FAQ Category: General Spine

You are asking a good question and one that will be of interest to many other people. Up to 80 per cent of all adults will have back pain at least once (and often more than once) in a lifetime, so this is a significant problem.

No one has a perfect answer yet because we still don’t know what treatment works best. Physical therapists have contributed some answers by looking at patients who got well with certain specific treatments. They used this information to start classifying patients by treatment results rather than by diagnoses. Finding groups of patient characteristics that suggest one treatment would be more beneficial than another for each patient is one way to approach the problem.

There are also groups who have published recommendations for treatment based on best-evidence available. These are called Clinical Practice Guidelines (CPGs). For example, right now, the recommended standard-of-care for acute episodes of low back pain is conservative (nonoperative) care. This begins with pain relievers, a day or two of rest, then activity modification while staying as active as possible.

This approach results in improvement within two weeks for the majority of patients. For those who do not respond to this plan, referral to a chiropractor or physical therapist may be advised. If several months of care under the supervision of these individuals does not yield improvements, referral to a specialist may be the next step.

There isn’t a quick and easy answer for patients like yourself who have gone the full route of visits to all of these health care providers. You fall into a category referred to as chronic pain. There are specialty pain clinics set up to help individuals whose bodies have not responded to standard care. Chronic pain is more of a management issue — helping you find ways to increase your activities and function within the confines of your pain (and without increasing your pain).

You may be able to realize a cost savings by consolidating all of your care with a management team. And if you were able to achieve some of your goals, it would be money well-spent.

Patients in need of major surgeries like spinal procedures are faced with some unique dilemmas. Back (and sometimes buttock or leg pain) keep you from being active. Physical inactivity can lead to weight gain. Obesity is a risk factor for many potential post-operative complications from infection and blood clots to heart attacks, stroke, and even possible death.

Surgeons are trained to assess and evaluate each patient individually. Studies have provided clear information about predictive risk factors. This refers to patient characteristics that can predict a positive (or negative) outcome. Surgeons must select patients for success — your success, not theirs. They want you to have the best results possible with the fewest adverse events.

Weight loss and smoking cessation are two important keys to good or better health. These are not unreasonable requests or requirements before surgery. Together your actions to improve your health will insure a better outcome following surgery.

There are many helps available in most communities that focus on these two lifestyle changes. TOPS (taking off pounds sensibly), Weight-Watchers, support groups, and smoking cessation clinics have proven success in helping people change the direction they are going (or as in your case, prepare for surgery).

Talk with your doctor (or the clinic nurse) about options that might work for you. Try to see this as an investment in your health, your future. It may take some time to accomplish but the results are well-worth it. Some patients have even reported no longer needing surgery when they were able to stop smoking, lose a little weight, and get more active.

You may want to explore other possibilities as well. For example a fitness coach can assist you in setting up a reasonable, do-able exercise program. A life coach can help you identify your life goals and pursue them successfully. Other tools to aid in changing difficult behaviors such as hypnosis, acupuncture, meditation, yoga, tai chi, qi gong and so on are also possibilities.

That is a very good question and one that leaves even the surgeon’s scratching their heads. So much so that a group of surgeons from New York University Hospital for Joint Diseases went back through their patient records for a two-year period of time to see how often these unplanned readmissions occurred and why.

Patients included in the study had one of 12 common spine procedures (e.g., spinal fusion, kyphoplasty, laminectomy). There were a total of 3673 people operated on with 156 of these patients requiring return to the hospital. That works out to be a 3.8 per cent overall readmission rate.

Most of the readmissions (90 per cent) were unplanned. In the remaining 10 per cent, the patient was scheduled for a two-part (staged) procedure and came back for the second surgery. Lumbar stenosis (narrowing of the spinal canal) and disc herniation were the two most common problems patients were being treated surgically.

Taking a closer look at the data collected, the authors divided the readmissions into two groups: those who had surgical complications and those who had nonsurgical complications. Infection was definitely the biggest problem for both groups.

Surgical complications occurred most often in patients who had more spinal levels fused (average of six spinal segments). There were difficulties with implants (plates, screws) caused by infection or wound drainage in a smaller number of patients. Nonsurgical complications were most often related to GI problems and systemic illness with a few cases caused by heart, lung, or neurologic conditions.

Does any of this describe what might have contributed to your father’s difficulties? Patient factors such as general health, pre-existing conditions (heart disease, cancer) and obesity can make the difference between smooth sailing and problems that linger.

We agree though we aren’t sure what kind of preparation you have in mind. Medical complications following spinal surgery do account for a rather high rate of unplanned readmissions to the hospital. This can be very confusing to the patient and upsetting to the family.

A smooth transition from hospital to home does require careful planning and management involving both the hospital staff and family members. Almost 25 per cent of all early readmissions to the hospital after spinal surgery can be traced back to medical complications. This could include a previous history of cancer, heart disease, and obesity. Or it could be the development of blood clots, pneumonia, or infection.

Any of these problems that develop (or get worse) as a result of surgery can cause delays in discharge and even a return to the hospital shortly after discharge. A closer analysis of all the factors present in patients who do go back to the hospital might reveal some helpful clues. For example, there may be certain aspects of the surgical procedure that is contributing to the high rate of infection. Or patient factors such as general health, pre-existing conditions (heart disease, cancer) and obesity may make a difference.

In addition to screening patients more carefully before surgery, closer postoperative monitoring may be a useful way to reduce readmissions. Studies show that medical complications after surgery are a big factor. And this may be one cause hospital staff can change with coordinated efforts and planning. If you have specific ideas that might help your local group, a letter or phone call with your suggestoins might be welcome.

The United States Census keeps track of different racial groups such as Native Americans, Hispanics, and Asian or Pacific Islanders. States like California that have a hospital database also collect information on patient demographics. Besides race, they also record gender (male versus female), age, place of residence, your weight, and the procedure you are having done. In addition, the records also contain how many days patients were in the hospital and the total costs.

Data like this makes it possible to study a large number of people for a variety of different reasons. For example, in a recent study from California, researchers looked at the effect of morbid obesity on complications and complication rates associated with spinal fusion.

Obesity is defined by a body mass index (BMI) of 30 or greater. Morbid obesity is determined by a BMI of 40 or more. The BMI is a measure of body fat based on height. It isn’t the only way to identify obesity but it is a quick and easy method to get a general idea of relative sizes.

They looked at four groups of patients based on location of the fusion (cervical or lumbar) and type of surgical approach (anterior or posterior). As part of the study, they also collected data on race including four groups: white, black, Asian or Pacific Islander, and Native American.

Analysis of the data did not show a statistically significant effect of race on results. They found that morbid obesity was, in fact, the single most significant predictor of postoperative complications. The rate of complications among the morbidly obese was 97 per cent higher than among patients of normal weight.

That high rate was consistent for all types of postoperative problems (e.g., heart attacks, blood clots, pneumonia, infections). Fortunately, the death rate was not higher in those who were morbidly obese. Overall costs were increased by 28 per cent. Older age combined with morbid obesity resulted in even higher complication rates.

Race as a biologic patient characteristic is typically not as much of a risk factor that requires a specialist to treat you. The most common underlying factor is really how you live, what your lifestyle choices are, and your willingness/motivation to make healthy choices. Surgeons must watch out for patients who smoke, who are overweight, or who are not likely to follow their instructions. Any of these choices can lead to higher postoperative problems and complications.

We recently reported on a study performed at the University of Pennsylvania in Philadelpia about the cost of complications and comorbidities associated with spinal surgeries. With more and more people seeking health care for back problems, this seemed like an easy one to spot and bring to the attention of everyone interested in reducing health care costs.

The authors start out with the basic proposition that many people in need of spinal surgery also suffer from other health problems such as high blood pressure, diabetes, cancer, obesity, neurologic problems and many others. As you know, these additional conditions are referred to as comorbidities. Patients often have more than one comorbidity. And then there are the complications that can occur after surgery. Comorbidities and complications take their toll on patients but can also add quite a bit to the hospital bill and cost of health care overall.

Data on 226 patients undergoing spinal surgery for a variety of reasons was collected. Age, sex (male or female), body mass index (BMI, an indicator of obesity), number and type of comorbidities, type of procedure, and type and number of complications were reported and analyzed. The researchers determined which problems are the most significant but also looked at the costs.

They found that although high blood pressure (hypertension) was the most common comorbidity, the problems that caused the most difficulty were pulmonary (blood clots, pneumonia), improper positioning of hardware used in spinal fusions, new neurologic problem (caused by the surgery), and wound infection.

Costs started escalating when a problem developed as a result of being in the hospital. This is referred to as a hospital-acquired condition or HAC, a concept you are probably very familiar with. Those additional costs spiraled upwards as complications increased in number or severity. Longer hospital stays required more care and greater use of resources. The result was an increase in the cost to insurance companies (or payers like Medicare). When the costs were greater than the reimbursement, then hospitals took a financial hit, too.

The question arises: should patients with multiple health problems be refused surgery? This study actually shows that the majority of problems were caused by the hospitalization and/or the surgery itself. And many of the problems required an additional surgery further raising costs associated with hospital acquired conditions.

What can be done to change all this? The authors do not offer any immediate solutions. They suggest the move to electronic medical records will make it possible to track costs and risk factors more closely. Likewise, any interventions applied to the problem can be analyzed to find the most efficient and effective course of action for each problem.

Being able to identify patients at risk and predict the likelihood of a complication may help target those patients for prevention. As this study shows, much of the burden for change lies with improving internal measures (e.g., surgeon technique, hospital care) to reduce complications (and thereby costs).

This is an excellent question and one that some researchers are actively studying. Many people in need of spinal surgery also suffer from other health problems such as high blood pressure, diabetes, cancer, obesity, neurologic problems and many others. These additional conditions are referred to as comorbidities. Patients often have more than one comorbidity. And then there are the complications that can occur after surgery. Comorbidities and complications take their toll on patients but can also add quite a bit to the hospital bill and cost of health care overall.

In a recent study from the University of Pennsylvania, the effect of comorbidities and complications (both minor and major) are examined. The researchers determined which problems are the most significant but also looked at the costs.

Efforts are being made to contain costs. Hospitals, private payers, and government are starting to take a closer look at what’s going on and how to cut costs. This study is an example of those efforts. The focus here is on patient characteristics that affect the cost of spinal care. Along with known risk factors such as obesity and smoking, other areas of health concerns were included.

Data on 226 patients undergoing spinal surgery for a variety of reasons was collected. Age, sex (male or female), body mass index (BMI, an indicator of obesity), number and type of comorbidities, type of procedure, and type and number of complications were reported and analyzed.

They found that although high blood pressure (hypertension) was the most common comorbidity, the problems that caused the most difficulty were pulmonary (blood clots, pneumonia), improper positioning of hardware used in spinal fusions, new neurologic problem (caused by the surgery), and wound infection.

Costs started escalating when a problem developed as a result of being in the hospital. This is referred to as a hospital-acquired condition or HAC. Those additional costs spiraled upwards as complications increased in number or severity. Longer hospital stays require more care and greater use of resources. The result is an increase in the cost to insurance companies (or payers like Medicare). Likewise, when the costs are greater than the reimbursement, then hospitals take a financial hit, too.

Questions such as you raised come up: should patients with multiple health problems be refused surgery? Who is responsible to pay when problems develop outside the patient’s control and possibly the result of the care they received (or didn’t receive)?

This study actually shows that the majority of problems were caused by the hospitalization and/or the surgery itself. And many of the problems required an additional surgery further raising costs associated with hospital acquired conditions.

eing overweight is a definite risk factor for back pain associated with spinal degeneration. Surgery in the form of spinal fusion may benefit obese patients but is also linked with higher complication rates, especially for those who are in the category of morbid obesity.

Obesity is defined by a body mass index (BMI) of 30 or greater. Morbid obesity is determined by a BMI of 40 or more. The BMI is a measure of body fat based on height. It isn’t the only way to identify obesity but it is a quick and easy method to get a general idea of relative sizes.

You can go to the U.S. Department of Health & Human Services website and easily calculate your own BMI (http://www.nhlbisupport.com/bmi/).

In a recent study from California, researchers looked at the effect of morbid obesity on complications and complication rates. California has a database with information on every patient who goes into the hospital anywhere in the state. Information is collected on a broad range of patient demographics such as age, gender, race, insurance coverage, and procedure performed. Patient body weight is another variable entered into the database. Using this database, the researchers were able to find 1,455 morbidly obese patients who had spinal fusion surgery.

The type of surgery was divided into four groups: cervical and lumbar fusions and anterior or posterior approach for those two locations. Total time in the hospital, total costs, and all complications were also recorded and available for comparison among the four groups. They found that morbid obesity was, in fact, the single most significant predictor of postoperative complications.

The rate of complications among the morbidly obese was 97 per cent higher than among patients of normal weight. That high rate was consistent for all types of postoperative problems (e.g., heart attacks, blood clots, pneumonia, infections). Fortunately, the death rate was not higher in those who were morbidly obese. Overall costs were increased by 28 per cent. Older age combined with morbid obesity resulted in even higher complication rates.

The authors of the California study were not suggesting that morbidly obese individuals should not have spinal fusion. On the contrary, they pointed out that individuals who are morbidly obese seem to benefit from spinal fusion as much as adults who are not obese. The main idea from these findings is the need to reduce patient risks when pre-operative weight loss is not an option.

Surgeons don’t perform spinal surgery on just anyone without a strong chance that the procedure will help the patient. Possible complications are always considered ahead of time. And if a patient has too many risks, surgery may not be advised. In a recent study from the University of Washington in Seattle, surgeons explored the various risks for medical complications after spine surgery. The information they presented may help you.

In this study, they used national databases of information (e.g., Medicare, Worker’s Compensation, National Inpatient Sample) collected on thousands of patients. The amount of data collected in studies like this can be very helpful. Demographic factors such as age; gender; use of tobacco, alcohol, or other drugs; and diagnosis can be factored in. Body mass index (an indication of obesity), presence of other health problems (e.g., diabetes, high blood pressure, heart disease, history of cancer) can also be considered.

In this study, they also looked at area of the spine operated on (cervical, thoracic, lumbar, sacral) and the underlying pathology (degenerative, trauma, tumor, infection, fracture). The surgical approach (anterior, posterior, combined) was also recorded and compared with the number and type of complications after surgery. All patients were followed for at least two years after the first spinal surgery.

The most common problem after spinal surgery was pulmonary complications (e.g., acute respiratory distress syndrome, pneumonia). This was followed by hematologic complications (e.g., blood loss requiring transfusion, blood clots), urologic problems (e.g., urinary tract infections), and cardiac complications (heart attack, arrhythmias, heart failure).

Other problems involving the gastrointestinal (GI) system or neurologic complications though less common were also reported. GI bleeding, colitis, or ascites (fluid in the abdomen) were the most common adverse events. Neurologic problems stemmed most commonly from strokes, delirium, electrolyte imbalances, and seizures.

After gathering and analyzing all the data, they found the two strongest risk factors for complications after spinal surgery were age (older than 65) and extent of surgery (invasiveness). Surgical invasiveness refers to the number of spinal levels involved, the amount of hardware used, and the approach (anterior, posterior, both). A special scoring system was used to calculate level of invasiveness for each procedure.

Two other risk factors affecting almost all the body systems were hypertension (high blood pressure) and anemia. History of diabetes, heart disease, and thoracic surgery were major risk factors affecting four of the six major organ systems included in this study. Patients who had cardiac or pulmonary complications were four to 10 times more likely to die during the first two years after surgery.

That last statistic sounds pretty grim. The actual number of patients who die from complications after spinal surgery is pretty low. The best thing to do is to sit down with your surgeon and review your specific risk factors. The decision to have surgery, the type of surgery, and the invasiveness of the procedure can be influenced in part by considering potential complications but also looking at the likelihood that you would be at risk for any of those problems.

Every surgery comes with its own set of risks and possible problems. The surgeon and all the staff do everything possible to prevent such things as infections, but it can still happen. And the presence of MRSA (methicillin resistant Staphylococcus aureus) heads the list of potential risk factors for surgical site infection following spinal surgery.

Your quote about hindsight being accurate is quite true for many things. To use another common expression, “the best defense is a good offense.” Generally the idea is that offensive action preoccupies the opposition and ultimately its ability to directly harm. In the world of surgery, reducing the risk of infection is the number one defense AND offense.

Studies have been able to show which patients are at risk for surgical site infection after spinal surgery. And now there is new evidence to help surgeons identify who might be at increased risk for multiple clean up procedures (called irrigation and debridement). There’s even a scoring system surgeons can use to determine at the first diagnosis of surgical site infection who is likely to need a series of wound debridement procedures.

With that information, the surgeon can set up counter measures to prevent this from happening whenever possible. The end result is reduced hospitalization and costs and increased patient satisfaction with less need for that hindsight you mentioned.

Your preoperative care of yourself is one thing you can do to aid in a faster recovery with fewer complications. Good nutrition, adequate sleep at night, and staying hydrated (drinking fluids until they tell you to stop) are all good ways to go into surgery in the best health and able to resist “bugs” (bacteria) that cause infection.

The longer your preoperative hospital stay, the greater your chances for infection because you will be exposed to more bacteria during that time. Patients who have hardware put in (metal plates, wires, pins or screws) are at increased risk for infection. And patients who have diabetes or who are obese are also at increased risk for postoperative infections.

The surgeon and his or her staff are also aware that if you develop a wound infection, your risk of continued infection (despite antibiotic and surgical treatment) is increased due to six additional factors. These include: 1) location of infection in the spine, 2) patient’s health (presence of other diseases like diabetes, pneumonia, or heart disease), 3) type of infection, 4) presence of infection elsewhere in the body, 5) use of hardware in the spine such as metal plates and screws, and 6) the need for bone graft for the initial spinal surgery.

Your surgical and postoperative team will do everything they can to reduce your risks and help prevent infection. Likewise, they will do what is necessary to decrease the need for surgery. When antibiotics do not clear up the problem, a procedure called irrigation and debridement to clean the wound area may be needed (sometimes more than once if the infection persists).

Follow any instructions you are given before and after surgery. Report any unusual or developing symptoms that might suggest a new infection (e.g., fatigue, scratchy throat, fever, nausea). Early diagnosis and intervention for any infection is ideal and will give you the best results should it happen.

Any type of surgery has risks and the potential for complications afterwards. Sometimes adverse events occur during the procedure while others are postoperative. Some postoperative problems occur immediately. Others don’t crop up for weeks, months, or even a year or two.

Because of liability, surgeons must inform all patients of all potential risks — even if these are unlikely to happen. Some patients have certain risk factors that can increase the chances of something unfortunate happening. For example, with spinal surgery, we know that older age (65 and older) is a red flag risk factor. So is an extensive (invasive) spinal procedure.

Surgeons are usually very careful in their patient selection. They want the patients to have a successful outcome. That’s why assessing and discussing risks for complications is an important part of the pre-operative work up. The decision to have surgery, the type of surgery, and the invasiveness of the procedure can be influenced in part by considering potential complications.

Your mother’s decision to cancel her surgery may really be the best thing right now — either based on what the surgeon told her, her own gut feelings, or both. This may be just a postponement for now. She can always reschedule the procedure at a later time if further information reveals less risk for her than she thought.

Actually, a report of a FDA-monitored clinical trial just came out about a product that sounds suspiciously like what you are asking about. It’s called oxiplex gel and the reported results sound good so far.

Oxiplex gel is made up of carboxymethylcelulose, polyethylene oxide, and calcium. It can be applied to all the soft tissues around the surgical site after discectomy (disc removed to take pressure off the nerve). A coating of the gel is placed on the nerve root, annulus fibrosus (covering around the disc), and dura (lining around the spinal cord). It works like teflon to create a mechanical barrier that keeps out pain messages. And it even reduces the amount of scar tissue called fibrosis that can develop after surgery.

In this particular study, two groups of patients were compared: one group received the oxiplex while the second (control) group did not. Patients in both groups had the same surgical procedure: a single level laminectomy or laminotomy and discectomy. A laminectomy involves cutting away some of the back of the vertebral bone (the lamina) in order to remove the central portion of the herniated disc. In a laminotomy, the surgeon drills a hole through the lamina to aspirate (suck out) the disc.

The results were measured based on back and leg pain before and after surgery and presence of other distressing (adverse) symptoms. Patient satisfaction and number of disability days were also compared. And each patient was examined for neurological and motor function (e.g., numbness, weakness, dizziness, headache, loss of sensation, muscle or joint pain, stiffness, muscle spasm). The last comparison made between the two groups was the number of reoperations necessary due to pain.

After analyzing all the data collected, they found that for patients with severe pain before surgery, the use of oxiplex gel made a significant difference. Those folks had less postoperative back and leg pain, fewer reoperations, and greater satisfaction with the results. There were also fewer patients in the oxiplex gel group who had adverse effects after surgery and there were fewer abnormal musculoskeletal problems as well.

From this preliminary study, it looks like this new oxiplex gel is safe and effective for relieving the postoperative pain many patients experience after discectomy. This was especially true for the more challenging patients who had severe back pain before surgery (a group likely to experience persistent pain after surgery).

One of the other advantages of the oxiplex gel was the prevention of cerebrospinal fluid leaks. With the gel painted on the dura, the fluid was contained, which also prevented any postoperative headaches. Other applications of this product may be discovered with further research and study. From what we know so far, you are spot on with your suggestion!

Spinal injections are used for people with back pain that has not improved with conservative care. Such injections include epidural steroid injections, nerve blocks, radiofrequency neurotomy (heat nerves to stop pain transmission), sacroiliac injections, and discography (injecting dye into the disc to look for disc protrusion or herniation).

There is a concern about this pattern of overuse because as you point out, research does NOT support this treatment as an effective way to manage back pain. And in the case of spinal injection treatment, more is not better. In other words, if the first three injections didn’t help, further injection therapy isn’t likely to benefit the patient either.

In studies of Medicare and VA patients, the majority of spinal injection procedures were being done by a small number of medical specialists. Anesthesiologists, neurologists, and physicians at specialty pain clinics were the ones most likely to be giving these injections.

And the top 10 per cent of providers were responsible for one-third of all spinal injections. Similar patterns of overuse were found in a recent study at the University of Colorado School of Medicine by using data entered into a central database for privately insured adults

The authors of that particular study pointed out it is important to remember that all high utilization doesn’t necessarily mean overuse. There may simply be some physicians who are so skilled at this treatment that patients do get better. They spread the word and before you know it, more patients are going to the same physicians. But there is a way to find out if this is really what is happening.

And this study sheds light on the subject. By showing who is doing how many procedures and then evaluating the results, it is possible to see whether improved outcomes are the result of clinical expertise. It looks more like a certain group of physicians are using spinal injections to treat more people than should be included (based on evidence of who is a good candidate for this procedure). It is also possible (though not proven yet) that these same providers are accepting less than optimal results. And profit can certainly be a strong motivator for some physicians.

What can be done about this pattern of overutilization of spinal injection procedures? Guidelines for the responsible use of injection spine procedures must be published based on high-quality evidence. Such guidelines would give physicians a standard by which to guide treatment decisions. Insurance companies could also use the guidelines to base reimbursement on.

That sounds simple enough but what may be excessive for one patient may be just right for another. Some insurance companies have set limits and restrictions (e.g., only covering four injections in a six month period).

Until major guiding organizations such as the North American Spine Society can give more than suggestions for the use of spinal injections, perhaps treatment should be guided by practice consensus (best opinions of current experts based on current evidence).

You are exactly right that studies have shown Medicare and VA (Veterans Administration) patients receive a large number of spinal injection procedures. Spinal injections are used for people with back pain that has not improved with conservative care.

Such injections include epidural steroid injections, nerve blocks, radiofrequency neurotomy (heat nerves to stop pain transmission), sacroiliac injections, and discography (injecting dye into the disc to look for disc protrusion or herniation).

There is a concern about this pattern of overuse because research does NOT support this treatment as an effective way to manage back pain. And in the case of spinal injection treatment, more is not better. In other words, if the first three injections didn’t help, further injection therapy isn’t likely to benefit the patient either.

In studies of Medicare and VA patients, the majority of spinal injection procedures were being done by a small number of medical specialists. Anesthesiologists, neurologists, and physicians at specialty pain clinics were the ones most likely to be giving these injections. And the top 10 per cent of providers were responsible for one-third of all spinal injections.

You are not alone in wondering about the use of spinal injections in the private sector. As a result of reports of overutilization of spinal injections, a new study was set into motion. Researchers at the University of Colorado School of Medicine looked for similar patterns of overutilization among privately insured adults.

They found similar patterns of overuse by using data entered into a central database for privately insured adults between the ages of 18 and 99. Billing codes were used to calculate how many of each type of spinal injection were given to each patient over a 12-month period of time.

Ten per cent of all injections were given by the same providers (neurologist and pain management specialists). This group of physicians did nine times as many procedures per patient than providers in the lowest 10 per cent group. And more than half of all spinal injection procedures were done by 20 per cent of the providers who did these kinds of injections.

This was not a small study. There were 200,000 patients, 20,000 physicians, and over 875,000 injections given. Besides the groups already mentioned (anesthesiologists, pain management specialists, neurologists), other types of providers giving spinal injections included orthopedic surgeons, radiologists, internal medicine physicians, neurosurgeons, physiatrists, and family practice physicians.

When considering your own hospital situation, you may want to read the study for yourself.The authors concluded that policy makers must be very careful with the information provided in their study. It would not be in the best interest of patients to rush in and cut and slash services — especially if those services (i.e., spinal injections) are helping someone in pain.

They suggest, it may be too soon for aggressive regulations. But certainly when a small number of physicians are providing a large number of treatments that have not been shown effective, it’s time to target those cases and take a closer look.

Fear of movement (also known as fear-avoidance behavior or FAB) is fairly common after whiplash injuries. Some people respond to pain with anxiety about their pain and fear about what it might do to them. They start to catastrophize the pain (build up negative thoughts in their minds about pain).

Before you know it, they are no longer moving freely out of fear that certain movements and actions “might” cause pain. They stop moving and start avoiding activities they previously enjoyed freely. Over time they become deconditioned and even disabled.

It sounds like your therapist thinks this model applies to you. There are ways to test for fear-avoidance beliefs and behaviors. Special surveys just to measure fear avoidance beliefs have been developed and tested. For example, the Tampa Scale of Kinesiophobia, Pictorial Fear of Activity Scale, Fear Avoidance Beliefs Questionnaire, and Photograph Series of Daily Activities are in use by many health care professionals who work with people who have chronic low back pain.

Testing patients with post-whiplash (neck) pain using these same tools is a fairly new focus of research. It is not possible to assume that neck pain after whiplash influences (fear-avoidance) behavior and leads to disability just because this relationship has been shown for low back pain. A separate analysis is necessary, which is why some researchers are starting to take a closer look at measuring fear of movement in patients with chronic neck pain following whiplash injuries.

You may want to ask your therapist to review the results of these tests with you if you have already taken them and that’s how she knows you are experiencing fear-avoidance behaviors. Or, if you haven’t taken any of these tests, this may be a good time to do so to confirm (or rule out) catastrophizing or fear avoidance beliefs in your situation.

If none of these suggestions work for you, it may be time to consider seeing a different therapist. But be prepared for the same approach with another therapist if there is, in fact, a strong influence of fear and anxiety fueled by your pain and affecting your movement.

It sounds like the pain clinic has made some policy changes based on a recent study published by the University of Colorado School of Medicine. The study was done because it has become obvious that spinal steroid injections, nerve blocks, sacroiliac joint injections, and heat treatments to kill nerve endings have reached explosive numbers. For example, they showed that in a 12-month period of time almost one million of these interventionalprocedures were done on 200,000 patients.

The patient database used for this study only included privately insured patients. Medicare, worker’s compensation, motor vehicle insurance, and Veterans Administration were not included. About 12 to 14 million people from all 50 states were represented in this study. And that only represents about five per cent of the total U.S. population surveyed. So it’s likely that many, many more of these interventional spinal procedures are really being done.

But is that so bad? Perhaps these numbers reflect the fact that physicians have found a treatment that works for back pain. And once they sharpen their skills by doing more of these procedures, their results improve. Word spreads and more people seek their services. That is one possible scenario.

But the authors of this study think it’s more likely that a small number of physicians have found an easy way to make a profit. They suggest that overutilization of these procedures is contributing to the high cost of health care without corresponding high-quality evidence to support this treatment.

Here’s a closer look at what they uncovered. Only a few providers are responsible for a disproportionately high number of interventional spinal procedures. Neurologists and pain specialists are at the top of the list for the number of these spinal procedures that are done. In fact almost 40 per cent of all spinal pain procedures mentioned here are done by this small group of physicians.

What is the significance of these findings? The bottom-line in the economics of health care is preventing overutilization and cost containment. This study showed that a small number of providers are responsible for a large number of interventional spinal procedures for back pain.

This pattern of high utilization may represent overutilization and may be behind changes in this pain clinic’s policies. Studies like this help shape health care policy by calling for accountability that includes reasonable and justifiable treatment guidelines.

There is no reason not to seek a second opinion. There may be individual factors in your case that would still suggest steroid injections is the appropriate treatment. Don’t be surprised though if you get the same response as the staff at the first clinic offered. Most of the research to date shows that this type of conservative approach really does work best for most people.

Universally accepted guidelines on the use and number of epidural steroid injections (ESI) have not been established or published as yet. That’s because research just hasn’t shown convincing, reproducible, reliable evidence that this treatment works any better than a placebo.

Right now, based on what little evidence there is, the North American Spine Society has issued a statement onthe use of ESI for cervical pain. They have “suggested” a maximum of four injections over a six-month period of time.

Since there is no evidence-based accepted guideline in this area, insurance companies are free to set their own limits. The insurance company that administers Medicare coverage in many states currently limits ESI for cervical pain to three injections in a six-month time period. Other private insurance companies use this to determine their limitations as well.

Does this mean all patients will get the maximum benefit possible in three treatments? No — in fact, it is recognized by patients and physicians alike that there may be a variety of individual factors that could make two or four (or some other number of injections) the best choice for some patients.

One thing you may be able to take to your insurance company is a letter from your physician stating why a fourth injection is being recommended. It might be helpful if the physician mentioned in that letter of justification what the North American Spine Society’s 2011 recommendations are on this point:

A maximum of four ESI injections in six months is suggested for cervical radicular pain. An absolute limit of four cervical ESIs per year would seem inappropriate and may overly restrict some patients from receiving necessary and reasonable care. You can find a copy of these recommendations on-line at http://www.spine.org/Documents/CESI_RR_032811.pdf.

In the Canadian study you mentioned, data from a large university hospital was reported. From this report, we get an idea just what kinds of morbidity (problems) and amount of mortality (deaths) occur in adults undergoing spinal surgery. This particular university setting serves 4.5 million people. In a year’s time, there were 942 patients who had emergency or elective (planned) spinal surgeries.

The researchers conducting the study used a spine specific system called the Spine AdVerse Events Severity System (SAVES V2) to collect the data. This tool is designed to collect complete and accurate information about all complications from minor to major. Data was collected before, during, and after spinal surgery.

The SAVES V2 form includes a place to record the severity of each problem. The grade given each problem ranged from the number one (event does not require treatment and has no adverse effect) to six (adverse event resulting in death). Some examples of these intraoperative “adverse events” include allergic reactions, heart attack, blood loss, pressure sores, nerve root injury, or other organ injury. Intraoperative refers to complications and problems that developed during the operation.

Pre- or post-operative adverse events ranged from heart failure, blood clot, and wound infection to delirium, pneumonia, urinary tract infection, and cerebrospinal leak. In both categories (intraoperative and pre- or post-operative), surgeons could report and record “other” complications and provide a description of what that was.

Besides collecting data about specific adverse events, the authors also took this opportunity to compare their results using this tool against the more traditional (and previously used method) of reviewing patient charts some time after treatment to assess results.

They found that the old method significantly under-recorded postoperative events. The SAVES system was much more accurate and thorough. Deaths were more likely to occur in patients requiring emergency surgery for gunshot wounds, cancer, traumatic neck injuries, and spinal infections. Older adults with traumatic injuries were at the greatest risk of death during spinal surgery.

Four per cent of the total group had to have a second surgery. There was a variety of reasons for this including infection, nerve pain, problems with hardware, and the need for additional decompression of disc herniations. Infection was the number one reason why patients were readmitted to the hospital during the first year following the primary (first or initial) surgery.

Not surprisingly, the types of adverse events were different during surgery compared with after surgery. Blood loss, dural tears, and anesthetic-related problems were the most common intraoperative complications. After surgery, electrolyte imbalances, problems caused by medications, heart complications, urinary tract infections, and spinal deformities were among the most problems reported.

The SAVES tool used by this Canadian group brought to light the significant underreporting of complications associated with complex spinal surgeries. How those statistics compare to U.S. surgeries will only be known if a similar American study is done and results can be contrasted between the two groups.

There’s no doubt complex spinal surgeries come with a whole host of potential complications and post-operative problems. Cancer metastasizing (spreading) to the spine is a particularly challenging problem. Without knowing the details of type of cancer (e.g., fast versus slow-growing) and location (e.g., vertebral bones, spinal cord, spinal column), we won’t be able to be specific.

But a recent report from Canada cataloguing intra- and post-operative problems associated with complex spinal surgeries might give you some of the information you are looking for. The thing that makes this study unique is the use of a spinal specific tool to measure all complications from minor to major and chart the severity of those problems.

Data was collected on 942 patients undergoing complex spinal surgeries before, during, and after spinal surgery. Some examples of the intraoperative “adverse events” include allergic reactions, heart attack, blood loss, pressure sores, nerve root injury, or other organ injury. Intraoperative refers to complications and problems that developed during the operation.

Pre- or post-operative adverse events ranged from heart failure, blood clot, and wound infection to delirium, pneumonia, urinary tract infection, and cerebrospinal leak. In both categories (intraoperative and pre- or post-operative), surgeons could report and record “other” complications and provide a description of what that was.

The grade given each problem ranged from the number one (event does not require treatment and has no adverse effect) to six (adverse event resulting in death). Deaths were more likely to occur in patients requiring emergency surgery for gunshot wounds, cancer, traumatic neck injuries, and spinal infections. Older adults with traumatic injuries were at the greatest risk of death during spinal surgery.

Four per cent of the total group had to have a second surgery. There was a variety of reasons for this including infection, nerve pain, problems with hardware, and the need for additional decompression of disc herniations. Infection was the number one reason why patients were readmitted to the hospital during the first year following the primary (first or initial) surgery.

Not surprisingly, the types of adverse events were different during surgery compared with after surgery. Blood loss, dural tears, and anesthetic-related problems were the most common intraoperative complications. After surgery, electrolyte imbalances, problems caused by medications, heart complications, urinary tract infections, and spinal deformities were among the most problems reported.

Patients who had to have emergency surgery for metastatic disease had a slightly higher morbidity (complications) and mortality (death) rate compared with those who had elective surgery. Patients with metastatic tumors of the spine were also more likely to develop significant problems due to deep infection.

Knowing that morbidity and mortality surrounding spinal surgeries is much higher than previously reported will give surgeons an opportunity to address this problem. Having the specifics about type of adverse events, severity of complications, and subgroups of patients most likely to be affected will also help direct prevention and treatment efforts.

Given this information, you may be able to come up with some questions for your surgeon that will better help you evaluate your own situation.