Spinal fusion surgery helped Tiger Woods collect another Masters golf championship last month — and a Presidential Medal of Freedom last week — but Minnesota sports medicine specialists caution back-pain sufferers against having similar dreams for a procedure that can be overused and rife with long-term risks.
Many patients saw Woods’ success and wondered if they should have been pursuing surgery all along, rather than using pain relievers or physical therapy, said Dr. Chuck Kelly from the Roseville-based Physicians Neck and Back Center.
“Boy, that is fraught with problems,” said Kelly, whose clinic treats low-back pain with physical therapy. “The majority of people who go through the same thing he did would not have the outcome he had.”
The contradiction between Woods’ success and efforts to limit fusion surgery — at least as a first-choice option for low-back pain — reflects one of the great tensions in American medicine over the past decade.
Spinal fusion, which stabilizes the spine by welding vertebrae together, is the third most common non-obstetric inpatient hospital procedure; more than 463,000 fusions took place in U.S. hospitals in 2014, compared with 316,000 a decade earlier, according to federal data.
Despite that growth, there is little research evidence that fusions work better for common lower-back ailments than less-invasive procedures or nonsurgical options. A group of leading global specialists concluded last year in the Lancet, a British medical journal, that fusions are grossly overused and waste billions in health care spending.
Federal data showed 7,925 fusions in Minnesota hospitals in 2014, a 35% increase from 2004. But Dr. David Thorson, a local sports medicine specialist, said those numbers might be too old to reflect the state’s progress in managing more bad backs without surgery.
“You want to try to treat conservatively, because surgery is not necessarily the best answer,” said Thorson, who helped rewrite treatment standards for low-back pain for the Institute for Clinical Systems Improvement, a Bloomington-based health policy think tank.
Efforts to curb unnecessary fusions have included an education campaign about the most cost-effective back-pain treatments by the Minnesota Health Action Group, a coalition of large companies whose benefit plans cover thousands of workers.
HealthPartners started in 2012 to require people in its health plans to consult medical spine specialists before being approved for fusions. The number of lumbar fusions — those involving vertebrae in the lower back — declined 23% from 2011 to 2013.
Such consults give new options to patients who are grasping for pain relief, said Dr. Kevin Ronneberg, HealthPartners’ associate medical director of health initiatives.
“When people have a lot of pain, it’s easy to perceive that as a serious problem that requires significant intervention,” Ronneberg said. “And that isn’t always the case. … When you talk to most people, they say, ‘I want to feel better,’ not ‘I want surgery.’ ”
Tiger is an outlier
Doctors say Woods’ use of fusion surgery was somewhat typical, because he had reportedly undergone three other surgeries and conservative treatments. Other procedures often tried first include shaving down portions of vertebrae or discs that might be out of position and causing pain by pressing against nerves.
Dr. Christian DuBois, a spine surgeon with Twin Cities Orthopedics, argued that the attention to Woods’ case had benefits, because fusion surgeries have received considerable criticism. “Fusion became almost a boogeyman or anathema,” he said.
Much of the controversy centers on using fusions to treat lumbar pain that is undefined or caused by erosion of the discs that provide padding between vertebrae. But DuBois said fusions are important early options for patients whose back pain is due to infections, traumatic injuries or spinal abnormalities.
How well lumbar fusions work is debatable. Some studies have shown 70% pain reduction for patients. Minnesota Community Measurement, a nonprofit that ranks clinics on their performance, found an average 20 percentage-point reduction in pain levels for patients one year after lumbar fusions.
Kelly said it was remarkable that Woods played four rounds of golf in four days to win the Masters. Most average golfers after fusions might return to the game once a week at most. The doctor said he suspects Woods did so well because of his athleticism and strong core back muscles.
Building those muscles in the absence of surgery is the focal strategy of Kelly’s group, which is part of HealthPartners. Strong core muscles can in some ways replace the stability that’s lost when discs erode.
More surgery later?
Chronic back pain is diagnosed when patients have it for three months or endure two prolonged episodes of pain in a year, Kelly said. “Once you get it, it’s typically not 100% cured, but with treatment and conservative care it becomes for many patients at most a nuisance.”
Dan Sadoff of St. Paul was an early adopter of Kelly’s approach after being recommended for surgery. His pain was so severe it prevented him from walking to the grocery store, much less continue one of his joys, riding horses.
The therapy worked so well that surgery hasn’t been a consideration years later, Sadoff said. “I do sometimes ride horses. I don’t jump 6-foot fences or anything, but I can get on a horse and not worry that it’s going to cripple me.”
The major concern with fusion surgeries isn’t the immediate result, but the likelihood of more surgeries down the road. Fusing vertebrae together adds torque and stress on the sections of the spine immediately above and below, and they can degrade and need treatment.
The surgery can also result in infections or nerve damage. Fusions haven’t been a major source of malpractice lawsuits in Minnesota, though. Constellation, one of the state’s largest medical malpractice insurers, reported only 29 claims out of 4,946 surgeries from 2010 through 2017.
Determining the cause of lower-back pain is one of the major challenges in deciding whether to pursue fusions, DuBois said. Fusions might address disc problems, but they won’t eliminate pain if it also has other causes, including problems with surrounding nerves and joints and even psychological factors.
“That’s the most challenging part of my job,” he said.
Complicating matters are studies that have found disc problems in many people who have no back pain, Kelly said. “That explains why there has been a lot of failed treatments.”
New technologies and techniques are increasing the safety of fusions. Abbott Northwestern Hospital in Minneapolis bought a Mazor X robotic system to increase the accuracy of fusions and the placement of screws and cages to hold vertebrae together while they heal after surgery. Doctors said these advances likely won’t change the consensus that fusions should be tried only after other therapies fail. Even so, they predicted increases in fusions, because the population is aging and suffering more back problems.
“That’s just a demographic trend,” DuBois said. “We’re living longer and we’re developing more issues.”