Over our careers, we have witnessed numerous occasions wherespine surgery was not in the best interest of the patient, employerand ultimately, the treating physician performing the surgicalprocedure.

This article will provide some background on when spine surgeryshould be performed, the impact on the insurance industry, andeducation that can be used to help others take control of theirfuture in order to drive better outcomes for all.

The Need for Spine Surgery

In his book, Back in Control: A Spine Surgeon's Roadmap Outof Chronic Pain, David Hanscom, M.D., explains the importanceof understanding the two sets of variables that affect the decisionto undergo spine surgery: the source of the pain and whether thepatient is under a significant amount of stress, which may or maynot be related to the pain.

The source of pain falls under two categories: structural ornon-structural. A structural problem is one that is clearlyseen on a diagnostic test and there are matching symptoms. Incontrast, non-structural pain originates from soft tissues or canoriginate directly from the nervous system. Neither of thesenon-structural pains can be identified on an imaging study. Softtissues have a high density of pain fibers and frequently, withongoing irritation, the pain generated can be severe and prolonged.When the brain generates pain impulses without a source, it iscalled the Mind Body Syndrome (MBS). Surgery can only be successfulfor a structural problem.

Chronic anxiety, frustration, and eventual depression affectboth the perception of pain and the capacity to cope with it. Ifthe nervous system is “fired up,” it has been repeatedly shown thatsurgical outcomes will be compromised. It is critical to calm downthe nervous system prior to undergoing surgery or even making anydecisions about it.

Since what cannot be seen cannot be fixed, Dr. Hanscom does notrecommend surgery, under any circumstances, for non-structuralissues. His focus is on explaining why the patient likely does notneed surgery and how he or she can overcome chronic pain by using aself-directed structured spine care program. He uses a process thatevolved out of his personal experience with chronic pain —Defined Organized Comprehensive Care (DOCC).

Much of spine surgery is performed on patients with non-specificpain and no identifiable source. The success rate in thiscircumstance is less than 30 percent at two-year follow up, and thedownside is significant.¹

Dr. Hanscom notes that for a patient to be ready for anysurgery, he or she must also be sleeping at least seven hours anight for three months and have an anxiety/frustration level belowa five on a scale of 10. Additionally, he or she should be activelyengaged in learning about the pain and exercising. Even when thesegoals are achieved, surgery should be performed only on anidentifiable structural problem with matching symptoms. Surgeryrarely, if ever, solves non-specific lower back pain (LBP).

Workers Compensation

Over the years, workers' compensation insurers and self-insuredorganizations have seen clusters of spine surgeries emerge in theirclaims data. In discussions with medical professionals, claimsadjusters, risk managers, and environmental and health safety(EH&S) professionals, the conversations usually come back toinjured workers being told that spine surgery was a “cure all”(e.g., spine fusion). These spikes have often been observed incertain areas of a state where word spreads throughout theworkforce about a surgical remedy or a treating physicianperforming a high number of these surgeries.

Surgical outcomes in the workers' compensation population areless successful than the general population. Dr. Hanscom realizedabout 15 years ago that people on workers' compensation tend to beangrier than the general population. Not only are they experiencingongoing pain, they are often caught up in a system that provideslimited options and have a feeling of no control, which leads tofrustration 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 anamped-up nervous system has a lower chance of resolving pain.

Medical Professional Liability

National malpractice data shows that the top two categories ofmalpractice cases are diagnosis-related cases and surgical cases.With some regional variability, diagnosis cases account forsomewhere between 24 to 30 percent of all cases, and surgery isclose behind at 20 to 25 percent. The dollars associated with thesetwo categories are astronomically high, largely because themajority of cases represent high-severity injury events.

A close examination of surgical malpractice cases reveals thatthe three most frequently named surgical specialties are generalsurgery, orthopedic surgery, and neurosurgery. This begins tosharpen the focus as to where the greatest risks lie. A furtheranalysis into procedure type fills out the risk profile: thesurgery most frequently involved in malpractice-related scenariosis spine.

These spine cases may relate to any one of the following:

• Technical errors — in spine cases, just the slightest slip intechnique can sometimes lead to a catastrophic outcome.

• Errors in cognition/judgment — making a wrong decision while thesurgery is in progress.

• Human factors/systems errors — operating on the wrong level, orother scenarios which result from interruptions in the surgeon'sconcentration.

• Poor outcomes associated with operating on a patient wheresurgery was not medically indicated.

• But is malpractice data meaningful? Many would argue that it issuch a thin slice of the world of healthcare data, there is limitedvalue in using it for analysis. However, we would take the oppositeposition.

In many event types, data traditionally — and routinely —collected by healthcare organizations (whether hospitals or otherentities) largely misses the factors that are actually driving thegreatest vulnerabilities in safe patient care. Much is known aboutslips and falls, hospital-acquired infections, retained foreignbodies, lost test results — all the visible misadventures in thecare delivery environment. But the more subtle risk factors arefrequently missed, largely because traditional approaches toreporting are not designed to capture them. As a result, there isvery little monitoring and ongoing reporting related to poorlydesigned processes, human factor issues, communication breakdowns,cognitive failures, and skill-based issues.

This is exactly why malpractice data should have attention paidto it. Even though it can — and often does — defy statisticalsignificance, malpractice data and associated case studiesrepresent critical signals as to where patient care hasbeen at risk, and where it may continue to be at risk.

Moving Forward

Legislation passed in Minnesota last fall is directly related tospine surgery. Injured workers who participate in the pilot programwill get a clearer understanding of the pros and cons of having aspine fusion. Through what is essentially “a second opinion,” theinjured worker and his/her family can make a more educated decisionabout the treatment options. The Minnesota Department of Labor& Industry also provides a two-page fact sheet explaining whatinjured workers should know about lumbar fusion surgery as atreatment for degenerative disc disease.² The fact sheetnotes that studies of injured workers show that about half getbetter after the surgery, with one-third of patients reporting a“poor” result.

The departments of labor and industry in a number of otherstates routinely publish surgical guidelines for back surgeries.The state of Washington publishes a Surgical Guideline for LumbarFusion (Arthrodesis), which addresses the medical necessity andclinical appropriateness of lumbar fusions, in addition to servingas an instructional aid for physicians when treating injuredworkers who present with low back pain (LBP) and associatedsymptoms.³

Dr. Hanscom was instrumental in working with a Washington statehealth plan to implement a policy that would only allow a lumbarfusion for a structural problem, regardless of the amount andeffectiveness of non-operative care.

The surgical guideline also clearly states that onlysingle-level fusions will be approved for patients with no priorlumbar surgery. Regardless of the length and type of conservativecare, it is Dr. Hansom's position that surgery for LBP is not anoption. The common reason given for performing a fusion for LBP isdegenerative disc disease. It has been clearly demonstrated inseveral papers that discs degenerate with age and have nocorrelation with LBP.^4,5 Degenerative disc disease isnot a structural problem.

In 2011, the Michigan Hospital Association released a patientsafety alert on spine level localization.⁶ The alertaddressed the key issues driving the adverse events and provided anumber of recommendations to improve the delivery of care such asappropriate pre-operative images, site marking, and the use ofpauses.

Solving Back Pain

Chronic pain is almost always a solvable problem regardless ofwhere it is located in the body. It is one of the core symptoms ofthe MBS. There are over 30 different manifestations of the MBS,including insomnia, eating disorders, anxiety, irritable bowelsyndrome, spastic bladder, fibromyalgia, and migraine headaches. Toimplement an effective treatment plan first requires the correctdiagnosis.

LBP is almost always a soft tissue pain arising from the tissuesthat support the spinal column. However, whether pain originatesfrom the soft tissues, a structural problem, or is generated fromthe nervous system, there are always pain impulses processed by thebrain that create neurological pathways. The result is similar toan athlete or musician learning a new skill so that the circuitsare memorized with repetition. The problem with pain is that thespeed of the signals is similar to a machine gun with very rapidinput. Once a pain pathway is laid down, it is permanent. Therewill be pain every time these pathways are triggered.

The solution is centered on calming down the nervous system andre-routing new pathways around the dysfunctional ones. There arethree aspects of the Defined Organized Comprehensive Careprogram.

• Education — it is critical to understand that there are not onlydifferent sources of pain, there are many variables that affect theperception of pain.

• All aspects of pain must be addressed at the same time. The DOCCprotocol addresses:

  |

  • Sleep

  • Stress

  • Medications

  • Goal Setting

  • Physical conditioning

• The final aspect is that every patient who has gone topain free has taken charge of his or her own care. People's livesare far too complex to be “fixed” by the medical profession. Thepatient/injured worker is the one who has to view the medical worldas a resource.

Medical malpractice insurers, workers compensation insurers andorganizations self-insuring their workers compensation risk candrive better outcomes. For medical professional liability insurers,educating their physician customers through on-line courses,newsletters, podcasts and patient safety alerts can make a bigdifference in promoting effective strategies and sharing real lifelessons learned. In an ideal world, one could envision better backrelated protocols in office practice electronic health records,along with the use of surgical checklists and time outs to helpavoid wrong level surgery in the hospital setting.

For workers compensation insurers and self-insureds, it isimportant for claims adjusters, nurse case managers and companyrisk managers to understand when surgery is and is not appropriate.By recognizing the differences between structural andnon-structural pain, appreciating the role sleep plays insuccessfully treating back issues, understanding the importance ofcalming down the nervous system, and being knowledgeable aboutprograms, it becomes easier to interact effectively with theinjured worker's physician.

Footnotes

¹ Carragee, E., et al. “A Gold Standard Evaluation ofthe 'Discogenic Pain' Diagnosis as Determined by ProvocativeDiscography.” Spine (2006); 31: 2115-2123.

² http://www.dli.mn.gov/WC/Pdf/fact_sheet_lumbar_fusion.pdf

³ http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/LumbarFusion.pdf

⁴ Boden SD, Davis DO, Dina TS, Patronas NJ, WieselSW. Abnormal magnetic-resonance scans of the lumbar spine inasymptomatic subjects. A prospective investigation. J Bone JointSurg 1990;72:403– 8.

⁵ Jensen MC, Brant-Zawadzki MN, Obuchowski N, ModicMT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbarspine in people without back pain, N Engl J Med. 1994 Dec 1;331(22):1525.

⁶ http://www.mnhospitals.org/Portals/0/Alert_Advisory_3-16-11.pdf