from 1999, according to the National Center for Health Statistics, which tracks Medicare data. The number has continued to rise, though not as explosively. The Millennium Research Group estimates 445,300 spine fusion surgeries were done last year.
Surgical costs vary widely, according to data compiled by UnitedHealth Group. A complex lumbar fusion surgery can vary from $25,000 to almost $80,000 in a "typical" major metropolitan market.
Deyo has argued that the rising costs, high rates of complications and wide variations in the number of procedures performed from one state to another "generate concern that the procedure may be overused."
Others link the increase in fusion surgery to improvements in technology and the simple fact that baby boomers are aging. "Americans think longevity is a right and death is optional," said Dr. Sam Ho, chief medical officer for UnitedHealth Group, the nation's largest insurer. "We all want to be as active as we can -- and for as long as possible."
The surge in fusion surgery has meant big money for Fridley, Minn.-based Medtronic, whose spine business reported $3.5 billion in sales last year.
Critics argue that influence by big medical device companies -- including lucrative royalty and consulting arrangements bestowed on influential surgeons -- factors into the skyrocketing number of spine fusion surgeries. Earlier this year, Medtronic disclosed these payments for the first quarter; of $16 million paid to doctors, $14 million went to spine and orthopedic specialists, mostly for royalties.
Medtronic and others insist that collaboration with doctors is crucial for creating innovative new tools. But California spine surgeon Charles Rosen, head of the Association for Ethics in Spine Surgery, says financial incentives create demand for certain brands. "That's one reason why you're seeing so many fusion surgeries," he said.
Other specialists say the situation is more nuanced. Each patient is different, they say.
With costs and doubts rising, many insurers are starting to push back. Some are implementing rules that require doctors to prove that they offered their patients conservative treatments, such as physical therapy and pain-numbing injections, before the plan will pay for certain types of back surgery, including fusion.
Others require doctors to offer conservative treatments before they approve payment for some types of back surgery.
Such rules are, predictably, controversial.
If research has shown that surgery works on some low back pain, "why would you put someone through weeks or months of physical therapy?" said Dr. Daniel Resnick, vice chairman of the University of Wisconsin neurosurgery department.
Resnick argues that much of the back-surgery data are incomplete. "We don't know who exactly is getting back surgery," he said. "... My personal feeling is that we need to be doing more of the right kind of surgery and less of the wrong kind of surgery."
Up to 90 percent of people with acute low back pain will heal on their own, no matter what they do, according to several studies.
Some doctors are exploring nonsurgical options.
For example, Physicians Neck & Back Pain, a Twin Cities chain of clinics, has gained national attention for its sports medicine approach to treating back pain. Now a HealthPartners subsidiary, the clinic offers an aggressive rehabilitation program aimed at back strengthening.
It can be a painful journey, according to CEO Dave Carpenter. "Generally patients tend to get worse before they get better," he said.
(E-mail reporter Janet Moore at jmmoore(at)startribune.com.)
(Distributed by Scripps Howard News Service, www.scrippsnews.com.)
With BACKSURGERY-TYPEMust credit Minneapolis Star Tribune
