What are the current issues in orthopaedic spine care?

Current Issues in Orthopaedic Spine Care

Rising Surgical Volume and Healthcare System Strain

The most pressing issue in spine orthopaedics is the dramatic increase in surgical procedures occurring alongside an aging population, creating unsustainable healthcare costs and access challenges. Between 1992 and 2003, lumbar fusion surgeries among Medicare patients increased from 0.3 to 1.1 per 1,000 enrollees, with annual spending rising 500% to $482 million by 2003 1. More concerning, complex fusion procedures increased 15-fold between 2002 and 2007, from 1.3 to 19.9 per 100,000 beneficiaries 1.

• The proportion of Americans over age 65 is projected to reach 20% by 2030, driving increased demand for spine surgery 2
• Lumbar epidural steroid injections increased by nearly 900,000 procedures annually between 1999 and 2009 2
• Physical therapy evaluations increased by 1.4 million visits per year during the same period 2
• Within Medicare databases, there was a 16.5% decrease in lumbar diagnoses but an 18.5% increase in fusion procedures between 2006 and 2012 3

Complications and Morbidity in Elderly Patients

The expansion of surgical indications and complexity has led to significantly increased complication rates, particularly in older patients. Patients over 65 years demonstrate a 70% increase in complication rates following lumbar fusion compared to patients aged 45-64 1. This creates a critical tension between meeting surgical demand and managing perioperative risk.

• Instrumented fusion procedures carry complication rates of 31-40% compared to 6-12% for non-instrumented procedures 1, 4
• Interspinous process device implantation shows higher reoperation rates than standard spinal decompression 1
• The aging population presents with multiple comorbidities including osteoporosis, which complicates surgical planning and outcomes 5, 6

Evidence-Quality Gaps and Clinical Uncertainty

A fundamental problem is the low quality of evidence supporting many common spine procedures, with GRADE quality ranging from very low to low for most interventions 1, 7. This creates uncertainty about which patients truly benefit from surgery versus conservative management.

• Meta-analyses comparing surgical decompression to conservative treatment show similar effects for operative and non-operative interventions 1
• Lumbar spine fusion shows no difference in Oswestry Disability Index scores compared to non-operative management, but is associated with surgical complications 1
• No randomized controlled trials have compared lumbar spinal decompression or fusion with placebo or sham surgery 1
• Different surgical techniques (PLIF, TLIF, ALIF) show no consistent differences in outcomes when compared to each other 1

Cost-Effectiveness and Economic Burden

The lack of comprehensive economic analyses creates uncertainty about whether improved fusion rates justify the substantial costs of new technologies and biologics. There is insufficient data to perform meaningful cost-effectiveness analyses for most fusion procedures 1.

• Medicare reimbursement may underestimate real charges and grossly overestimate true costs 1
• New methodology is needed for long-term assessment of health costs 1
• The cost of bone morphogenetic proteins (BMPs) must be weighed against incremental improvements in outcomes 1, 4
• Despite beneficial effects on fusion rates, current literature has not adequately addressed whether improved fusion rates justify costs, especially for routine degenerative disease 1

Overutilization and Inappropriate Indications

A critical issue is the 20-fold regional variation in lumbar fusion rates among Medicare enrollees—the largest variation for any surgical procedure 1. This suggests significant overutilization in some regions and potential underutilization in others.

• Fusion is being performed in patients without documented instability or spondylolisthesis, despite lack of evidence supporting benefit 7, 4
• Many patients undergo surgery without completing comprehensive conservative management including formal physical therapy for 6 weeks to 3 months 7, 4
• Discography should NOT be used as a stand-alone test for treatment decisions, as it may accelerate degenerative processes 7

Osteoporosis Management Challenges

Osteoporosis has historically been considered a contraindication for spinal surgery, yet the aging population increasingly presents with this comorbidity requiring surgical intervention 5. This creates technical challenges with instrumentation and fusion.

• Osteoporosis predisposes patients to fracture, progressive deformities, and stenosis 5
• Advances in surgical technology now make it possible to operate successfully on elderly osteoporotic patients 5
• Careful attention to surgical technique and instrumentation selection is required 5, 8

Technology Adoption Without Adequate Evidence

New technologies including bone graft substitutes, minimally invasive techniques, and interbody devices are being adopted without adequate long-term outcome data or cost-effectiveness analyses.

• Bone morphogenetic proteins demonstrate excellent fusion rates but are associated with complications including postoperative radiculitis (14% incidence), osteolysis, and heterotopic bone formation 1, 4
• Total disc replacement shows superiority over traditional fusion with improved pain, satisfaction, reduced reoperation rates, and shorter hospital stays 1, 7
• Minimally invasive TLIF offers modest advantages including less blood loss and shorter hospital stays, but with longer fluoroscopy time 1

Future Research Imperatives

The most critical need is for prospective randomized trials with long-term follow-up that include comprehensive economic analyses and patient-centered outcomes 1. Specific priorities include:

• Determining optimal approaches for interbody fusion at different lumbar levels with lowest complication rates and highest fusion rates 1
• Identifying patient populations at risk for pseudarthrosis who would benefit from BMPs 1
• Establishing cost-effectiveness of various fusion methods with long-term clinical outcomes data 1
• Creating prospectively registered databases to report efficacy and complications of new approaches 1