State of Spine Care
The state of spine care in the USA
Despite technological advances in diagnosis and treatment options for spinal conditions, the state of spine care in the USA appears to be getting worse. After more than 30 years as a provider for spine sufferers (both in the UK and USA), and as one who has spent a lot of that time exploring and developing the least traumatic approaches to spine conditions, I feel it is incumbent upon me to share my experience publicly. The purpose of this write-up is to highlight the problem of spine care, and to share solutions which I have applied for the benefit of my patients.
Problems with Spine care include, but are not limited to, lack of standardized approach to spine care; lack of universal anatomic classification of spinal disease; lack or inadequate communications between different spine care professionals; lack of expertise in the cutting edge, least traumatic surgical care of the spine; denial of surgical options to specific demographics, especially the younger and older age groups; and reliance on chronic use of opioid medications which is leading to epidemics in the use of opioid related disorders and deaths.
Opioid pain relievers are often prescribed for chronic spinal pain. About 45% of low back pain sufferers are treated with opioid pain medications chronically, and most of these patients also have additional medical conditions, such as depression and anxiety, which may have resulted from their chronic back conditions.
In 2012, an estimated 2.1 million Americans suffered substance abuse disorders related to prescription opioid pain medications. The number of unintentional overdose-deaths related to prescription opioids has more than quadrupled since 1999. In 2014, 1,700 young Americans between the age of 18-24, died from prescription drug overdoses. (mainly opioids) 91 Americans die of prescription opioid overdoses every day!
What are some of the reasons for the inadequacies of spine care in the USA?
- The Lack of standardized approach to spinal conditions: – there are three joints at each mobile segment of the spine (one disc and two facet joints), each joint may cause spinal symptoms individually or in combination with others; multiple motion-segments are superimposed on each other; and more than one segment may have evidence of disease, contributing to the patient’s symptoms. These anatomic facts, often, make it difficult to clinically determine exactly which joint (or disc) is responsible for the patient’s symptoms. This has led to emergence of multiple treatment options which are used in less than organized manner.
- Lack of universal, anatomic image-based classification of spinal motion-segment disease – Despite imaging technologies such as MRI and CAT scans giving us detailed anatomic information of the spine, there is no universally accepted, precise classification system of the anatomic localization or severity of the diseased entity. The lack of such precise classification system has led to vague descriptions of the spinal disease and offer of treatment options based on such descriptions.
- Lack of co-ordination of spine care across specialties – Because of lack of standardized protocol for spine care, the pain management doctors and spine surgeons often don’t have formal channel of communication. This problem is made worse by the fact that the pain doctors and spine surgeons, often, function independently and not as a team.
- Lack of adequate tailoring of spine care based on the patient’s clinical attributes – Young and elderly patients are, often, denied surgical option. Conventional spine surgery, and many of the so-called minimally invasive surgery, may not be appropriate for a 16-year-old teenager, and may be too traumatic for an elderly patient. Hence, many of these patients often end up being treated with opioid medications chronically.
- Heavy reliance on un-physiologic surgical treatment approach – When spine is fused, that segment no longer shares the stresses associated with spinal motions. The result is, less number of joints are left to bear the stresses of normal spinal motion. Thus, fusion fixes the patient’s current problem and set the stage for next problem by accelerating wear and tear at the neighboring levels.
- Problem with health insurance companies: Health insurance companies often deny pre-authorization of the newer, less traumatic procedures because they consider them experimental or unproven. A case in point is a technique my colleagues and I developed about 22 years ago – Arthroscopic Thoracic Discectomy and Interbody Fusion. Even today, some insurance companies consider the technique experimental and would rather pay for the patient’s chest to be opened, to remove a fragment of herniated thoracic disc.
Spine Industry: There is reluctance to invest in technologies which restore the physiologic functions of the spine!
What are the solutions to the problem of spine care?
The treatment of spinal conditions is often difficult and efforts must be made, by all concerned, to offer a precise, anatomic, least traumatic, and safe treatment options, thus avoiding the trap of ever increasing narcotic medication which may have catastrophic consequences for the patient, family, and society. Here are some principles I have used successfully in my practice, and some thoughts about way forward in the care of spine sufferers:
1. Application of standardized protocol – Protocols which combine pain management and surgical treatment for the care spinal problems in a manner that avoids repetitions, thus, placing the patient on the path to cure as expeditiously as possible, need to be adopted urgently! Such an approach avoids repeated injection and ever increasing dosages of opioid medication and their attendant complications!
2. Application of precise anatomic, image-based classification of spinal disease – Such a classification defines the anatomic structures that are abnormal and grade the severity of the abnormality in a concise manner, so that physicians across specialties can communicate with each other precise terms. My colleagues and I have developed such anatomic classification system which I use regularly, to grade the spinal disease process and tailor treatment to the classification and the patient’s clinical presentation.
3. Application of the least invasive spine technology – My colleagues and I have developed endoscopic spine surgical techniques and published them over the years, and these techniques are now mainstream in Europe, Asia, and South America! But less than 1% American spine surgeons use the technology, currently! The least invasive nature of these techniques has allowed us to relieve spinal pain in the very young, the elderly, and those with other medical conditions, often, under sedation.
4. High standards – Proper training of surgeons in the techniques of endoscopic spine surgery, using standardized treatment protocols and precise anatomic classification system is needed to speed up adoption of modern surgical technologies. Such high quality approach to spine care, will help resolve patients’ problems, and make results of publications of spine care more credible.
5. Independent, National Committee to determine safety and effectiveness of new spine technologies – Insurance companies often refuse to authorize surgical options because the procedure is considered “experimental”. It is time to consider formation an independent national committee of spine specialists, statisticians, economists, etc., to determine what is experimental or clinically proven to be helpful to the patient and is an appropriate choice for a specific disease entity. Such determination must be based on the review of publications which employ precise anatomic classification of the diagnoses, thus facilitating comparison of like with like.
6. Spine Industry: Spine device manufacturers should be encouraged to invest in the least traumatic, physiologic, motion-preservation technologies, so that the risk of patients returning, repeatedly, for extension of fusion is minimized! This is particularly important for the younger patients who are considered not candidates for conventional procedures.
7. Detoxification: For patients who are suffering from opioid related disorder, a standardized protocol to wean them off these medications should be established by all practices. This should be followed, in a coordinated fashion, with surgical or other means of resolving the underlying spinal condition, and weaning them off opioids.
Said G Osman, M.D., F.A.A.O.S., F.R.C.S.Ed, F.R.C.S.Ed. (ortho)