Advocacy Alert: Journalists Using Sensationalistic Stories to Bias Public Opinion about Spinal Fusion Surgery
January 10, 2011
The International Society for the Advancement of Spine Surgery (SAS)
Lumbar Fusion Evidence & Policy Review Task Force
The Bloomberg business news website recently published an article asserting that fusion is an unnecessary and unfounded procedure.(1)The article is unscientific and based on incomplete information. The International Society for the Advancement of Spine Surgery (ISASS) would like to take this opportunity educate the business community about the medical benefits of lumbar fusion surgery.
The Bloomberg article is based primarily on sensationalistic anecdotal patient stories, not on a review of the scientific medical evidence. Although patient stories are always highly captivating to read, the medical world considers them to be one of the worst forms of evidence to use as a basis for evaluating treatment or making healthcare decisions.(2-4) The patients presented by the Bloomberg article are not representative of the usual outcomes of fusion surgery, and they cannot be properly assessed in a news article devoid of all their relevant medical data, x-rays, and so on. Assessments of lumbar fusion should be based on fair and balanced reviews of the published scientific evidence,(5-7) not on sensationalistic journalism.
The Bloomberg article asserts that “evidence is lacking” for lumbar fusion. This is patently false. There are numerous good quality clinical trials on lumbar fusion available in the literature.(8-15) ISASS is currently reviewing these scientific studies on lumbar fusion. It is telling that the Bloomberg article completely overlooked or ignored the best clinical trial to date on lumbar surgery – the SPORT study – a high-quality multicenter randomized comparative trial, funded by the NIH for $15 million and published in the top medical journals.(16-19) The SPORT trial for stenosis concluded that “patients who underwent surgery showed significantly more improvement in all primary outcomes than did patients who were treated nonsurgically”.(17) The success rates continue to improve gradually each year as new and better technologies are developed – often by American companies – such as minimally invasive approaches to fusion.(20)
It is true that some low back pain patients will not improve from surgery. These failed patients often have issues with substance addiction, worker’s compensation claims, litigation, and unrecognized psychiatric co-morbidity such as depression, anxiety, and somatization.(21-24) The Bloomberg article richly illustrates all these issues in the patient stories it tells. The spine surgery community has long been aware of these potential pitfalls, but they are difficult to identify and navigate, especially if the patient is in pain, distressed, and demanding surgery.
We are all doing our best to help the patients get well and lead healthy lives. The scientific evidence shows that lumbar fusion surgery has a reasonably good probability of providing meaningful clinical benefit in properly selected back pain patients.(8-15) But there is no magic wand in medicine. Healthcare will be improved by further excellent research (such as the Comparative Effectiveness Research (25-28) recently promoted by the US government as part of healthcare reform and economic recovery), not by sensationalistic, one-side, poorly-informed mudslinging in the popular press.
1. Waldman P, Armstron D. Doctors Getting Rich With Fusion Surgery Debunked by Studies. New York: Bloomberg; 2010. Accessed on 1 January 2011, at: http://www.bloomberg.com/news/2010-12-30/highest-paid-u-s-doctors-get-rich-with-fusion-surgery-debunked-by-studies.html.
2. Centre for Evidence Based Medicine. Levels of Evidence. Oxford: Oxford University; 2009. Accessed on 4 January 2011, at: http://www.cebm.net/index.aspx?o=1025
3. GRADE Working Group. Grading quality of evidence and strength of recommendation. BMJ. 2004; 328: 1490.
4. Wright JG. A Practical Guide to Assigning Levels of Evidence. Bone Joint Surg Am. 2007; 89: 1128-1130.
5. Errico TJ, Gatchel RJ, Schofferman J, Benzel EC, Faciszewski T, Eskay-Auerbach M, Wang JC. A fair and balanced view of spine fusion surgery. Spine J. 2004; 4: 129S-142S.
6. Resnick DK, Choudhri TF, Dailey AT, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine – Part 1: introduction and methodology. J Neurosurg Spine. 2005; 2: 637-638.
7. Pearson AM, Weinstein JN. Introduction [Evidence-Based Medicine for the Spine]. Semin Spine Surg. 2009; 21: 201.
8. Resnick DK, Choudhri TF, Dailey AT, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine – Part 7: intractable low-back pain without stenosis or spondylolisthesis. J Neurosurg Spine. 2005; 2: 670-672.
9. Resnick DK, Choudhri TF, Dailey AT, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine – Part 8: lumbar fusion for disc herniation and radiculopathy. J Neurosurg Spine. 2005; 2: 673-678.
10. Resnick DK, Choudhri TF, Dailey AT, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine – Part 9: fusion in patients with stenosis and spondylolisthesis. J Neurosurg Spine. 2005; 2: 679-685.
11. Resnick DK, Choudhri TF, Dailey AT, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine – Part 10: fusion following decompression in patients with stenosis without spondylolisthesis. J Neurosurg Spine. 2005; 2: 673-678.
12. Moschetti W, Pearson AM, Abdu W. Treatment of Lumbar Disc Herniation: An Evidence-Based Review.Semin Spine Surg. 2009; 21: 223-229.
13. White AP, Albert TJ. Evidence-Based Treatment of Lumbar Spinal Stenosis.Semin Spine Surg. 2009; 21: 230-237.
14. Berven SH, Herkowitz HN. Evidence-Based Medicine for the Spine: Degenerative Spondylolisthesis.Semin Spine Surg. 2009; 21: 238-245.
15. Coe M, Mirza S, Sengupta D. The Role of Fusion for Discogenic Axial Back Pain Without Associated Leg Pain, Spondylolisthesis or Stenosis: An Evidence-Based Review. Semin Spine Surg. 2009; 21: 246-256.
16. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis. NEJM. 2007; 356: 2257-2270.
17. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis. NEJM. 2008; 358: 794-810.
18. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation: the Spine Patient Outcomes Research Trial (SPORT) Observational Cohort. JAMA. 2006; 296: 2451-2459.
19. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation: the Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial. JAMA. 2006; 296: 2441-2450.
20. Errico T. The Promethean Role of Industry in Spine Surgery Research. J Spinal Disord Tech. 2010; 23: 491-492.
21. Krebs EE, Lurie JD, Fanciullo G, Tosteson TD, Blood EA, Carey TS, Weinstein JN. Predictors of Long-Term Opioid Use Among Patients With Painful Lumbar Spine Conditions. J Pain. 2010; 11: 44-52.
22. Carreon LY, Glassman SD, Kantamneni NR, Mugavin MO, Djurasovic M. Clinical Outcomes after Posterolateral Lumbar Fusion in Workers’ Compensation Patients: A Case-Control Study. Spine. 2010; 35: 1812-1817.
23. LaCaille RA, DeBerard SM, Masters KS, Colledge AL, Bacon W. Presurgical biopsychosocial factors predict multidimensional patient outcomes of interbody cage lumbar fusion. Spine J. 2005; 5: 71-78.
24. Zieger M, Schwarz R, König H-H, Härtner M, Riedel-Heller SG. Depression and Anxiety in Patients Undergoing Herniated Disc Surgery: Relevant but Underresearched – A Systematic Review. Cent Eur Neurosurg. 2010; 71: 26-34.
25. Iglehart JK. Prioritizing Comparative-Effectiveness Research — IOM Recommendations. NEJM. 2009; 361: 325-328.
26. Sox HC, Greenfield S. Comparative Effectiveness Research: A Report From the Institute of Medicine. Ann Intern Med. 2009; 151: 203-205.
27. Avorn J. Debate about Funding Comparative-Effectiveness Research. NEJM. 2009; 360: 1927-1929
28. Conway PH, Clancy C. Comparative-Effectiveness Research — Implications of the Federal Coordinating Council’s Report. NEJM. 2009; 361: 328-330.