Annals of Medicine: Refuse to Fuse?

February 21st, 2011 by

Dr. Trang Nguyen has some serious doubts about the effectiveness of spinal fusions, especially in workers comp. In his study of 1,450 cases of chronic lower back pain in the Ohio comp system, Dr. Nguyen focused on an outcome near and dear to the hearts of all comp practitioners: the number of injured workers returning to the workplace after surgery. The results of his compelling (if less than purely scientific) study, published in Spine Magazine, are cause for alarm.
Dr. Nugyen looked at cases involving chronic back pain that were at least two years old, divided equally among workers who had spinal fusions and those who did not. Among those with fusions, only 25% returned to work, compared to 66% among those who received conservative (non-invasive) treatment such as physical therapy.
That is a huge differential. In addition, 27% of the fused workers had to undergo a second surgery, and as any claims adjuster can tell you, doubling up on spinal surgery places workers on a downward slope toward failed back syndrome: permanent total disability. Among the fused workers, 11% were permanently disabled, compared to only 2% among those who avoided surgery. Finally, most of the workers who underwent fusions were still on strong opiates two years after the treatment. In other words, they still suffered from the pain that led them to treatment in the first place.
While this is not a definitive study, the findings surely offer a cautionary tale not only for workers who suffer from back pain, but for their families and employers as well. It is no great mystery why fusions have become the treatment of preference for so many medical specialists. One doctor used the analogy of giving out hammers: people with hammers – surgeons who can do fusions – look for nails (people who might need the treatment).
Something for the Pain
We are an impatient culture. When in pain, we want immediate relief. Given time, appropriate medications and the skilled hands of physical therapists and chiropractors, the pain usually goes away, or at least reaches more tolerable levels. To be sure, there are severe injuries when fusion is the necessary option; however, pain alone is not an indicator of such severity. The problem with fusion is that it creates rigidity in a part of the body that is designed for flexibility. A rigid spine is an open invitation to lifelong pain and despair.
From the comp perspective, we should remain aggressively sceptical of most proposed spinal fusions. Claims adjusters should routinely require a disciplined utilization review, an objective second opinion and an independent medical exam. Place a strong burden of proof on any doctor proposing fusion for an injured worker. Fusion should be the treatment of last resort.
These are not merely delaying tactics. Rather, they are essential strategies for buying precious time, time for the natural healing process to take place and time to avoid what often becomes a path to oblivion. If, as this study shows, the odds for return to work are more than double for workers receiving conservative treatment, then it is in everyone’s best interest to avoid fusion surgery. Refuse to Fuse. That’s a motto worth posting over the desk of every comp adjuster in America.

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