Policy Statement on Lumbar Spinal Fusion Surgery

Introduction Pain and other symptoms of the lower back are some of the most prevalent health problems experienced by the populations of developed nations. They cause prolonged suffering and diminished quality-of-life to the patients, resulting in enormous losses of productivity and substantial costs for ongoing medical care. Many patients can (and should) be treated adequately by medical management, but a small portion of patients will not respond sufficiently, and some spinal conditions can never really be treated non-operatively. For these non-responders and patients with more severe spinal conditions, lumbar spinal fusion can eliminate painful motion and restore local stability and correct alignment to the spine, but proper patient selection is essential for achieving good outcomes. For decades, fusion has been the established standard surgical treatment for many conditions of the lumbar spine. As the world continues making progress into the future, our populations are living longer lives and expecting to remain more active later into life. Medical knowledge, surgical technology, and the quality of healthcare in general have all been improving noticeably from year to year. Spine surgery in particular has undergone dramatic maturation over the past decade with many new advances in diagnostic imaging, surgical technique, and spinal implants. Furthermore, many major studies have been published just recently, providing a whole new higher level of scientific evidence to this specialty. Thus it is possible to treat many conditions and more severe patients with greater success and safety today than 20 years ago. This has led our populations to have rising expectations for medical treatment and decreasing acceptance of these painful and debilitating spinal conditions as simply an inevitable fate from ageing. At the same time, increasing success and optimism may be leading some surgeons to overuse procedures beyond what the current state of medical evidence really supports. It has often been remarked that there is substantial geographic variation in the rates of spine surgery. Although geographic variation in treatment choices and/or insurance coverage policies can have many causes, this variation does also suggest in part a lack of collective adherence to the current state of medical evidence. Professional medical societies have the responsibility to review the evidence and provide expert guidance on the current standards of treatment. This document specifies when lumbar spinal fusion surgery is medically indicated, when it is investigational, and when it is not medically appropriate, based on the currently available scientific evidence. This Policy Statement on Lumbar Fusion thus serves to communicate clearly to all spine surgeons the indications for which our profession and the scientific evidence will or will not provide support for lumbar fusion as a medically indicated treatment. It should be kept in mind that healthcare policy is formulated at a population-level based upon scientific evidence, some of which comes from optimally selected patient populations and carefully monitored research settings. When applied to individual patients in a routine setting, the surgeon must consider how well the evidence would apply to the individual patient. In particular, many patient factors – such as smoking, obesity, age, other medical co-morbidities, and patient psychology – may modify the outcomes that can be expected from treatment. This policy statement states which diagnoses should be eligible for lumbar fusion surgery under which general pre-conditions; the spine surgeon must still use his or her expert experience and expert judgment to determine if the individual patient is well suited for spine surgery, and if so, which specific techniques to use.