From technologies to payer systems, many aspects of spine surgery and care that promise benefits could be causing more trouble instead.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.
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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CST Wednesday, Nov. 6.
Editor's note: Responses were lightly edited for clarity and length.
Question: What's something doing more harm than good in spine surgery?
Tan Chen, MD. Geisinger Musculoskeletal Institute (Danville, Pa.): There are more and more spinal procedures, even fusions, being performed by non-spinal surgeons. These are typically practitioners who have not undergone an orthopedic or neurosurgical residency, and subsequently a spine surgery fellowship. Without fully understanding both the short- and long-term risks of specific spinal procedures, these practitioners can often place patients at significant surgical risk postoperatively.
Quentin Durward, MD. Center for Neurosciences, Orthopaedics & Spine (Dakota Dunes, S.D.): I think the biggest new technology doing more harm than good is the spinal surgical robot.
My partners and I tried one of the most popular and commonly used robots over a one year period. Approximately 25 cases were performed by two of us, and in general we found it to be unhelpful, time-wasting and unsafe. The fiddle factor, futzing around and registration inaccuracies added at least an hour to the average case, and still there were a number of misdirected and misplaced screws. We abandoned its use, fortunately without having had a disastrous complication.
Unfortunately this is not the experience everywhere, including that of a major midwestern tertiary referral center. I recently was referred to a patient for a second opinion who had suffered a severe complication from the use of robot screw placement for a routine L3 to L4 degenerative spondylolisthesis. One of the 4 drill-paths went through the right side of the patient's spinal canal and dural sac leading to a severe partial cauda equina injury with permanent lower extremity weakness and loss of sphincteric function.
I recognize that there is always the risk of neurological injury when performing spinal surgery, but in my personal experience now with over 16,000 spinal procedures, I have never seen such an appalling complication. I think the whole issue of technique, training and application of the spinal surgical robot needs to be re-thought with patient safety considerations the first agenda item to be resolved.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The ridiculous payment system we currently use through third party payers is hurting patients. Prior authorization is its own morass but once the surgery is done, the patient does well, and then you try to collect, it’s an additional maze of nonsense. We need to link payment to authorization. When a surgeon submits a claim with the same exact codes they got authorized, there should be zero delay in getting a check out. Patients suffer as more surgeons drop insurance. A single payer model will only exacerbate the lack of access and silo patients even further away and delaying care unfairly.
Jason Liauw, MD. Hoag Orthopedic Institute (Laguna Hills, Calif.): Spinal cord stimulators are good therapeutic options that can be used for chronic or neuropathic pain or failed back syndrome. However, I have seen providers use spinal cord stimulation as a first-line therapy for patients who have severe spinal stenosis. To me, a prescription of using spinal cord stimulation as a therapy to reduce pain without addressing underlying severe spinal stenosis is doing more harm than good because the therapy is not addressing the root cause of the problem. Additionally, with further degeneration and compression of the nerves, the stenosis can progress, and the patient will suffer permanent neurological damage.