Seniors’ Surgery for Spinal Stenosis Is Growing More Complex . . .

Spinal stenosis results from progressive degenerative changes in the spine, leading to narrowing of the spinal canal and the ‘windows’ (foramina) between vertebrae.  Compression of the spinal cord and nerves can produce the symptoms of pain, numbness, and weakness in affected areas.  While pain medications, physical therapy, and steroid injections may provide relief, many patients require surgery. 

The simplest surgery is decompression, in which the surgeon cuts away part of the bone that's pressing on nerves.  Fusion of vertebrae using a bone graft, with or without plates and screws, is often done to provide stability.  And more elaborate fusion, called complex fusion, involves 3 or more vertebrae or more than one side of the spine.  Several studies have shown that decompression plus spinal fusion offers no better results for the patient than decompression alone, unless there is a degree of spondylolisthesis (displacement of one vertebrae on another). 

A study in the Journal of the American Medical Association, using Medicare data from 2002 to 2007, has shown that older people with lumbar spinal stenosis are undergoing complex fusion surgery much more frequently, although the total numbers of stenosis operations declined somewhat.  In fact, complex fusion surgeries have increased 15-fold in the 5-year period, without any clear evidence of their improved outcomes.

Complex lumbar fusion surgeries had double the number of major medical complications (e.g. stroke, heart attack, wound hemorrhage, wound infection), and double the 30-day mortality of decompression alone.  And the charges for the procedures were roughly $60,000 to $90,000 for the complex fusion approach, vs. $20,000 to $30,000 for decompression.

Why the shift to more elaborate surgeries?  The article, and an editorial, and an Associated Press report, all suggest that money is the culprit.  For instance, a surgeon’s reimbursement for the complex fusion procedure can be 10 times that for a simple decompression.  And medical instrument firms have been shown to have a financial interest in the testing and use of their specialized instruments and hardware. “Follow the money!”  Of course, if you’re the patient, get a good, independent second opinion before embarking on major surgery.