From Medscape Medical News

Allison Gandey

An increasing number of older patients with spinal stenosis are undergoing lumbar surgery. Clinical trials suggest that for some decompressive surgery offers an advantage over nonoperative treatment.

But investigators led by Richard Deyo, MD, from the Oregon Health and Science University in Portland, point out that surgeons are increasingly recommending more invasive fusion procedures.

Reporting in the the Journal of the American Medical Association, they record a nearly 15% increase in invasive operations.

15% increase in invasive operations

The researchers conducted a retrospective analysis of Medicare claims and report it is unclear why more complex operations are increasing.

"It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just 6 years," they note. "The introduction and marketing of new surgical devices and the influence of key opinion leaders may stimulate more invasive surgery, even in the absence of new indications. Surgeons may believe more aggressive intervention produces better outcomes."

But Dr. Deyo's team also saw more perioperative mortality, major complications, and resource use. The adjusted odds ratio of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval, 2.50 – 3.49).

Table. Risk of Major Complications After Surgery

"It is not surprising that fusion procedures are associated with more complications than decompression alone," Dr. Deyo explained. "Compared with decompression, spine fusion requires more extensive dissection, decortication of bone, longer operative time, and often involves placement of implants."

The adjusted mean hospital charges for complex fusion procedures in the United States was $80,888 compared with $23,724 for decompression alone.

In an accompanying editorial, Eugene Carragee, MD, from Stanford University in California, said the findings should remind patients, surgeons, and payers that the efficacy of basic spinal techniques must be carefully assessed against all of the unproven but financially lucrative alternatives.

"Newer and more complex technologies are being used for patients with little specific indication for the approaches and for whom there is good evidence that simpler methods are highly effective," Dr. Carragee said.

Risky and Expensive

In 2007, Consumer Reports rated spinal surgery as number 1 on its list of overused tests and treatments. Many clinicians agreed this criticism was heavy-handed given the benefit of many basic spinal operations.

Still, medical practice in the United States has been criticized for what some say is a proliferation of risky and expensive practice beyond reasonable supporting evidence.

Dr. Carragee suggests that conflicting economic incentives are at work — especially in spinal surgery. "Simple decompression operations rarely have well-funded advertising campaigns or well-orchestrated promotions at professional meetings," he noted.

Dr. Deyo's study is an analysis of an administrative database, and like most studies such as this one, questions remain about data quality and completeness.

Editorialist Dr. Carragee says that new reimbursement practices and quality surveillance have afforded tangible incentives for accurate coding. "More likely," he suggests, "the data are generally accurate."

This study was funded by the National Institute of Arthritis, Musculoskeletal, and Skin Diseases, the National Institute on Aging, and the National Center for Research Resources. The researchers have disclosed no relevant financial relationships.

JAMA. 2010;303:1259-1265.