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Going Under the Knife


"Malpractice cases are very traumatic to a physician and as you might imagine an easy fallback position is why take a chance?"

Your physician tells you that you need surgery. Assuming it’s not an emergency how do you respond? Say “Yeah sure where do I sign?” Or — “Whoa wait a second! I appreciate your input but I need to get more information and a second opinion.”

According to a USA Today review of government records and medical databases tens of thousands of patients undergo unnecessary surgery each year. There are multiple reasons why these unneeded procedures take place. In the worst of scenarios they’re the result of criminal acts in which surgeons intentionally dupe patients deliberately performing surgeries they know are not medically justified.

More often however physicians perform unnecessary surgeries out of incompetence or a lack of training in less-invasive alternatives. Some doctors may believe that surgery is the only answer even when the success rates are minimal and better nonsurgical treatment options exist. Then there are those providers who are more businessmen than medical professionals and perform surgery simply because it helps the bottom line and they can justify it as medically “necessary.”

Eager to Operate

Speak to experts in various medical fields and many will readily acknowledge that surgeries are sometimes performed without due cause. Nancy Epstein MD chief of neurosurgical spine and education at Winthrop University Hospital in Mineola New York says that “many unnecessary spinal procedures are performed in the US.”

Consider for example the case of Rachel Gold a 65-year-old secretary for a furniture company. She was referred to a spinal surgeon by her internist after she slipped and wrenched her back while moving a heavy office chair at work. At the surgeon’s office she filled out a medical form which included her history of osteoporosis.

After she met the spinal surgeon he ordered a CT scan and then recommended a transforaminal lumbar interbody fusion (TLIF). This surgical procedure involves removing a disc from between two vertebrae placing a device inside the disc space and fusing the vertebrae together with screws and rods to enhance the fusion.

Three months later Rachel was back in the doctor’s office: Her back pain had worsened because the spinal instrumentation inserted to keep the fusion in place was loosening. This result of TLIF surgery is actually not uncommon for someone with osteoporosis which causes bones to become weak and brittle. “The problem with operating on an osteoporotic patient” Dr. Epstein explains “is that you can’t put screws into butter; they are likely to loosen or fall out.”

According to Dr. Epstein TLIF and PLIF (posterior lumbar interbody fusion) are too often performed without sufficient indications — e.g. for pain alone without neurological deficit (no nerve compression showing on MR/CT studies). Aside from the risks associated with any surgery patients can also potentially suffer from postoperative problems.

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With osteoporosis there’s a risk of instrumentation loosening (as occurred in Rachel’s case). With diabetes there’s an increased risk of infection. For patients on aspirin or other blood thinners for heart disease there are risks associated with postoperative bleeding.

Further complicating issues Dr. Epstein says that since 2002 bone morphogenetic protein has typically been used off-label in spine surgery over 90% of the time. This has resulted in major postsurgical complications such as an increased potential risk of cancer osteolysis (the disappearance of bone) tremendous soft tissue swelling and more infections.

Dr. Epstein maintains that the marked increase in spinal fusions may be attributed to several factors including inadequate medical training (for example operating based on complaints of pain alone) or for the surgeon’s financial gain.

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