Doing Harm vs Doing Wrong: The Ethics of Spinal Surgery

Recently Tim Flynn PT, PhD shared a very interesting post on the EIM page. The blog was thought provoking as it discussed the difference between ideas of doing wrong and harm. Dr. Flynn referenced writings and presentations by Malcolm Gladwell regarding this topic. To quote Gladwell, “Wrong” and “harm” are separate concepts; and “wrongfulness is not contingent on harmfulness.” The idea is that something can be wrong, yet not harmful. Additionally, something that is wrong typically will have moral or ethical implications versus something that is harmful might not. Gladwell argues that we live in an age in which the ability to distinguish the difference between wrong and harm has been lost, and that we only equate wrongfulness with something that causes harm. 

An example of this can be seen if you think back to a time you may have pulled a prank on someone. Maybe you spent a Halloween night toilet papering a friend’s house. This act did not actually harm the individual or their house, however it was wrong to deface their property. You have intruded on an individual’s private property and completed a task that is morally dubious, yet Gladwell argues that current day thought styles would not classify this as wrong since there wasn’t anyone harmed.

So how does the concept of wrong and harm play into what we do in the medical field? Below I have listed the 4 ethical principles of medicine we all learned early on in our training as a quick reminder.

1. Respect for autonomy – the patient has the right to refuse or choose their treatment.
2. Beneficence – a practitioner should act in the best interest of the patient.
3. Non-maleficence – "first, do no harm"
4. Justice – concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).

In the last few years I have noticed quite an increase in the number of patients that that have undergone lumbar spine surgery for persistent LBP. Spinal fusions, in particular seem to be rapidly on the rise. As physical therapists, we keep thinking to ourselves “why fusion, why surgery, why not PT pre and post op, why not any other treatment other than surgery”? Is it due to patient’s lacking the locus of control or self-efficacy to advocate for themselves? Is it a breakdown in our medical system leading to over utilization of surgery? Is it a societal misconception that surgery can be a quick fix to all pain problems? 

The list goes on. From my own observations, it appears to be a function of all of the above. In fact the prompt for me to write this post came when I recently watched a commercial for minimally invasive spinal surgery. I am sure you have all seen one of these before. Below is an example of one of these ads (not the actual one I saw).

After viewing this commercial, I did a web search of these groups/procedures and below are some of my findings. This will probably provide clarity as to why our patients continue to seek out surgery to relieve their spinal pain.

Consultations: Most if not all offer free MRI or free review of MRI

Conditions treated: Mechanical low back pain, herniated disc (slipped disc, ruptured disc, torn disc), bulging disc, spinal stenosis, degenerative discs, sciatica, pinched nerve, facet disease, foraminal stenosis, degenerative joint disease, muscle and ligament strain, fractures, arthritis, scoliosis.

Surprisingly, none of the groups I searched treat my favorite bagel from the donut shop: The Lumbago.

Outcomes:

80-95% Success Rate

90-95% Recommendation Rate

90+ % Satisfaction Score              

More than 8,000 – 60,000 Success Stories

“No lengthy recovery”

“100% free from pain”

Now IMO, despite the above mentioned *phenomenal* services provided and outcomes listed, continued advertisement of these surgical procedures and said outcomes is causing significant harm to our society and are completely morally wrong. Below are the reasons and evidence to support why I think this.

Persistent pain rates rising despite continued utilization of surgery

• Over 100 million Americans suffer from persistent pain. That affects more Americans than diabetes, heart disease, and cancer combined. This is 1/3 of Americans. (Institute of Medicine Report from the Committee on Advancing Pain Research., 2011)

Overwhelming assumption that there is a quick fix to persistent pain - belief that pain is a tissue issue, not a multisystem/ CNS issue.

Through the Therapeutic Pain Specialist (TPS) program we define pain as a “multiple system output, activated by an individual’s specific pain neural signature. The neural signature is activated whenever the brain concludes that the body tissues are in danger and action is required.” Our biological system is constantly adapting trying to maintain allostasis: a process of achieving stability, or homeostasis, through physiological or behavioral change. This can be carried out by means of alteration in HPA axis hormones, the autonomic nervous system, cytokines, or a number of other systems, and is generally adaptive in the short term (McEwen & Wingfield 2003). We theorized that chronic wide spread pain or persistent pain states are due to an individual facing prolonged stressors, or potential threats, associated with the pain that triggers our biological system to activate various systems to deal with the stressors/threats. Although our tissues play a role in the pain experience, it is likely that persistent pain is due to a multisystem issue, not a disc issue.

Are you aware that based on a very large demographic study the top predictor of spine surgery is a patient’s ZIP CODE???  

1. Zip code - how many surgeons within a zip code and utilization of advanced imaging correlated to prevalence of lumbar spine surgery. If surgeon owns MRI, likelihood of spinal surgery increases 34%. - (Lurie, Birkmeyer et al. 2003)

Wrong: We know that correlation does not equal causation however, there is an obvious ethical conflict of interest demonstrated here. Zip code being the strongest predictor of likelihood of spine fusion his is completely wrong as well as harmful not only to patient’s bodies, but also to their pockets, insurance companies bottom line, and subsequently all of our insurance premium prices . A better predictor should be whether or not the surgery is actually indicated (see below), not if you live close to surgeons or how your spine looks on a fancy picture. Here is some other information regarding spinal surgeries that might interest you.

• Spinal surgery reimbursement is higher for orthopedic and neurosurgeons, compared to most of the other surgical procedures they perform.
• The average cost of a spinal fusion is $34 000, excluding the professional fees.
• Medtronic is spending > $10 billion per year on spinal implants

Imaging and the literature

Harmful: When it comes to physical appearance, our society already tends to be hypervigilant towards perfection. We can thank all shows on the E network, all the emphasis on beauty, airbrushing photo shoots, botox, etc. Let’s face it, our society is very superficial. It is a no brainer why something like “arthritis” or “degenerative disc disease” can be perceived as a threat/stressor. It is a sign or indicator of imperfection to the uninformed healthcare consumer.

Wrong: The research on spinal imaging and asymptomatic individuals with “gray hair and wrinkles on the inside” has been around for over 20 years. Yet it seems quite apparent that our medical society continues to utilize this as a gold standard to operate on people with low back pain. (Free MRI consults here, free MRI’s here.) Also, we have been able to identify predictors of symptomatic disc herniation including multi-system variable that impact symptoms.

Here is the 1995 Volvo Award in clinical sciences paper titled: The diagnostic accuracy of magnetic resonance imaging, work perceptions, and psychosocial factors in identifying symptomatic disc herniations.

“ In age-, sex-, and risk factor-matched group of asymptomatic individuals, disc herniation had a substantially higher prevalence (76%) than previously reported in an unmatched group. Individuals with minor disc herniations are at a very high risk that their MRI are not a casual explanation of pain because a high rate of asymptomatic subjects (63%) had comparable morphological findings.”

“The best single predictor of a group membership was the extent of neural compromise. A combination of this with occupational mental stress, depression, and mental status was the best predictive model.”

Other relevant studies:

• Spinal fractures, CA, nerve root compression found in 1-2% people back pain (O’Sullivan and Lin, Pain Management, 2014) I find this one particularly important as it is relevant to when a spinal surgery is indicated. LBP is not an indication of spinal surgery, especially fusion, it is neural compromise. Therefore, IMO, only 1-2% of people with LBP should be undergoing spinal surgeries.

• There is a high prevalence of patho-anatomical findings such as disc degeneration, disc bulges, annular tears and prolapses in pain free populations.

• These patho-anatomical findings are not strongly predictive of future low back pain and poorly correlated with levels of pain and disability.  (Deyo, Archives of Internal Medicine, 2002;  Jarvik, Spine, 2005)

• Discs will spontaneously regress (absorb or “unbulge”) in roughly 40-90% of population over the span of 2-9 months. (Chiu, Clin Rehabili. 2015)

I AM NOT saying that no one should get an image! I am however, stating that imaging is heavily over utilized for nonspecific LBP and persistent LBP. If you suspect a fracture, s/s consistent with sinister pathology or severe neural compromise then an image is indicated to rule out the scary stuff, notto rule in LBP. If a patient has experienced unexpected significant weight loss/gain, saddle paresthesias, change in bowel/bladder, or if you suspect true nerve root compression (pattern specific), then an image is likely indicated. 

Generalizing outcomes: False and unrealistic expectations

Harmful:People in pain want to be out of pain and to live a better life. These ads indicate that they treat every diagnosis associated with back pain with a surgical technique with outstanding results. These ads are giving society a false sense of hope that a surgical procedure is a quick fix to their pain. This in turn drives up dependency on passive treatments, lowers self-efficacy, and pours gasoline to the overwhelming burning fire of the biomechanical model to pain that is ravaging our communities.

Wrong:When it comes to lumbar fusion, said outcomes do not match with current literature, yet these procedures continue to be marketed as a cure for all types of back pain. Research from a group in Sweden analyzing all RCT’s shows that fusionis no better than conservative care in improving pain and disability in persistent low back pain. 

When looking at the origins of spinal fusion, it was a technique that was developed to help those with severe scoliosis, fractures, or grade 3-4 spondylolisthesis (true instability), not persistent non-specific LBP. 

Furthermore, the incidence of chronic pain after any surgery is estimated to lie in the range between 10% and 50%, and in instances of LBP, patients may report that their pain is more severe than it was pre-op (Kehlet, Lancet. 2006).

Now, there are instances when surgery is indicated with favorable outcomes: neural compromise. Remember, nerve compression or neural compromise produces neurological type symptoms, not necessarily pain. You might feel numbness/tingling, decreased sensation, fatigue-able weakness, changes in reflexes, but all in a pattern. Think of any time your arm has “falling asleep” or when you have hit your “funny bone,” that is what neural compromise/compression feels like. If these symptoms do not resolve with positional changes then you might consider further investigation.

Laminectomy/discectomy demonstrates success rates of roughly 80%. Their efficacy is for leg symptoms (pain, neurological symptoms) that are triggered due to neurological compromise. Most of this research is for spinal stenosis (Atlas, Keller et al. Spine. 2005) Once again, pattern specific leg symptoms, not persistent non-specific LBP.

So why do patients continue to get spinal surgeries and who is at fault?  They continue to get surgeries due to this false perception of a quick fix to their pain, misunderstanding of pain, and the continued reliance on passive treatments. Ultimately, we are all at fault. If we as health care providers want to be the practitioner of choice we need to start advocating for our patients. We need to continue to educate not only our patients, but our community of health care practitioners. We need to push this information to all to initiate change. If we do not, persistent pain associated to LBP will continue to rise as will over utilization of imaging/surgery. Assuming you are still reading, if you do not use this information to educate your patients then you are not practicing within the 4 ethical principles of medicine, you are doing your community harm, and you are practicing in a manner that is morally wrong. Begin to consider the different aspects of wrongfulness and harmfulness. 

Dr. Lopez graduated from the University of Texas El Paso in 2012. He then completed an orthopedic residency program at the University of Texas Southwestern Medical Center in 2014. In 2016, he completed International Spine and Pain Institute’s Therapeutic Pain Specialist (TPS) certification. He presented at the Texas Physical Therapy Association Annual Conference in 2013 and 2014 on the efficacy of utilizing pain neuroscience education in patient care and methods to improve the therapeutic alliance through optimizing contextual effects. He currently resides in Dallas, Texas where he practices at 3D Physical Therapy, a private practice outpatient clinic. 

References:

(Institute of Report from the Committee on Advancing Pain Research., 2011)

Surgical predictors: Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine. Mar 15 2003;28(6):616-620.

Boss N., et al. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine. 1995;20(24):2613-2625

Brinjikji W., et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am. J. Neuroradiol. 2014  

Chiu CC., et all. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabili. 2015. 29(2): 184-195

Mannion AF, Brox JI, Fairbank JC. Consensus at last! Long-term results of all randomized controlled trials show that fusion is no better than non-operative care in improving pain and disability in chronic low back pain. Spine. 2016;16:588-50

Kehlet H, Jensen TS, Woolf CJ: Persistent postsurgical pain: Risk factors and prevention. Lancet2006; 367:1618 –25

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