Solving the Epidemic of Unnecessary Surgery

For decades, the U.S. healthcare system has been burdened by medical overtreatment. Every year, millions of Americans with chronic pain undergo tests and procedures which don’t lead to healthier outcomes. This invasive approach pushes them toward complications and spiraling medical expenses. In my role as head of surgery at the Hartford Medical Center and as Chief Medical Officer at Sword Health, this is my mission: to help people find the best, least-invasive way to lead full, active, happy lives. 

Even physicians acknowledge the problem. A landmark survey of board-certified doctors found that 64.7% believe that at least 15–30% of medical care is unnecessary. The issue is most problematic when it comes to unnecessary surgery. The risks of surgery are already great — thus, performing unnecessarily can be even more devastating, leading to hospital readmissions, post-surgical pain and injury, and even death. 

This is not a new problem. As far back as the 1950s, Dr. Paul Hawley, the director of the American College of Surgeons, warned that “the public would be shocked if it knew the amount of unnecessary surgery performed.” 

What is new, however, is the innovative technology that now makes procedures much less necessary. In fact, studies prove how holistic and conservative care can resolve back and joint pain more effectively than surgery, and as a result, exercise therapy, behavioral support, and education should become a larger focus for care. 

Let’s learn more about the problem. 

Surgery doesn’t always solve the problem 

Low back pain is one of the top musculoskeletal complaints and the leading driver of disability worldwide. While extremely common, the condition is difficult to diagnose. In most cases, the origins of the pain remain unknown to both patient and medical provider. Yet, these patients are often counseled to receive lumbar spinal fusion as a remedy (among other options, such as laminectomy). 

Spinal fusion is not an insignificant surgery. It lasts hours and involves joining, or fusing, two or more vertebrae to stop motion between the bones that might be causing pain. However, clinical trials have shown that most spinal fusions do not lead to better long term outcomes. In fact, studies show that surgery is rarely better than a non-operative treatment, including physical therapy and core strengthening exercises. In many cases, surgery actually leads to worse outcomes than no surgery at all.

The risk of surgical failure 

Research shows that 20% to 40% of back surgery patients report having the same or increased levels of pain one to two years after their procedure. This phenomenon is so common that clinicians have given it a name: Failed back surgery syndrome, or FBSS. The more complex the surgery, the greater the risk that the patient will develop FBSS. For lumbar fusion, the rates range from 30% to 46%. Yet, despite the known risks and unpredictable efficacy of back surgery, the number of spinal fusion surgeries has grown exponentially in the U.S. 

It’s not just back surgeries. About 750,000 arthroscopic knee surgeries are performed in the U.S. each year, at a cost of $3 billion. Yet, multiple studies have shown that arthroscopic knee surgery is not any more effective than non-operative treatments for conditions like arthritis, torn cartilage, and knee pain. One study involving 205 patients who underwent total knee arthroplasty found that a majority of the procedures were unnecessary and added cost, impacted lives, and caused pain to patients. 

What happens when the best non-invasive interventions are ignored? 

Of course, surgery is not the only way to treat back, knee, and other musculoskeletal pain. One of the most reliable and most effective treatments—physical therapy—is also, perplexingly, one of the treatments least recommended by medical providers. 

Physical therapy–based rehabilitation uses fewer resources to provide better outcomes for patients with (musculoskeletal (MSK) pain, especially compared to operative procedures. But for this to happen, physical therapy must be the first line of defense against pain. Surgery should be positioned as a last resort, with the patient made well aware of the risks. When surgery is warranted, it should be the last option, not the default first course. 

A multidisciplinary approach to solving pain 

Together with a team of fellow researchers, I published a study in 2017 looking at treatment decisions for lumbar degenerative spine disease, which found that a multidisciplinary decision-making approach, which includes physical therapists, orthopedic spine surgeons, and pain specialists, results in fewer patients choosing lumbar spinal fusion. A wider lens and more voices in the room may lead to better decisions —and better outcomes — for the patient. Of the 137 patients who were evaluated during a 10-month period, 100 had been previously recommended to pursue back surgery. But when non-surgeons were empowered to make decisions in their cases, non-surgical options were deemed appropriate for more than half (nearly 66%!) of these patients. In the end, using this multidisciplinary approach, only nine patients underwent lumbar posterolateral fusion, compared to 100 who had been recommended to undergo the procedure by an outside surgeon. 91 avoided surgery, and were recommended solutions that were less invasive and expensive, lower risk, and with a higher likelihood of success.

What this study shows is that siloed surgical decision-making often results in suboptimal treatment recommendations, leading more people to pursue tests and procedures they do not need. This creates more needless harm and wastes precious healthcare resources. 

How Sword is driving better outcomes at lower cost 

As employers try to rein in outrageous medical costs, Sword Health is providing a compelling, cost-effective solution for treating MSK disorders in the workplace. Our virtual, at-home program allows members to perform their prescribed physical therapy exercises whenever and wherever is most convenient for them. As a result, Sword has the highest adherence and engagement rates in the digital MSK space, leading members to see a 62% reduction in pain, a 49% drop in medication consumption, and a 42% increase in productivity, on average. 

Sword helps our patients avoid surgery 

Patients who use Sword report a significant decrease in surgery intent. When we ask members how likely they are to pursue surgery, they are 60% less likely to pursue surgery at the end of their program as they were at the beginning. 

That’s 60% less likely to endure expensive, invasive, and potentially unnecessary surgery. That’s 60% less likely to need time away from work, family, or other activities due to post-surgery recovery. That’s 60% less likely to suffer potential complications of surgery. Meanwhile, employers are saving an average of $2,472 per member per year, according to an independent evaluation by the Validation Institute. 

The majority of this savings is due to prevented surgeries. Additional cost savings come from preventing other interventions, such as injections. With physical therapy done right, you’re putting your workforce on a better path to living pain free—and avoiding costly surgeries they likely don’t need. 

In addition to improving patient lives, see why 3 out of 4 employers choose Sword over other digital physical therapy solutions.

About the author, Dr. Vijay Yanamadala

Vijay Yanamadala, MD, MBA, FAANS is a board certified neurosurgeon who specializes in the treatment of spinal disorders. Dr. Yanamadala has extensive experience in treating medical conditions including scoliosis, spine trauma, spinal vascular diseases, and spinal deformities. A graduate of Harvard Medical School, he has published over 70 scientific papers and received numerous awards on the safe and effective treatment of complex spinal conditions through advanced and innovative techniques paired with the use of multidisciplinary teams. Much of his work has centered on better coordination of musculoskeletal care and the avoidance of procedures and surgeries through care integration. 

Dr. Yanamadala is also a pioneering surgeon who was among the first surgeons in the tristate area and New England to offer awake spinal fusion surgery. He was also the second surgeon in the world to offer patient specific spine fusion surgery. He has done international spine surgery missions in Kenya, India, Mongolia and Sri Lanka, performing countless free surgeries during these trips. Dr. Yanamadala is certified by the Safety in Spine Surgery Project (S3P) and is a member of the American Association of Neurological Surgery, Congress of Neurological Surgery, North American Spine Society, and the Scoliosis Research Society.