Spinal fusion surgery is the bridging of at least two vertebrae in the spine together using instrumentation and creating one solid segment of bone (Ullrich 2013). Hardware such as screws, plates, and rods are used to hold the vertebrae together until the fusion heals. Fusion can occur in the cervical and lumbar regions of the spine and is designed to inhibit motion at a specific vertebral segment, which should decrease pain emanating from the joint. Spinal fusion surgery is currently the fastest growing treatment for back pain, which is one of the most common reasons Americans see their primary care provider (Eisler 2014). Between the years 2001 and 2010, the number of spinal fusion surgeries in U.S. hospitals increased by 70%, establishing fusion as a more frequent surgery than hip replacements, despite hip replacement surgery having one of the lowest cost per QALY (quality-adjusted life-year, a measure of the value of health outcomes) ~11,000-12,000 compared to spinal decompression surgery and spinal fusion surgery, respectively ~39,000 and ~100,000 (Eisler 2014, Prieto 2003, Nwachukwu 2015).
(N. (2015, June 12). Retrieved from https://www.youtube.com/watch?v=6zOMOLEG9lg&feature=youtu.be)
More than 480,000 spinal fusions are performed in U.S. hospitals each year and the annual cost of these surgeries is more than $12 billion, according to the Agency for Healthcare Research and Quality (Eisler 2014). However, not all of these surgeries are necessary, and though experts are in dispute on the exact amount, some believe it could be as much as 50%. The effect of spinal fusion surgery to treat back pain has been in dispute among doctors for decades, primarily because the scientific community is not confident in what causes back pain. The theory behind spinal fusion relies on disc degeneration as the primary pain generator, however it has been well documented in literature that there is no correlation between disc degeneration and pain. Upon examination, people with normal looking spines may experience back pain, while those with degenerated, aging discs may not have any pain. Long term studies have tested if disc degeneration leads to a higher chance of developing back pain during one’s lifetime, and the results show no higher likelihood compared to someone without disc degeneration (Cuccaro).
Spinal fusion surgery is only effective for specific indications and can only alleviate pain if the specific source of pain is identified, which is only 10-20% of the time (Ullrich 2005). Common conditions resulting in back pain are mild to severe degenerative disc disease, spondylolisthesis (a slipped vertebral body), and osteoarthritis of the spine. The long-term success of spinal fusion surgery has been studied by many. Nguyen, et al. published one of the most comprehensive studies in 2011. Over two years, the paper compared long term outcomes of lumbar treatment with or without fusion in a total of 1450 patients. Patients who did not undergo fusion, compared with patients who did undergo fusion, had significantly high rates of disability, opiate use, prolonged work loss, as well as low return-to-work status. These results demonstrated that lumbar fusion may not be an effective operation for spinal conditions such as disc degeneration (Nguyen 2011).
Further review of current research and the current class of evidence to ascertain the reliability of fusion as a treatment for degenerative spine induced back pain returns similar results. Prognoses using MRIs remain controversial, and only level II studies show any indication of postoperative improvement with early surgery. However, there is no consensus regarding surgical technique, including appropriate number of levels to fuse, anterior (front) or posterior (back) surgery, and type of graft used to fuse the vertebrae (Rasschaert 2012).
Despite the overwhelming data against fusion surgery to treat back pain, the medical community persists in performing hundreds of thousands of fusions for back pain each year (Cuccaro). The reasons the surgery is conducted so frequently is multifaceted. Doctors are compensated well for performing the surgery, and the price of the operation increases for every level fused and every piece of instrumentation. Additionally, the hospital system demands production, which requires more procedures. Nonetheless, the primary reason for the high rates of fusion surgery are due to patients’ emotional and physical pain tolerance. Back pain is debilitating, and drastically lowers HRQLs, Health Related Quality of Life (Cuccaro). Many experiencing back pain, in whatever form it manifests, are forced to leave work and stay inactive. The chronic pain leads to anxiety and depression, and people are desperate for something to alleviate the pain. For many, surgery is their last hope, and people demand doctors to operate in spite of other treatment paths (i.e. solid rehabilitation) (Cuccaro).
Considering the research published on spinal fusions, the controversial decision to pursue surgical treatment to alleviate back pain relates to the politics of health through models of biological citizenship, biopower, and the production of scientific knowledge. Ecks’ pharmaceutical citizenship (Ecks 2005), built on Petryna’s model of biological citizenship in the wake of the Chernobyl disaster in Ukraine (Petryna, 2013), largely applies to patients who undergo fusion surgery to treat back pain. Analogous to how pharmaceutical companies targeted the marginalized communities in India with antidepressant medication, promising de-marginalization and reintegration into society, so does the idea of spinal fusion surgery. Those subject to back pain may experience a degree of disability that isolates them from society and confiscates the possibility of contributing to and experiencing life. Depression and anxiety, as stated above, are commonly associated with chronic back pain, as well. Although surgery is not a pharmaceutical, in much the same way, it is an antidepressant, an immediate solution, and a promise for reintegration into society. One may coin this model of citizenship surgical citizenship, for those that undergo fusion surgery are indoctrinated into a community formed around their inconclusive diagnosis of back pain, and subsequent post-operative pain.
Biopower, as termed by Michel Foucault, establishes the life and health of individual bodies as objects of state and institutional power (Foucault 1978). Biopower is an application of power institutions use to organize and exploit economic and political relationships. Given the profit driven nature of private hospitals and healthcare providers, such institutions are placed in a grand position of power, considering patients with back pain seek medical help in times of desperation, and are handed control of their patients’ bodies. Moreover, published research is for consideration and practice by each individual doctor. Therefore, the increased production of scientific knowledge, the ever-growing mass of data proving the ineffectiveness of spinal fusions, is interpreted and incorporated into practices differently by each provider.
References:
Cuccaro, K. (2014). Why A Back Surgeon Doesn’t Recommend Back Surgery (For Most Patients). Retrieved from http://straightshothealth.com/what-everyone-needs-to-know-about-back-surgery/
Ecks, S. (2005). Pharmaceutical Citizenship: Antidepressant Marketing and the Promise of Demarginalization in India. Anthropology & Medicine, 12(3), 239-254. doi:10.1080/13648470500291360
Eisler, B. (2014, April 24). Tapping into controversial back surgeries. https://www.cbsnews.com/news/tapping-into-controversial-back-surgeries/3/
Foucault, M. (1978). The history of sexuality: the will to knowledge: vol. 1. London: Penguin.
Nguyen, T. H., Randolph, D. C., Talmage, J., Succop, P., & Travis, R. (2011). Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects. Spine, 36(4), 320-331. doi:10.1097/brs.0b013e3181ccc220
Nwachukwu, B. U., & Bozic, K. J. (2015). Updating Cost Effectiveness Analyses in Orthopedic Surgery: Resilience of the $50,000 per QALY Threshold. The Journal of Arthroplasty, 30(7), 1118-1120. doi:10.1016/j.arth.2015.02.017
Petryna, A. (2013). Life exposed: biological citizens after Chernobyl. Princeton, NJ: Princeton University Press.
Prieto, L., & Sacristán, J. A. (2003). Problems and solutions in calculating quality-adjusted life years (QALYs). Health & Quality Of Life Outcomes, 180-8.
Rasschaert, R. (2012, January 06). Controversies in Spine Surgery—Best Evidence Recommendations. Retrieved from https://www.nature.com/articles/sc2011140#author-information
Ullrich, P. & Cooper, G. (2005, March 21). Is Lumbar Fusion Surgery a Reliable Procedure? Retrieved from https://www.spine-health.com/treatment/spinal-fusion/lumbar-fusion-surgery-a-reliable-procedure
Ullrich, P. (2010, January 8). Lumbar Spinal Fusion Surgery – spine-health.com. Retrieved from https://www.spine-health.com/treatment/back-surgery/controversies-about-spinal-fusion-surgery-allografts-autografts-and-fusion
Ullrich, P. (2013, November 11). Lumbar Spinal Fusion Surgery – spine-health.com. Retrieved from https://www.spine-health.com/treatment/spinal-fusion/lumbar-spinal-fusion-surgery
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