Public health

Guidelines needed to stem the flow of spinal fusions

New guidelines and better access to pain clinics are urgently needed to stem the huge rise in “unnecessary” spinal fusions intended to treat non-specific low back pain, says a leading Australian neurosurgeon and pain medicine physician.

Associate Professor Leigh Atkinson, from Wesley Pain and Spine Centre in Brisbane, said both patients and surgeons often had “unrealistic expectations” that spinal fusions will eliminate non-specific low back pain.

He said a recent Australian study on trends in spinal surgery had noted a significant increase in the rate of fusions, over a 10-year period, of 175%. The rate had increased from 8.4 per 100 000 to 23.1 per 100 000, and 69.9% were instrumented.

“Patients expect new technology will work miracles,” he told the limbic. “And if the patient is determined sometimes it’s easier to do the surgery than argue with the patient.”

He said he supported the introduction of guidelines for spinal fusions, and suggested that surgeons undertake a national audit of patient-centred outcomes for the procedure, similar to the audit carried out for hip and knee arthroplasties by the Australian orthopaedic surgeons.

He said there were many underlining factors that could contribute to low back pain, including depression, inactivity, and other psychological and social stressors. Sometimes they can also be driven by the desire for financial gain through insurance or workers’ compensation, he said.

Addressing these issues could go a long way to helping treat pain without the need for expensive and invasive surgery.

“We can’t cure depression with an operation,” he said. “There is a place for guidelines.”

Professor Leigh Atkinson was talking about a Perspective  he co-authored in this week’s MJA with Associate Professor Andrew Zacest from Royal Adelaide Hospital.

They wrote that patients often had high expectations from modern medicine and expect a surgical solution to their back pain.

They cited a study of patients receiving workers’ compensation in New South Wales found surgery outcomes were so poor that the benefits were marginal.

“The incidence of persistent post-operative pain syndrome was as high as 40% and … there was a 50% success rate, at best, from the first operation, 30% from the second and 15% from the third,” the authors explained.

The authors referred to a Cochrane review of surgical fusions for back pain in 1999 that concluded there were no published randomised controlled trials which established effectiveness of fusions for chronic pain. In 2004, a review again concluded that there was insufficient evidence for effectiveness of surgery for a firm conclusion to be drawn. A further Cochrane review in 2005 reported “variable clinical outcomes ranging between 16% and 95%”.

“There was no evident difference, over a period of two years, between artificial disc replacement and the less expensive fusion technique,” they wrote.

Professor Atkinson told the limbic that many patients with non-specific low back pain presented to a surgeon having self-diagnosed through the internet, and were determined to have surgery as an answer to their problem.

“A lot of chronic pain can’t be resolved with surgery and it also can’t be resolved with opioids in some cases,” he said.

“It is complex and needs a multi-disciplinary response rather than just jumping in to do surgery.”

He said patients should be referred to pain clinics, where such multi-disciplinary teams work together, and should seek second opinions before embarking on surgery. He said governments needed to better fund these clinics to allow all patients access.

“Pain clinics can be expensive but there is growing evidence of their efficacy and cost-effectiveness,” he said.

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