The Challenges of Spine Education and the “Dark Side” of Spine Surgery

by Elizabeth Hofheinz, M.P.H., M.Ed., September 5, 2019

A surgeon’s brain contains much, to be sure…and sometimes, it holds a dash of cynicism. Shining a wee light on a less-explored corner of such a brain, we spoke with one high-profile spine surgeon who has a lot to say about the variability in spine surgery.

“The high variability in treating the same spinal disorder leads to a host of issues and challenges in educating the learners in the spine specialty. There is substantial variation in the indications for surgery (who needs a lumbar fusion?), but there is even more variability in the actual techniques of doing the surgery. Trainees may see all different treatments, which may be a positive, but they may also not see that they are on the wrong side of the bell curve if they were trained by a spine surgeon who is too ‘aggressive’ in his/her surgical treatment. The high variability in surgery is the reason why there seems to be a higher failure rate on the American Board of Orthopaedic Surgery oral board exams by spine surgeons.”

“This is an important issue due to how we teach principles and techniques to residents and fellows. In a patient with chronic mechanical low back pain due to disc degeneration (without any neurologic symptoms), the treatment variations can span from conservative physical rehabilitation to that of multilevel lumbar fusion surgery. Even if surgery is the agreed upon treatment modality (e.g. in a 65-year old patient who suffers with neurogenic claudication from spinal stenosis and spondylolisthesis that has failed conservative treatments), some surgeons will propose a simple laminectomy and posterior fusion using rods and screws. Others would advocate for interbody cages and screws. Some would address the situation with both anterior and posterior surgery. Some will use expensive biological products to achieve fusion while others use local bone graft …the variability is amazing.”

Can we blame technology?

“The annual onslaught of new technologies—robotics, augmented reality, new devices, an array of biologic agents for grafting, different types of screws and cages—results is a hodgepodge of surgical options. A patient can see five surgeons and get five opinions as to how to proceed.”

Is there anything good about the variability?

“Spine surgery is very attractive and exciting for many young residents and fellows because it has the vast array of new technologies and procedures with seemingly endless amount of innovation. Our younger generation of trainees love innovation. The fact that one has multiple options for a specific diagnosis means that a surgeon can “artfully” devise a specific procedure that may better fit the patient specific profile. As an experienced surgeon, it is nice to have a host of technical options and discuss the pros and cons with the patient. A surgeon that is versed in a variety of techniques will clearly have advantages for his/her patients.”

Are CPT codes part of the problem?

Unfortunately, some of the variability problem is driven by CPT codes, i.e., the more you code the more you can get reimbursed. The conflicts of interest are immediately evident, with some surgeons rationalizing the need for bigger operations and justifying more intensive surgeries involving cages, rods, and biologics by saying that these will result in improved outcomes.

“This is separate from the very real conflicts of interest with companies. In spine, there seems to be a growing number of surgeons that have these conflicts with industry, especially amongst the academic surgeons who teach the next generation of learners in spine…it is really a slippery slope. It is of course necessary for surgeons to collaborate with industry to promote innovation, but there have been many instances where physicians have misbehaved due to these relationships. There are standards of care, and I am not saying that what some surgeons are doing is necessarily wrong or rises to the level of malpractice. But you have surgeons saying that they will get better outcomes by doing a big surgery when all of the studies comparing more intensive surgeries with less intensive procedures indicate that patient-reported outcomes are really no different. That is where value-based medicine comes in. If a surgeon isn’t careful, it is easy to ramp up the cost, but more importantly, patients are put through more complicated surgery. And then you are not doing cost-effective medicine, but simply adding to the rising cost of healthcare.”

“When someone finishes their spinal fellowship training and enters practice, they bring their techniques they learned with them. There are enormous variations in treatment that they possess, and what they learn depends on the training facility and their fellowship director and other mentors. After two years in practice, they must sit for part two of the oral boards (in Orthopaedic Surgery)—and it’s no secret that spine surgeons have the highest failure rate—10-12% as opposed to 3-4% in other specialties. There is simply no other rational explanation for this statistic.”

What are some solutions?

“We need more research into patient reported outcomes and cost-effectiveness in spine surgery. The more convincing data we have, the more the surgeons who practice ethical medicine can base their treatment plans on to provide the best outcomes. In addition, great data will also lead to payors and insurance carriers to provide some pressures to standardize treatment for various diagnosis. Although our specialty does not want to be ‘regulated,’ I think we may need help to narrow the lanes a bit without affecting patient quality. The good news is that spine surgery is still a great specialty and we can really change people’s quality of life in substantial way.”

“Many of these variability in treatment exists in other fields of orthopaedics, so this topic is not specific to spine surgery. In North America, where capitalism is healthy and thriving, we may have to accept such variations in treatment as a symptom of our free markets, but we as a specialty should constantly reflect on what is best for our patients. Sometimes, we have to take a hard look at the ‘dark side’ and make sure we do not head into a ‘darker’ side.”