The State of Spine Care in North America

The State of Spine Care in North America
Dr. Said Osman Orthopedist Frederick, Maryland

Dr. Osman was born in the border town of Moyale, Marsabit County, Kenya. He went to Moyale Primary School, Marsabit Boys, Kang’aru High School and University of Nairobi. Dr. Osman obtained his Medical Degree with Honors from University of Nairobi, Kenya. He went on to complete his Post-Doctoral Fellowship training in the... more

Despite technological advances in the diagnosis and treatment options for spinal conditions, the state of spine care in North America is far from being satisfactory! After 30 years as a provider for spine sufferers (both in the UK and USA), most of that time spent exploring new options and developing the least traumatic spinal techniques (now being applied by surgeons all over the world), I feel the need to share my experiences and views, publicly! The purpose of this article is to highlight the problems of spine care, and to share solutions which I have applied for the benefit of my patients. I do not have perfect solutions - nobody has - but sharing experiences will help us all come together as communities and professionals to improve spine care!

Spine care problems include deficits in: strategic approaches to spine care; classification of spinal disease; communications between spine care professionals; expertise in the cutting edge surgical technologies for spine care; surgical options for specific demographics, especially the younger and older age-groups; and reliance on chronic use of opioid medications.

About 45% of back pain sufferers are treated with opioid pain medicines chronically, and most of these patients also have additional medical conditions such as depression and anxiety, which may have resulted from their chronic back conditions! The number of unintentional overdose-deaths related to prescription opioids more than quadrupled since 1999. In 2014, 1,700 young Americans (18-24 years) died of prescription drug overdoses (mainly opioids)!  About 116 Americans die of prescription opioid overdoses every day!

Here are some highlights of the inadequacies in spine care:

Lack of standardized approach to spinal care: There are three joints at each level of the spine (one disc and two facet joints behind the disc), and there are 23 to 25 mobile segments in each spine. Each joint may cause spinal symptoms individually or in combination with others. These anatomic facts, often, make it difficult to clinically determine exactly which joint (at a given level) is responsible for the patient’s symptoms. This has led to the emergence of multiple treatment options which are applied in less than organized fashion.

Lack of universal, anatomic, image-based classification of spinal motion-segment disease: Despite imaging technologies such as MRI and CT scans giving us detailed anatomic information of the spine, there had no universally accepted, precise classification system which anatomically localizes the diseased entity or grades its severity, until my recent classification.  The lack of such precise classification system has led to vague descriptions of the spinal diseases, and offer of treatment options based on such descriptions.

Lack of co-ordination of spine care across specialties: Because of lack of standardized protocols for spine care, the pain management doctors and spine surgeons often don’t have formal channel of communication. This problem is made worse by the fact that the pain doctors and spine surgeons, often, function independently and not as a team.

Lack of adequate individualization of spine care based on the disease and patient’s clinical attributes:  Young and elderly patients, and those with other medical conditions are, often, denied surgical option due to lack of expertise in the least invasive techniques on the part of the provider. Conventional spine surgery, and many of the so-called minimally invasive surgery, may not be appropriate for a 16-year-old teenager, and may be too traumatic for an elderly patient. Hence, many of these patients often end up being treated with opioid medications chronically, with devastating consequences!

Heavy reliance on un-physiologic surgical treatment approach: Following fusion (elimination of joint movement), the fused segment no longer shares the stresses associated with spinal motions. This results in accelerated wear-and-tear of neighboring spinal segments, creating a domino-effect which perpetuates repeated medical/surgical interventions.

Problem with health insurance companies: Health insurance companies often deny authorization of the newer, less traumatic procedures, because they are considered experimental or unproven! A case in point is a technique my colleagues and I developed about 22 years ago – Arthroscopic Thoracic Discectomy and Interbody Fusion. Even today, most insurance companies consider the technique experimental and would rather pay for the patient’s chest to be opened to remove a fragment of herniated thoracic disc, instead of an endoscopic, outpatient procedure!

Some solutions to the problem of spine care

Efforts must be made by all concerned to offer safe, precise, least traumatic, and cost-effective treatment options, to avoid the trap of ever increasing narcotic medication which may have catastrophic consequences for the patient, family, and society! Here are some principles I have used successfully in my practice, and some thoughts about way forward in the care of spine sufferers:

Application of standardized protocol: This combines pain management and surgical treatment options in standardized manner, placing the patient on the path to cure as expeditiously as possible. Such an approach avoids repeated injection and ever-increasing dosages of opioid medication and their attendant complications!

Application of precise anatomic, image-based classification of spinal disease: Such a classification defines the anatomic structures that are abnormal, grades their severity in a concise manner, and guides targeted therapy, thereby minimizing collateral damage of normal tissues. I have developed such anatomic classification system which I, and many across the globe, use for the benefit of our patients.

Application of the least invasive spine technology: We have developed endoscopic spine surgical techniques and published them over the years, and these techniques are now mainstream in Europe, Asia, and South/Central America! But very few American spine surgeons use the technology, currently! The least invasive nature of these techniques have allowed us to relieve spinal pain in the very young, the elderly, and those with other medical conditions, often, without general anesthesia. High quality training of young surgeons in these new technologies and protocols is necessary for the benefit of all.

Independent, National/International Committee to determine safety and effectiveness of new spine technologies: This is needed to determine what is experimental or clinically proven to be helpful to the patient. Such determination must be based on the review of publications which employ precise anatomic classification of the diagnoses and standardized protocols, thus facilitating comparison of like with like. Currently, insurance companies independently determine what is experimental, thus making it difficult for providers to give appropriate treatment options.

Spine Industry: Spine device manufacturers should be encouraged to invest in the least traumatic, physiologic, motion-preservation technologies, so that the risk of patients returning, repeatedly, for extension of fusion is minimized! This is particularly important for the younger patients who are considered not candidates for conventional procedures.

Said G Osman, M.D., F.A.A.O.S., F.R.C.S.Ed, F.R.C.S.Ed.(ortho)