Q: What is the biggest challenge facing spine surgeons today?
Jaideep Chunduri, MD, Spine Surgeon, Beacon Orthopaedics & Sports Medicine, Cincinnati: The biggest challenges spine surgeons face today are several and include the lack of objective and documented studies on the efficacy of procedures as well as bone grafting substitutes. Insurance companies are making criteria strict for patient selection for surgery sometimes to the detriment of patients. In addition, bone grafting products and newer technologies are being greatly scrutinized as being experimental even though several products (ie Viotss) have some great clinical background. Patients come to my office everyday stating they want to have surgery but will not have it if I take iliac crest bone graft as they know that can be a painful portion of the procedure. Unfortunately, with the expensive medical environment we live in, doing these studies can be impossible.
Dennis Crandall, MD, Founder and Medical Director of Sonoran Spine Center, Mesa, Ariz.: Getting the care our patients need authorized and paid for by insurance carriers. A close second for us is finding a way to make Medicare reimbursement cover our costs. We are very close to not being able to care for Medicare patients, given the level of reimbursement.
Richard Kube, MD, Founder & CEO, Prairie Spine and Pain Institute, Peoria, Ill.: There are many challenges we constantly face such as decreasing reimbursements, increasing regulations and paperwork, greater malpractice concerns etc. These issues all tend to boil down to the fundamental need for time. Time is that most precious commodity that is eroded by the added regulations and paperwork. We spend numerous hours with patient and professional advocacy issues, constantly lobbying to continue providing valuable services to our patients. We still need to spend time for maintenance of board certifications and core competency in our areas of practice. There are added benchmarks of quality control and outcomes that are followed to satisfy payor requirements. These issues all lead to less personal and family time to maintain personal health and well-being if we are to maintain our current standards of living and level of service to our patients.
Steven Lee, MD, Spine Surgeon, Muir Orthopaedic Specialists, Walnut Creek, Calif.: Curing the common problem of “low back pain” is the Holy Grail of our field. There are various accepted surgical treatments available to treat some of these patient based on their diagnosis. However, the majority of patients with low back pain do not have a clearly identified cause. Also, current treatment options have had variable outcomes.
A big interest has been trying to regenerate and restore injured or degenerated discs back to health. Techniques studied have involved gene therapy, biologic materials and autologous cell treatments. None of these has been tested enough to prove their effectiveness and safety. It seems that within the next five years or so, I believe a breakthrough may come to help certain patients with low back pain. For example, a subset of patients with severe back pain that is believed to be due to “annular tears” may be able to be treated with biologic agents injected directly into or near the injured disc to promote healing of the tear. This may be able to prevent chronic back problems from developing.
A second challenge involves our aging population. People are living longer with expectations of maintaining an active lifestyle. More are unfortunately experiencing degeneration of their spine. The first priority in this population is identifying which patients will benefit from surgical treatment. Second, we need to reduce complication rates associated with surgery, such as infection or anesthesia related events. Third, surgeons need to continue to improve techniques to improve recovery times and get patients back to activities.
Scott Tromanhauser, MD, Spine Surgeon, Boston Spine Group: I am seeing increasing scrutiny of my recommendations for more complex spinal procedures. These are the procedures for which there is an insufficient evidence base, specifically, spinal fusion procedures. Many insurers in my area use very strict criteria for approval of spinal fusion, essentially limiting its use to cases of trauma, well documented instability, and tumors. Spinal fusion for degenerative disease is under attack. Without doubt it is an over applied procedure. There are clearly patients who benefit greatly from fusion but it is sometimes difficult to distinguish those patients from patients who will not do well.
The consequence is that we have created a perception that fusion just doesn’t work. Those of us who use this procedure carefully and with the best selection criteria know that it can change people’s lives. Just because there isn’t a strong evidence base to support it doesn’t mean fusion doesn’t work. Unfortunately spine surgeons are either “Lumpers” or “Splitters” when it comes to fusion for degenerative spinal disease. Lumpers fall into two categories at either end of the spectrum. On one end there are those that feel they can’t tell who will get better so they operate more often in the mistaken belief that they are helping everyone who could potentially benefit. The down side to this is that they wind up operating on too many people who won’t get better.
At the other end of the Lumper spectrum are those that feel that can’t tell who will get better but take the position that they won’t operate on anyone which denies many patients life changing surgery. Both positions are a display of lazy thinking. We do know from decades of clinical research that there are some patient characteristics that portend a poor outcome so avoiding surgery in those patients is wise, no matter how much pain they have or how much non-operative care they have been through. On the other hand, if a patient doesn’t have these well known factors then they shouldn’t be deprived this surgery. Splitters are in the middle and take these patient characteristics into consideration and thereby help as many as possible but not hurt anymore than necessary to achieve that goal.