Is elective spinal surgery overused in private health care in Australia?

When approached some years ago to join a multicentre randomised controlled trial of decompression for people with spinal canal stenosis, I said I couldn't possibly do this, as I firmly believed it was a good treatment in the right circumstances. However, I now had a slow growing worm in my brain. Was this in response to my own cognitive dissonance, or the subliminal effect of scepticism about the benefits of much surgery?1 No doubt I was also influenced by the number of older people I was seeing in my clinic (I have just successfully undertaken a laminectomy in a woman of quite advanced age) and the delays caused by the COVID‐19 pandemic (I have just seen a teenager with scoliosis who had been referred to me in 2021).

This is the state of the public health system in Melbourne, the world's most locked down city. When I could only speak on the phone or online with my patients with canal stenosis, their overall condition did not necessarily deteriorate, although MRI images might have looked less rosy after a “flare” of pain. And I would encourage my motivated patients, who thought that they might need surgery this time, to work on getting back to their usual maintenance interferential and exercise programs. The most frequent outcome was that their condition indeed settled back to its usual, manageable level: a fine example of the natural history of disease.2 To qualify as a good treatment, surgical interventions must do better than the natural history of a condition, but do they?

In this issue of the MJA, Tran, Lewin, Jorm and Harris shine a spotlight on this question with their fascinating study of people undergoing elective spinal surgery.3 In their retrospective observational investigation, they examined the numbers of elective spine operations (decompressions, fusions, disc replacements) for people with degenerative conditions over a 20‐year period in New South Wales, stratified by funding type (private, public, workers’ compensation). Although limited to one Australian state, their findings can probably be extrapolated to the rest of the country, as the private and public hospital systems are similar everywhere, and workplace medical insurance systems are all covered by the same national law. The authors found a disproportionate increase in the number of privately funded elective spinal fusions during 2001–20, particularly for people aged 65 years or more. They also report the curious finding that the number of privately funded decompressions increased between 2001–02 and 2014–15, but then declined, while that of total disc replacements steadily increased across the study period. I do not consider decompressions and disc replacements interchangeable procedures. As possible causes of these changes, Tran and colleagues suggest our ageing population, technical advances, financial considerations, and changes in health system funding.3

The strength of the study by Tran, Lewin, Jorm and Harris was that they analysed population‐level data, albeit for a single state, but this strength is diminished by limitations in the quality of their data. As always, reliable knowledge is underpinned by good data. With respect to the study question, a clinician would be most interested in the spinal level at which surgery was undertaken, the type of surgery, diagnoses, and indications; unfortunately, this study cannot provide information on these details, as this type of information is simply not collected nor readily available.

What are the challenges? We surgeons believe that we work with robust definitions, but we actually have no information based on good natural history studies,4 especially with respect to older people. To add insult to injury, we have no patient‐important outcomes data to guide translating the information we do have into good clinical practice. The challenge articulated by Tran and colleagues is consequently to face the uncomfortable possibility that we are perhaps undertaking too many operations. I do not think that the lower number of publicly funded procedures reflects undertreatment or lack of resources: our post‐COVID‐19 spinal surgery waiting lists do not include massive numbers of patients, unlike those for some other procedures.

So why are some surgeons happy to operate without or with only poor evidence regarding its value?5 In my experience, many believe they can fix the structural problem (that's logical!) and that they have the skills for performing a technically excellent operation (perhaps true). Is this simply human altruism or narcissism, or are they ignoring the evidence? But remember: the patient's behaviour can also influence decisions about surgery. Why do people want surgery, with its risks of sometimes catastrophic complications? Over the course of my career, I have learned that many want a quick fix, secretly trusting that the outcome will be excellent and that they will be able to return to “normal” health. Is this understandable hope or poor health literacy? In many instances, private health insurance might simply be an enabler for those who can afford it.

What should we do? We need to get serious about collecting data, using robust definitions of diagnoses, surgical indications, and patient‐important outcomes. And then we need to consider and use this information wisely. Laozi, the father of Taoism, wrote that a “thousand mile journey begins where one stands”.6 Tran and colleagues have shown us a starting point for our own journey toward enlightenment.