Sunday, January 20, 2013
Do we have the backbone to confront the problem of the aging spine?
We should all be happy that through advances in science, health-care and personal health management more and more Americans are living into their 80's and 90's and even reaching 100. The best news about this extension of life expectancy is that more and more of our "super" seniors continue to lead active life-styles. We have been very good at managing heart disease and vascular disease. Lung disease has significantly diminished as smoking has become much less common. Diabetes is more well-controlled and the treatment of cancers improves every day. What has not improved and, in fact, has yet to be addressed is degenerative disease of the spine. It is inevitable that everyone experiences some degeneration of the spine as we age. For many the degeneration can become severe with pain secondary to nerve compression and pain secondary to spinal deformity. These infirmities lead to profound life-style changes. Chronic pain leads to depression and limited mobility. No one wants to live their lives afflicted by pain, unable to participate in the normal activities of daily living, let alone unable to play sports, take walks with family and friends, go to the movies, go out for dinner or play with grandchildren . So as these individuals start to become intolerant of their pain and limitations they seek out help within our health-care system. There are certainly non-surgical approaches that can help, especially if treatment is instituted before the structural abnormalities become too severe. These include chiropractic, physical therapy, acupuncture, massage, Alexander training, injection therapy, and many more. All cost money and stress the finances of our health-care system but these treatments are relatively inexpensive and there are a large number of practitioners who offer these treatment. However, many individuals will require surgery to alleviate symptoms. This is were things become very confounding. Bigger, more complex surgeries have higher risks. Should "super" seniors be allowed to subject themselves to these increased risks which can add substantially to health-care costs when complications do occur? Furthermore, there are relatively few spine surgeons with the capability of performing complex spine procedures in the elderly. It will become more difficult for those who are prepared to go through extensive operations to even find a surgeon who can place them on their operative schedule. What greatly compounds this problem is that medicare payments for these procedures are exceedingly low. These operations also take many hours to perform. It will be very difficult to encourage surgeons to perform more of these procedures when they take up a large amount of their work time with very limited reimbursement. From a practical business point of view it is simply impractical and unaffordable. Those surgeons receiving a salary have little motivation to perform these extensive operations when they could in the same amount of surgical time be performing more operations with less risk, helping more individuals. So those suffering from severe spine problems may well need to find surgeons who do not participate in medicare and who will perform the surgery for an appropriate usual and customary fee. Even with a limited number of seniors able to proceed with a surgical option, the costs to the health-care system will be high. Do those controlling the health-care dollars want to spend them on seniors with bad backs? There is no question that the criteria for proceeding with this kind of surgery will be so extensive that few will ultimately be able to meet those criteria. What are possible solutions? First of all, individuals need, from an early age, to be taught how to take care of their spine, including exercise, body mechanics and weight control. We need to put money into research that can lead to treatments in the early stages of spinal disease such as stem cell injections to regenerate damaged discs. However, there will always be those who will fail all non-surgical treatments. For them, spine surgery may indeed be life-saving. New surgical techniques are being developed that are less risky. Minimal access spine surgery now is able to correct spine disorders with less trauma to the spine and surrounding tissues and less risk in general. Most importantly, the specific problem that is causing the pain and limitation needs to be identified and addressed with minimal access techniques. The entire spine does not need to be rebuilt. It doesn't matter what the spine looks like on an MRI or xray as long as the individual does not suffer from incapacitating pain and neurological dysfunction. More spine surgeons will be needed who are able to assess these problems accurately and perform these focused minimal access techniques. Finally, patients should be able to see surgeons who do not participate in medicare and receive the allowable medicare reimbursement that they can apply to their out-of-pocket costs, which currently is not allowed by federal law. Spine disorders in an aging population needs to be an issue that is carefully analyzed by our politicians, our health-care pundits and the medical community. We are currently very much behind the eight ball.