The Gray Tsunami: The Aging Spine in America
Aging Baby Boomers (those born between 1946 and 1964) are now being referred to as the age wave or gray tsunami. With an expected 64 million adults turning 65 over the next few years, health care costs are expected to soar. Based on current statistics for older adults, surgeons expect to see a significant rise in Medicare dollars spent on lumbar spine surgery.

One area of particular interest is centered around the diagnosis of lumbar spinal stenosis. Spinal stenosis is defined as a narrowing of the spinal canal where the spinal cord travels down the spine. The effects of aging (e.g., bone spur formation, thickening of spinal ligaments inside the canal, disc degeneration) shrink the amount of space for the spinal cord.

Spinal nerve roots that leave the spinal cord can also be affected. The resulting pressure or irritation of nerve tissue can cause low back pain, leg pain, and other symptoms such as numbness, tingling, weakness, or foot drop. Successful treatment of this problem remains a complex, puzzling, and expensive challenge. How so?

Well, the government reports that 1.65 billion dollars is spent in one year just in hospital costs for the surgical treatment of this problem. Yet, it's not at all certain that this taxpayer money is spent wisely. Do patients get better and stay better? Are they able to do more with less pain? Given the way information is collected, we simply don't know at this point what are the outcomes of surgery for lumbar spinal stenosis.

When surgery is done, there are two main choices: decompression (remove the disc and/or remove bone from around the disc) and fusion. The decision to perform one or both of these procedures is determined by surgeon preference, not always evidence of what works best. But don't blame the surgeons for not following an evidence-based approach. The research to support treatment selection and patient selection for each treatment method just isn't there yet.

You might ask if there isn't a less invasive, less expensive way to treat this problem. There is -- physical therapy, steroid injections, medications for pain control and to combat inflammation. But there's not enough strong evidence to support these approaches either.

In this commentary on the treatment of lumbar spinal stenosis, a well-known surgeon from Kaiser Permanente Center for Health Research (Dr. Richard Deyo) shares how the surgeon faces many challenges when dealing with this patient population.

Advancing age often comes with a whole host of other problems we call comorbidities. Additional health problems like high blood pressure, diabetes, heart disease, cancer, and so on add to the complexity of patient treatment. Younger, healthier, and less frail patients may be treated differently compared with older adults with more comorbidities.

Data collected from hospital records suggest that two-thirds of the patients having decompression and fusion are younger (less than 65 years old). The remaining one-third of the procedures are for just decompression and in the older group with more health problems. It makes sense that surgeons select lower-risk patients for the more complex procedures (decompression and fusion) but what does the evidence show?

That's the problem. The research to show when to perform a fusion, when to use instrumentation (metal plates, screws, pins), and what type of fusion to do just isn't available. Now with health care reform entering the picture, problems like spinal stenosis that affect many older adults and cost the government huge sums of money will get the attention they deserve.

The future of health care involving spinal surgery is expected to bring less invasive techniques that are safer and yield better results with fewer complications. Patients are going to be more involved in the decisions made about their care. Patient education about their condition, choices of available treatments, and expected outcomes (based on research evidence) will change the way decisions are made regarding surgery.

It's predicted that in the future of lumbar spine surgery, surgeon preference won't be the only deciding factor in whether decompression versus decompression plus fusion is used to treat spinal stenosis. And the role of less invasive techniques (e.g., interspinous process spacers, automated percutaneous discectomy) will be investigated more carefully and completely.

When it comes to treating Baby Boomers, they are active consumers. As the name suggests, the gray tsunami is going to change how medicine is carried out. They expect and even demand a patient centered consent process.

In other words, they want to know the who, what, when, where, and how of their condition and its treatment. They expect full disclosure including the pros and cons of each treatment, the costs of care, and the potential complications and expected outcomes.

Along these same lines, Dr. Deyo suggests that researchers need to get busy and find out more about the best way to treat lumbar spinal stenosis. Newer techniques are great but their benefit(s) must be proven, not just assumed. And finally, Dr. Deyo points out that surgeons will be expected to make the treatment decision an individual one based not just on their own preferences, but the preferences of their patients.
Richard A. Deyo, MD, MPH. Treatment of Lumbar Spinal Stenosis: A Balancing Act. [Commentary]. In The Spine Journal. July 2010. Vol. 10. No. 7. Pp. 625-627.