Spinal fusions: why, when, how and who pays

The number of spinal fusions performed in Australia has skyrocketed over the past few decades, with the number of privately funded procedures far outstripping those done in the public system.

Spinal fusions, which help stabilise the spine by surgically joining two or more vertebrae together, can be used following traumatic injury, or to help correct scoliosis in children. But the most common use for spinal fusions is in degenerative conditions of the spine.

This episode of The Medical Republic Podcast explores when this procedure should be considered, and why we are seeing such a large increase in the number of these procedures being performed.

Dr Ashish Diwan, director of the Spine Service at St George Hospital in New South Wales, says there are several considerations to be weighed before undertaking a spinal fusion, including the duration, intensity and frequency of back pain; whether other treatment options have been tried; and what the patient wants.

Dr Diwan has sympathy for GPs with patients who are considering undergoing a spinal fusion, which is far from a straightforward decision: “It’s like trying to get married. If you’re in doubt, don’t do it.”

The decision not to do surgery can be equally challenging, according to Dr Diwan.

“There is also an incredible lack of evidence as to what you do for a person who continues to suffer. The alternatives [drugs, spinal cord stimulators or radiofrequency ablations] are not very clear … none of them stack up when you start dealing with people who have pain of a chronic nature.”

There are many reasons for the spike in the number of spinal fusions being performed, according to Professor Ian Harris, an orthopaedic surgeon and researcher from the University of NSW.

“There is an aging of the population, but [now] there are more so called ‘indications’ for spine surgery,” he tells the podcast. “The techniques of doing them have developed in a way that there’s now lots of different ways you can do spine fusions.”

Several reasons also exist for why more privately, rather than publicly, funded procedures are being done. But Professor Harris feels the inclusion of MRI scans on the MBS is glaringly obvious one.

This presents a fine line to walk between using imaging to rule out potential pathologies and jumping at shadows and operating unnecessarily on age-related changes. This reinforces the need for clear discussions with patients about any imaging findings.

“Just having a scan doesn’t hurt anyone. It’s what you do with the results that can harm people.”

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