Epstein Nancy E
Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, and Chief of Neurosurgical Spine and Eduction, NYU Winthrop Hospital, Mineola, New York, USA.
Surg Neurol Int. 2017 Oct 10;8:247. doi: 10.4103/sni.sni_300_17. eCollection 2017.
Lumbar surgery for spinal stenosis is the most common spine operation being performed in older patients. Nevertheless, every time we want to schedule surgery, we confront the insurance industry. More often than not they demand patients first undergo epidural steroid injections (ESI); clearly they are not aware of ESI's lack of long-term efficacy. Who put these insurance companies in charge anyway? We did. How? Through performing too many unnecessary or overly extensive spinal operations (e.g., interbody fusions and instrumented fusions) without sufficient clinical and/or radiographic indications.
Patients with lumbar spinal stenosis with/without degenerative spondylolisthesis (DS) are being offered decompressions alone and/or unnecessarily extensive interbody and/or instrumented fusions. Furthermore, a cursory review of the literature largely demonstrates comparable outcomes for decompressions alone vs. decompressions/in situ fusions vs. interbody/instrumented fusions.
Too many older patients are being subjected to unnecessary lumbar spine surgery, some with additional interbody/non instrumented or instrumented fusions, without adequate clinical/neurodiagnostic indications.
The decision to perform spine surgery for lumbar stenosis/DS, including decompression alone, decompression with non instrumented or instrumented fusion should be in the hands of competent spinal surgeons with their patients' best outcomes in mind. Presently, insurance companies have stepped into the "void" left by spinal surgeons' failing to regulate when, what type, and why spinal surgery is being offered to patients with spinal stenosis. Clearly, spine surgeons need to establish guidelines to maximize patient safety and outcomes for lumbar stenosis surgery. We need to remove insurance companies from their present roles as the "spinal police."
腰椎管狭窄症的腰椎手术是老年患者中最常见的脊柱手术。然而，每次我们想要安排手术时，都会与保险业打交道。他们常常要求患者先接受硬膜外类固醇注射（ESI）；显然他们并未意识到ESI缺乏长期疗效。到底是谁让这些保险公司来做决定的呢？是我们。怎么会这样呢？因为我们在没有充分的临床和/或影像学指征的情况下，进行了太多不必要或过于广泛的脊柱手术（例如椎间融合术和内固定融合术）。
对于患有或不患有退行性椎体滑脱（DS）的腰椎管狭窄症患者，仅提供减压手术，以及/或者不必要的广泛椎间融合术和/或内固定融合术。此外，对文献的粗略回顾在很大程度上表明，单纯减压手术与减压/原位融合手术以及椎间/内固定融合手术的效果相当。
太多老年患者正在接受不必要的腰椎手术，有些还额外进行了椎间/非内固定或内固定融合手术，而没有充分的临床/神经诊断指征。
对于腰椎管狭窄症/DS进行脊柱手术的决定，包括单纯减压、非内固定或内固定融合减压，应该由有能力的脊柱外科医生做出，要将患者的最佳治疗效果放在心上。目前，保险公司已经介入了脊柱外科医生未能对何时、何种类型以及为何对腰椎管狭窄症患者进行脊柱手术进行规范所留下的“空白”。显然，脊柱外科医生需要制定指南，以最大限度地提高腰椎管狭窄症手术的患者安全性和治疗效果。我们需要让保险公司不再扮演当前“脊柱警察”的角色。
