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Growing number of spinal fusions stirs national debate

Suffering from an aching back, truck driver Mikel Hehn went to see surgeon Jeffrey Gerdes in 2008. The St. Cloud, Minn., doctor diagnosed spinal disc degeneration, commonly treated with physical therapy, and said surgery wasn't called for.

Unhappy with the answer, Hehn turned to Ensor Transfeldt, a surgeon at Twin Cities Spine Center in Minneapolis. Transfeldt performed fusion surgery on Hehn, screwing together three vertebrae in his lower spine.

Fusion aims to limit painful spine movements. This one didn't work out. Two years later, the pain in Hehn's neck, lower back, buttocks and thighs is so bad that he can't hold a job and seldom leaves home, he said in an interview.

"There's days when I just can't take it and the tears run," said Hehn, 52, who lives in Sartell, Minn. He said he takes oxycodone for pain, Soma to sleep, Lexapro for depression and Imitrex for headaches.

Hehn's surgery generated a $135,786 bill from Abbott Northwestern Hospital in Minneapolis, feeding a national boom in costly fusion surgeries. It also illustrates how spine surgeons have prospered from performing fusions, which studies have found to be no better for common back pain than physical therapy is -- and a lot more dangerous.

The number of fusions at U.S. hospitals doubled to 413,000 between 2002 and 2008, generating $34 billion in bills, data from the federal Healthcare Cost and Utilization Project show. The number of the surgeries will rise to 453,300 this year, according to Millennium Research Group of Toronto.

The possibility that many of these and other surgeries are needless has gotten little attention in the debate over health care costs, which rose 6 percent last year to $2.47 trillion. Unnecessary surgeries cost at least $150 billion a year, according to John Birkmeyer, director of the Center for Healthcare Outcomes & Policy at the University of Michigan.

"It's amazing how much evidence there is that fusions don't work, yet surgeons do them anyway," said Sohail Mirza, a spine surgeon who chairs the Department of Orthopaedics at Dartmouth Medical School. "The only one who isn't benefiting from the equation is the patient."

The Twin Cities Spine bill for Hehn's surgery was $19,292, his medical records show. The firm received $8,978 after an insurance discount, $7,742 of it for Transfeldt's services. Hehn's insurer paid after his bid for workers' compensation coverage was denied on grounds he wasn't injured on the job.

Another beneficiary was Medtronic Inc., which makes products for spinal surgery, including Infuse, a bone-growing material widely used in fusions. Infuse accounted for $17,575 of Abbott Northwestern's charges, Hehn's medical bills and insurance records show.

Twin Cities Spine performs fusions on patients with conditions the surgery doesn't treat effectively, said Brian Nelson, an orthopedic surgeon and medical director of a Minneapolis clinic that stresses exercise for back pain.

"I have a lot of respect" for the practice and its surgical skills, Nelson said. "But we have a fundamental disagreement. I think there are too many people being fused."

Payments by medical-device makers pose an "irresistible" temptation to tailor treatment to more-lucrative procedures, said Eugene Carragee, chief of spine surgery at Stanford University in Palo Alto, Calif.

Twin Cities Spine believes in a "conservative course of treatment in the vast majority of cases," according to an e- mailed statement from Lisa Arrington, the practice's marketing director.

There are some people for whom surgery is appropriate, she wrote, and numerous patients "have experienced successful outcomes from spinal fusion procedures," regaining functionality. The operations "reduced pain and improved their quality of life," she said.

The firm declined to comment on individual patients, and did not make the doctors who treated them available for comment. Twin Cities Spine surgeons routinely warn of potential surgical risks, including nerve damage, blood clots and the need for more surgery, according to letters provided by several patients.

British and Norwegian researchers found fusion no better than physical therapy for disc-related pain in three studies, totaling 473 patients, published in the journals Spine, Pain and the British Medical Journal between 2003 and 2006.

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