Complex low back surgery – Sharp spike, but is there a benefit?


Study finds 15-fold increase in more invasive surgery among Medicare patients. Complex lower back surgery has a greater risk of life-threatening complications, sometimes without providing better results for older patients

There was a 15-fold increase in the rate of complex lower back surgeries performed on older Americans from 2002 to 2007 that caused more life-threatening complications, according to a study published in the Journal of the American Medical Association (JAMA) co-authored by Richard A Deyo, Kaiser Permanente Professor of Evidence-Based Family Medicine at Oregon Health & Science University.

This sharp rise in invasive operations nationwide caused more re-hospitalisations, more expensive hospital stays and more deaths, researchers found. The surgeries were performed to treat lumbar spinal stenosis.


The study, which appeared in the 7 April issue of JAMA looked at patients 65 and older who are covered by Medicare. “The risks of spine surgery are particularly important for older patients,” Deyo explained.

The results call into question treatment trends. “Studies have found that less complex surgeries are generally as effective for treating problems in the lumbar region as the more invasive fusion procedure,” he said. “But the rate of the less complex surgeries has declined while the number of more complicated surgeries has dramatically increased.”


There were 1.3 complex fusion procedures per 100,000 Medicare patients in 2000. It jumped to 19.9 operations per 100,000 Medicare patients in 2007. It is not clear why more complex operations are on the rise. The marketing of new surgical devices and financial incentives to hospitals may play a role in the trend, the study says.


Deyo has stated: “It may be prudent to consider whether other treatments, including less complicated operations, are a better tool for treating spinal stenosis.


All operations are not the same. Some seem associated with higher complication rates than others. It is  not necessarily true that the more aggressive surgery is better, at least in terms of safety.

“Patients should ask their doctors about alternatives to complicated operations,” he said.


Spinal News International asked Deyo some questions:

You have said that the trend of increasing complex spinal surgery is, in part, related to the introduction of new technology, such as spinal cages and special screws used to fuse vertebrae together…

As new surgical devices are introduced and marketed, surgeons often want to try them, and often believe they will be valuable, though data on clinical outcomes are sometimes meagre. As an example, there was a surge in fusion operations after fusion cages were introduced in 1996, even though the indications for spine fusion really had not changed.


“There is little evidence that these more complex operations actually improve pain relief or functional recovery.” Could you please put this statement in perspective?


Some randomised trials suggest that for most patients, simple fusion, as we defined it, is just as effective at producing pain relief and functional recovery as the more complex operations. So the two types of procedures appear in most cases to be equally effective, though the more complex procedures are associated with more complications.


For many patients with spinal stenosis, decompression alone–the least invasive operation–appears to be as effective as either type of fusion.


What is your key message to spine-specialist readers of Spinal News International from the results of the study?


Complex fusion procedures are increasing rapidly, without a clear scientific rationale. This appears to be associated with higher complications and higher costs. These older patients are often more frail and at higher risk of complications than younger spine surgery patients. It may often be appropriate to consider the least invasive type of surgery that can relieve the stenosis in these elderly patients.


Did the study have any limitations?


With this type of data (insurance claims), we could not assess pain relief or functional recovery. So we focused only on complications and re-hospitalisations. Also, the ICD-9 procedure codes do not have complete information about surgical details, such as use of implants. We also have no way of verifying the diagnoses (such as imaging results or exam findings), and must depend on the diagnoses reported.


In this time of healthcare scrutiny, do you think there will be more such studies looking for clear-cut evidence-based benefits?


I think these studies of comparative effectiveness (or in our case, comparative safety) will become much more common.