366- The Risks of Posterior Lumbar Spinal Fusion Surgery

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. Today we are continuing our conversation from last week, but this time we're talking about the perioperative risks and mortality that live in and around lumbar spinal fusion surgery. Anytime you go undergo surgery, there are risks, there are complications. We're gonna talk about a study that highlights exactly what those risk factors are. Additionally, what's basically the risk of dying, you know, after having this surgery. This is important because it sets the context when making decisions about what you're gonna do. If you've been struggling with back pain, people are trying to make accurate decisions and safety does play a huge role. And in my opinion, many people really have no clue about the abject risks that happen in surgery. So we're gonna break down this paper and more. Lots of clinical nuggets. Great opportunity to learn and then be able to teach, teach and invite, teach your patients about the risk associated with surgery based upon the facts and the evidence. Before we get started, I wanna say a few words about patient pilot by the smart chiropractor. We have been going through a huge open enrollment for patient pilot. We we hook you up with a 3x ROI guarantee. Yes, you heard that correctly, a 3x ROI guarantee. Why? Because we know the automated email campaigns that work if you're looking for new patients, better retention or more reactivations. We serve over 300 chiropractors around the world. We send over 1.1 million emails each and every month. And our average doc actually gets 26 people clicking over to their online scheduler each and every month. If you want to learn more, head over to thesmartchiropractor.com, i'll drop the link down below. We have wrapped up open enrollment, so if you'd like to access 25% off, click the demo button. Hop on a demo with our team. That's how you kind of get around the line, so to speak. And we can still offer you that preferred pricing, but as I said at the top. Today we are looking at a study from European Spine Journal and it is titled Perioperative Mortality after Lumbar Spinal Fusion Surgery. An analysis of Epidemiological and risk Factors. Now let's break down a few things and set the stage. The total number of lumbar spine fusion surgeries has increased dramatically over the past few decades. I have a slide in one of my presentation that showcases this. And there's a difference between elective surgery and emergency surgery. When we think about spine fusion surgeries, there's some of each, There are some that are a result of large scale accidents and are really emergent type situations. But many, and I'm gonna say most, fall in the realm of elective surgery. And many people out there believe I'm gonna say incorrectly, that surgery is the only thing that can, quote, unquote, fix the problem. And it's just not true. We're gonna talk about all that as we go through this study, but it's important to understand that as a starting point when we talk about patient communication. Often this starts with the imaging. I saw a friend of mine post something on social media and I think it was very accurate. He basically said, if you want to have spine surgery as quickly as possible, start taking MRIs. And the thing with an MRI is it shows everything that's not perfect, but it does a really poor job showing what the problem is. That's the doctor to help make that decision. But when a patient sees that, or a doctor who doesn't specialize in spine conditions, neuromusculoskeletal care, somebody like a primary care doctor looks at it, they're like, oh my gosh, you have a huge disc herniation. We're going to. The only way to solve that is to chop it off and cut it out. Obviously, surgical intervention, they say a slightly different way and it's just not true. But it's the prevailing knowledge that then gets transmitted down. The irony to all this is we all know people who have had spine surgery. And I got news for you. You probably ask 8 out of 10 people have spine surgery, would you have it again? And 8 out of 10 are saying, no way. It was the worst decision I ever made. Yet people are still clawing to get in, in many cases thinking that the surgery's gonna fix their problem. And I am empathetic too. If you are in pain and you have chronic pain and it's affecting your quality of life, I'm empathetic to really wanting to find a solution. But surgery has been dramatically. Spine surgery has been dramatically overutilized. Despite the fact that it's risky, it doesn't solve the problem. It befits more surgery down the road, and it just permanently alters the structure. It's not movement based care. It's actually the opposite. It not Only are there complications during workup. There's anesthesia complications as we'll talk about. There are postoperative, intraoperative and perioperative complications. There's just risk. And when we think about the Hippocratic oath of do no harm, I start to question really when I see lumbar surgeries, cervical surgery being done so incredibly often with the risks that take place, is that really holding true for every doc out there? So there is an estimated 1.3, roughly 1.3 million posterior lumbar spine fusions performed in the US over a 10 year period from 98 to 2008. So well over 100,000 of these. And this is just posterior lumbar fusions. That's not all spine surgery. Spine surgery is well over a million a year. Posterior lumbar spinal fusion over 100,000 a year for that 10 year period. And it's only gone dramatically up since then. The average mortality rate for lumbar spine fusion surgery was 0.2%. Now that might sound low, but that's well over. And we're going to look at the exact number in a little bit. I think there's well over a thousand people dying over the course of that 10 year period. So this is a real thing. It's like a hundred, it's like every two and a half days somebody is dying as a result of or because of or associated with a specifically just a posterior lumbar spine fusion. Add in all the others that goes up even more independent risk factors for in hospital mortality included things like advanced age, being a male, large hospital size, emergency admission, comorbidities. We'll break these down in detail as well as we go on. Comorbidities associated with the highest in hospital mortality after the surgery were coagulopathy, metastatic cancer, congestive heart failure, renal disease, which makes total sense. And the most lethal complications were cerebrovascular events, sepsis and pulmonary embolism. Absolutely no surprises there. Now what's interesting, and I hadn't really thought about this ever before, but the timing of death occurred early in the in hospital period for over half of the people. So by day nine, I guess this is a morbid way to say it, but if you're going to die as a result of or a complication due or around a lumbar spine surgery, you have over a 50% shot that it's going to happen in the first nine days. So the first few days are critical there. And a lot of that comes down to, hey, if you are super old with metastatic disease, most of the time you're not having a spine surgery, certainly elective, that would be more only in the emergent stage. And if you're over about 80, usually, most of the time, surgeons are trying to avoid doing spine surgery on patients above 80, incidentally. Also, by the time that occurs, usually the pain has died down. The height of pain is usually between 45 and 65 years old. So the interesting thing I've thought on this study, there's a quote at the start of one of these paragraphs. Although lumbar spine fusion is considered a relatively safe procedure, and I'm sitting here saying you have a 0.2% a person is dying associated with this single procedure, just a posterior lumbar fusion. Every two and a half days, somebody's dying, and it's considered relatively safe. Yet there are still questions and still docs out there and still surgeons, mind you, that are concerned about the safety of a cervical adjustment when tons of studies have been done and they're unable to even pinpoint a number because it's so small. The irony here is just dripping. But I think that was an interesting point. You can tell where this is being written from when you look at the European Spine Journal from the factor of they're in the business of doing spine effusion surgery. Maybe not the Journal is not in the business of it, but they certainly are in the ecosystem of it, let's put it that way. Now, a dramatic increase of utilization of more complex spine procedures has been shown, which is associated with increased mortality. And this is something that's been highlighted in some other studies. And I think it's important to keep in mind, surgery is surgery, you really want to avoid it at all costs, but then you want to do as little as possible. And there are, quite frankly, probably, I'm going to say too many, because there shouldn't be any cowboys and cowgirls out there. Surgeons really going above and beyond. And I've seen all kinds, believe me. So working in an orthopedic group for many years, I saw people from occiput to sacrum with one or two segments not fused. I saw stacked two and three level fusions, disc replacement, then two or three level effusion below it, the disc replacement's gonna blow out. It's just these things are completely unnecessary. And it's pretty much, in many of these cases, a guarantee that these individuals are gonna go back for more surgery because it's just never gonna hold up. And often the doctors know that, and they might be trying to push the envelope. And that's how we learn. But you have to temper that against too no harm. You have to temper that against exactly what the patient knows. And are they making a truly informed decision knowing that this is something that may not be the block and tackle of surgery? Let's put it that way. So between 98 and 2008, there were 1,288,496 posterior lumbar spine fusions performed in the United states. It was 1,938 patients that passed away or died during their in hospital stay. So if we do some quick math, I'm actually going to pull out my calculator right here. We have a 10 year period. So 10 years times 365 days is 3650 total days. That probably should have been easy math. 3, 3650 total days and nearly 20001938 deaths. So it was just about. If we go 1938 times two, it was every two days somebody died during their in hospital stay over a 10 year period, like clockwork, every two days somebody was dying after having that procedure performed. Now many of these people did pass away before day number nine, as we talked about earlier and not surprisingly, postoperative complications were associated with the greatest risk of mortality. And these are cerebrovascular infarctions, sepsis, myocardial infarctions, and pulmonary embolisms. And these are really, really important things to just drill down for a few moments. I actually had a spine surgeon who I practiced with a decade ago and he went in for a procedure and he did have a pulmonary embolism that led to him passing away. And he was still practicing and relatively young guy. So these are real complications and it's something that we need to take very, very seriously. And in my opinion, it's something that's probably overlooked. Often from a patient perspective, they're thinking about this as is the surgery gonna work or not? Am I gonna get pain relief or not? And they're not really thinking about the fact of the anesthesia is a real issue. And anesthesiologists have done a great job being able to put people to sleep in 10 seconds, wake them up in 10 seconds. But our bodies are dynamic and anesthesia can wreak havoc in some people. And the secondary component to that are these postoperative complications. When we look at sepsis, when we look at a pulmonary embolism, the there probably are yellow flags that can be identified previous to surgery. And you might go on some medications to try to minimize and mitigate this previous to the surgical intervention. But these are really big things. It doesn't matter if you're in a lot of pain. If you have sepsis and chudepulmonary embolism, the pain is not gonna be your concern at that point in time. So these are important considerations. The surgery is not just, oh, they're cutting into me. That's a real thing. You're cutting into a person. You're changing the biomechanics. You're instigating scar tissue. By definition, you have to instigate scar tissue. You are going to instigate some form of fluid collection. The question is, okay, that's a given. Then you have the wild cards afterward. That could be really, really challenging. And I've heard complication rates, I think we touched on this in a previous podcast episode. Complication rates in surgery upwards of 20% related to the spine. Now, all of those aren't catastrophic, but that's a pretty darn high. Like a 1 in 5 chance you're gonna have some sort of complication after a spine surgery, and there's probably a two or three in five chance you're gonna have to go back for more surgery. Again, I start to put. And that didn't even talk about the postoperative complications or the mortality within the first nine days that we discussed. You stack these things together and you start to look at it and say, is this really the best avenue? And is it almost ever the best avenue outside of a emergency situation? And I think it becomes pretty hard pressed to think that surgical intervention is really a great answer outside of an emergent situation with very, very few excep. And then we look at the data and we say 100,000 plus being performed per year, probably 150,000, maybe 200,000 at this point in time. Looking 15 years later, after this study, the data set from this study, and I start to really question whether or not how many of those surgical candidates actually exhausted conservative care, how many took medication for a few weeks, did a few rounds of physical therapy, a few visits, checked the box for what needed to be done, and then were moved forward towards surgery? And I got a. I don't have a sneaking suspicion. I saw it from the other side. That happens all the time. And it's something us as chiropractors need to take very, very seriously when we have patients asking us questions about surgery. This is not to dog surgeons or to put down any other profession, but it's when a patient comes in and they are trusting your opinion or they're mentioning the fact that they think surgery might be right for them and they're kind of walking around doing everything that they need to do and wanna do with 5 out of 10 pain and they're debating surgery. And yes, this happens all the time. I had people come in with 1 out of 10 pain when I was in some surgery groups asking if surgery was right for them. And it's not because they're foolish and it's not because they were given bad. They don't know any better. People have no idea. So it's on us. The onus is on us ultimately to be able to give the most accurate information possible, not with a bitter chip on our shoulder, but with an understanding of that might, maybe in some cases, again rare cases, it might be what's best for those people. But quite often movement based care is gonna be where they wanna stay. And even the level in between, when we start talking about epidural steroid injections, which for the spine are basically done off label from the fda, that really have limited efficacy outside of taking down acute pain and solve no issues whatsoever, it's really a fast track ultimately to surgical intervention. And these are things that we really need to be able to have informed, direct and accurate conversations with our patients about. So as one thing that was really interesting here, almost 90% of all life threatening complications among joint surgical patients occur within the first four days postoperatively. So that first four day to nine day window, that first week, let's just say, is really, really imperative and impactful. And I think this also takes place where you have to think about a lot of these outpatient surgery centers as well, that you're going home that same day. Now, I'm not instigating or insinuating that there is a dramatically higher risk. Quite often they are lower invasiveness and that's what enables you to get up and moving and out the door. But man, when we look at joint surgery and we just look at it as a totality, and 90% of these really life threatening challenges happen within the first four days, you also want to temper this because I would also have people that came in when I practiced at an ambulatory surgery center, and people would come in and they thought they were going to get back to work, you know, go snowboarding two days after, because it's minimally invasive, I'm up and moving. If I'm walking out the door, I can just get back to everything, right doc? Hold your horses, you know, and these are where patient behavior can actually instigate challenges, even if everything else. So all of this being said, surgical intervention is a big deal. It should continue to be considered an absolute last resort and you have to be able to guide and direct your patients appropriately. And that doesn't mean funneling people out to other doctors as soon as you don't get ants in your pants. I'm going to say to get them out of your office too quickly, but also be to have these intelligent conversations and have them understand the risks, the benefits, the potential rewards, and ultimately the real challenges with it in a meaningful way. Because when you have it in a meaningful way, then it doesn't come off as if you're just trying to, quote, unquote, keep their business, which you're not. You're actually trying to guide and direct them towards the best thing for them long term. So I hope there were some clinical pearls and some helpful bits here. 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Other than that, have a fantastic week in practice and I will talk to you soon.

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