Over our careers, we have witnessed numerous occasions where spine surgery was not in the best interest of the patient, employer and ultimately, the treating physician performing the surgical procedure.
This article will provide some background on when spine surgery should be performed, the impact on the insurance industry, and education that can be used to help others take control of their future in order to drive better outcomes for all.
The Need for Spine Surgery
In his book, Back in Control: A Spine Surgeon's Roadmap Out of Chronic Pain, David Hanscom, M.D., explains the importance of understanding the two sets of variables that affect the decision to undergo spine surgery: the source of the pain and whether the patient is under a significant amount of stress, which may or may not be related to the pain.
The source of pain falls under two categories: structural or non-structural. A structural problem is one that is clearly seen on a diagnostic test and there are matching symptoms. In contrast, non-structural pain originates from soft tissues or can originate directly from the nervous system. Neither of these non-structural pains can be identified on an imaging study. Soft tissues have a high density of pain fibers and frequently, with ongoing irritation, the pain generated can be severe and prolonged. When the brain generates pain impulses without a source, it is called the Mind Body Syndrome (MBS). Surgery can only be successful for a structural problem.
Chronic anxiety, frustration, and eventual depression affect both the perception of pain and the capacity to cope with it. If the nervous system is “fired up,” it has been repeatedly shown that surgical outcomes will be compromised. It is critical to calm down the nervous system prior to undergoing surgery or even making any decisions about it.
Since what cannot be seen cannot be fixed, Dr. Hanscom does not recommend surgery, under any circumstances, for non-structural issues. His focus is on explaining why the patient likely does not need surgery and how he or she can overcome chronic pain by using a self-directed structured spine care program. He uses a process that evolved out of his personal experience with chronic pain — Defined Organized Comprehensive Care (DOCC).
Much of spine surgery is performed on patients with non-specific pain and no identifiable source. The success rate in this circumstance is less than 30 percent at two-year follow up, and the downside is significant.1
Dr. Hanscom notes that for a patient to be ready for any surgery, he or she must also be sleeping at least seven hours a night for three months and have an anxiety/frustration level below a five on a scale of 10. Additionally, he or she should be actively engaged in learning about the pain and exercising. Even when these goals are achieved, surgery should be performed only on an identifiable structural problem with matching symptoms. Surgery rarely, if ever, solves non-specific lower back pain (LBP).
Over the years, workers’ compensation insurers and self-insured organizations have seen clusters of spine surgeries emerge in their claims data. In discussions with medical professionals, claims adjusters, risk managers, and environmental and health safety (EH&S) professionals, the conversations usually come back to injured workers being told that spine surgery was a “cure all” (e.g., spine fusion). These spikes have often been observed in certain areas of a state where word spreads throughout the workforce about a surgical remedy or a treating physician performing a high number of these surgeries.
Surgical outcomes in the workers’ compensation population are less successful than the general population. Dr. Hanscom realized about 15 years ago that people on workers’ compensation tend to be angrier than the general population. Not only are they experiencing ongoing pain, they are often caught up in a system that provides limited options and have a feeling of no control, which leads to frustration and anger. When angry, the body chemistry changes to a “fight-or-flight” mode, and the perception of pain is amplified. The additional stress of surgery performed in the context of an amped-up nervous system has a lower chance of resolving pain.
Medical Professional Liability
National malpractice data shows that the top two categories of malpractice cases are diagnosis-related cases and surgical cases. With some regional variability, diagnosis cases account for somewhere between 24 to 30 percent of all cases, and surgery is close behind at 20 to 25 percent. The dollars associated with these two categories are astronomically high, largely because the majority of cases represent high-severity injury events.
A close examination of surgical malpractice cases reveals that the three most frequently named surgical specialties are general surgery, orthopedic surgery, and neurosurgery. This begins to sharpen the focus as to where the greatest risks lie. A further analysis into procedure type fills out the risk profile: the surgery most frequently involved in malpractice-related scenarios is spine.
These spine cases may relate to any one of the following:
Technical errors — in spine cases, just the slightest slip in technique can sometimes lead to a catastrophic outcome.
Errors in cognition/judgment — making a wrong decision while the surgery is in progress.
Human factors/systems errors — operating on the wrong level, or other scenarios which result from interruptions in the surgeon's concentration.
Poor outcomes associated with operating on a patient where surgery was not medically indicated.
But is malpractice data meaningful? Many would argue that it is such a thin slice of the world of healthcare data, there is limited value in using it for analysis. However, we would take the opposite position.
In many event types, data traditionally — and routinely — collected by healthcare organizations (whether hospitals or other entities) largely misses the factors that are actually driving the greatest vulnerabilities in safe patient care. Much is known about slips and falls, hospital-acquired infections, retained foreign bodies, lost test results — all the visible misadventures in the care delivery environment. But the more subtle risk factors are frequently missed, largely because traditional approaches to reporting are not designed to capture them. As a result, there is very little monitoring and ongoing reporting related to poorly designed processes, human factor issues, communication breakdowns, cognitive failures, and skill-based issues.
This is exactly why malpractice data should have attention paid to it. Even though it can — and often does — defy statistical significance, malpractice data and associated case studies represent critical signals as to where patient care has been at risk, and where it may continue to be at risk.
Legislation passed in Minnesota last fall is directly related to spine surgery. Injured workers who participate in the pilot program will get a clearer understanding of the pros and cons of having a spine fusion. Through what is essentially “a second opinion,” the injured worker and his/her family can make a more educated decision about the treatment options. The Minnesota Department of Labor & Industry also provides a two-page fact sheet explaining what injured workers should know about lumbar fusion surgery as a treatment for degenerative disc disease.2 The fact sheet notes that studies of injured workers show that about half get better after the surgery, with one-third of patients reporting a “poor” result.
The departments of labor and industry in a number of other states routinely publish surgical guidelines for back surgeries. The state of Washington publishes a Surgical Guideline for Lumbar Fusion (Arthrodesis), which addresses the medical necessity and clinical appropriateness of lumbar fusions, in addition to serving as an instructional aid for physicians when treating injured workers who present with low back pain (LBP) and associated symptoms.3
Dr. Hanscom was instrumental in working with a Washington state health plan to implement a policy that would only allow a lumbar fusion for a structural problem, regardless of the amount and effectiveness of non-operative care.
The surgical guideline also clearly states that only single-level fusions will be approved for patients with no prior lumbar surgery. Regardless of the length and type of conservative care, it is Dr. Hansom's position that surgery for LBP is not an option. The common reason given for performing a fusion for LBP is degenerative disc disease. It has been clearly demonstrated in several papers that discs degenerate with age and have no correlation with LBP.4,5 Degenerative disc disease is not a structural problem.
In 2011, the Michigan Hospital Association released a patient safety alert on spine level localization.6 The alert addressed the key issues driving the adverse events and provided a number of recommendations to improve the delivery of care such as appropriate pre-operative images, site marking, and the use of pauses.
Solving Back Pain
Chronic pain is almost always a solvable problem regardless of where it is located in the body. It is one of the core symptoms of the MBS. There are over 30 different manifestations of the MBS, including insomnia, eating disorders, anxiety, irritable bowel syndrome, spastic bladder, fibromyalgia, and migraine headaches. To implement an effective treatment plan first requires the correct diagnosis.
LBP is almost always a soft tissue pain arising from the tissues that support the spinal column. However, whether pain originates from the soft tissues, a structural problem, or is generated from the nervous system, there are always pain impulses processed by the brain that create neurological pathways. The result is similar to an athlete or musician learning a new skill so that the circuits are memorized with repetition. The problem with pain is that the speed of the signals is similar to a machine gun with very rapid input. Once a pain pathway is laid down, it is permanent. There will be pain every time these pathways are triggered.
The solution is centered on calming down the nervous system and re-routing new pathways around the dysfunctional ones. There are three aspects of the Defined Organized Comprehensive Care program.
Education — it is critical to understand that there are not only different sources of pain, there are many variables that affect the perception of pain.
All aspects of pain must be addressed at the same time. The DOCC protocol addresses:
The final aspect is that every patient who has gone to pain free has taken charge of his or her own care. People's lives are far too complex to be “fixed” by the medical profession. The patient/injured worker is the one who has to view the medical world as a resource.
Medical malpractice insurers, workers compensation insurers and organizations self-insuring their workers compensation risk can drive better outcomes. For medical professional liability insurers, educating their physician customers through on-line courses, newsletters, podcasts and patient safety alerts can make a big difference in promoting effective strategies and sharing real life lessons learned. In an ideal world, one could envision better back related protocols in office practice electronic health records, along with the use of surgical checklists and time outs to help avoid wrong level surgery in the hospital setting.
For workers compensation insurers and self-insureds, it is important for claims adjusters, nurse case managers and company risk managers to understand when surgery is and is not appropriate. By recognizing the differences between structural and non-structural pain, appreciating the role sleep plays in successfully treating back issues, understanding the importance of calming down the nervous system, and being knowledgeable about programs, it becomes easier to interact effectively with the injured worker's physician.
1 Carragee, E., et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diagnosis as Determined by Provocative Discography.” Spine (2006); 31: 2115-2123.
4 Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg 1990;72:403– 8.
5 Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain, N Engl J Med. 1994 Dec 1; 331(22):1525.