We see the craziest stuff day in and out from spine surgeons. This week Dr. Schultz had a patient almost get completely unnecessary spine surgery. So today we’ll calculate the cost of that screw-up, which is very, very common. Let me explain.
A Misdiagnosed Patient
The patient came in pointing at one spot at the base of her skull. Her main complaint was headaches that began at this spot. Her MRI showed severe degenerative disc disease in the lower neck, but she had no symptoms of that problem. In fact, I bet you that given that she was elderly, that most of her friends without much neck pain had similar looking MRIs.
She decided to see a local spine surgeon because she had her hip replaced at the same group. After a cursory exam and looking at the images, the surgeon concluded she needed a two-level fusion in her lower neck. However, being a smart lady, she asked how that was supposed to help the pain at the base of her skull? The surgeon reassured her that he knew what he was talking about and that the headache pain would go away with the fusion.
When Dr. Schultz saw her for another problem, she discussed that her fusion surgery was planned 10-days from now. He performed more than a cursory exam and again, none of that looked at all like a symptomatic lower neck problem. Instead, she was only tender over one C0-C1 facet joint. Dr. Schultz took her immediately to one of our procedure suites and used fluoroscopy to inject the C0-C1 joint with a little anesthetic. By the time she was off the table, the relenting and severe pain at the base of her skull was 90% gone. She was angry at that point at the surgeon. She had trusted him. She, of course, canceled her surgery.
Why Did She Cancel Her Surgery?
Degenerative disc disease in the lower neck can cause numbness or weakness in the hands and arms, neck or shoulder blade pain. What it rarely causes is a headache. Especially one where the patient places their finger on the base of the skull on one side. This can be caused by a few different things, but one of the most common is arthritis or damage to the upper neck facet joints. So when Dr. Schultz numbed the C0-C1 facet joint and 90% of her pain went away, there was only one conclusion. The surgeon was about to perform unnecessary cervical fusion surgery.
What Would the Cost of this Screw Up Have Been?
How much does a spinal fusion cost? Not just the crazy procedure and hardware, but the real costs when complications, failures, and side effects are added in? Thankfully I figured that out for another project.
Spinal fusion is expensive, invasive, and interestingly, has poor outcomes. Here we’ll look at the outcomes for lumbar fusion because more has been published on that topic. For example, this meta-analysis of 33 studies found, “The available evidence does not support a benefit from spine fusion compared to non-operative alternatives for back pain associated with degeneration.” Despite this finding, in 2015, spinal fusion was the 5th most common elective orthopedic surgery performed in hospitals.
The cost of a spinal fusion at healthcare bluebook (HBB) is $43,112. Infection rates for common fusion surgeries are quoted at 2.4-8%. I pegged this as the middle of that range or 5.2%. An infection due to the surgery means at least one revision surgery (possibly more) and at least 6 weeks of IV antibiotics usually followed by oral antibiotics. I booked the cost of a revision fusion (removal of hardware, debridement, and insertion of new hardware) at the high end of the HBB cost range ($85,956) and used a recent study on the cost of IV versus oral antibiotics to treat osteomyelitis as a benchmark for these costs. These were a range of $13,611-$17,152 in the UK NHS, so I then increased this to 20K to match the higher costs in the US private insurance system. This complication alone increases the price of fusion surgery to $48,409.
Another cost axis to consider is treatment failure leading to chronic pain. In this case, there is additional healthcare spend on interventional pain management or medications or fusing more levels. For example, in one recent study, only 65% of patients at two years after various types of lumbar fusions reached the MCID for a spine functional questionnaire (meaning they had significantly improved function). Practically, this means that 1/3 of these patients will either continue with pain management or go onto another fusion. Given that the varied costs of interventional or medication-based pain management would be difficult to calculate, I added a revision fusion cost to one-third of the patients undergoing primary spinal fusion. This brings the total fusion cost to $74,196. Given that the average age for fusion surgery is 56 years and that adjacent segment disease can be seen in 11.7% of patients at 29 months, revision fusion costs related to new disease (which is likely, in part, contained in the above number) would drive the overall cost of lumbar fusion still higher. As a result, we increased the final fusion cost to $85,000. This is likely an underestimate of the final cost of lumbar fusion for the reasons stated above (i.e. many fusion patients undergo expensive interventional pain procedures before and after their fusions which were not considered in this analysis).
How Much Will It Really Cost to Get Her Better?
The game plan is a platelet-rich plasma injection at the cost of approximately $2,000 or in the worst case scenario a bone marrow concentrate injection at a cost of $5,000. Even if she needs a few PRP injections, the cost savings of making the right diagnosis are staggering. Meaning, if we compare even 20K in regenerative medicine costs to the 85K fusion, that’s a massive 70% savings! None of this, of course, speaks to the fact that the fusion would have made her headaches worse, as the fused levels below would have put more pressure on the segments above, which already hurt. To learn more about this concept of adjacent segment disease, see my video below:
What’s the cost of making her headaches worse? Likely tens of thousands of dollars in hospital-based pain management care as they try to define where the headaches are coming from. While Dr. Schultz’s procedures didn’t require hospital fees (the procedure was performed in the office), these pain management procedures in our area are more likely than not to be performed at a hospital ambulatory surgery center where just walking in the door for a single injection costs thousands of dollars before the pain management doctor charges for any procedure.
Another big problem is that few doctors have the skills to inject the C0-C1 joint. We’ve done thousands after reengineering the bad technique that’s usually taught (see my video below):
How Did We Get Here?
Why would a fellowship trained surgeon make such an expensive and more importantly, bad mistake for the patient? The answer is simple. Treating the MRI and not the patient. In addition, there is a huge financial incentive to fuse spines and all parts of the medical care system benefit. The physicians, surgery centers, hospitals, equipment manufacturers, etc… It’s the perfect storm for unnecessary surgery.
The upshot? If the base of your skull at the very top of your neck hurts and a surgeon wants to operate on your lower neck, please ask lots of questions and get a second or third opinion. While the unnecessary surgery will be expensive to your insurer or employer, most importantly, it will likely be devastating to you personally.