Spinal gap

On a sunny morning in July 2017, Gold Coast Titans NRL player Chris McQueen nervously lay waiting on a hospital gurney. Having swapped his bright blue jersey for a white hospital gown, he watched as the anaesthetist wiped his arm with an alcohol swab and winced as the needle of the intravenous cannula pierced his skin.

McQueen was about to undergo a cervical spine total disc replacement and anterior cervical fusion to help repair damage sustained through eight years and 154 first class games of brutal tackling in the NRL. He had felt comfortable with his decision to proceed with the surgery but as he lay bathed in the slab of fluorescent lights a wave of what-ifs finally hit him.

What if something went wrong? What if he was paralysed? What if he could never play another game of rugby again?

Just then his spinal surgeon, Laurence McEntee, entered the anaesthetic bay wearing blue scrubs and a clean-shaven smile.  “We’re ready to go,” Dr McEntee told McQueen, shaking his hand. “Do you have any questions?”

“Will I be any taller after you replace my disc?” McQueen asked.

Dr McEntee laughed. “Maybe by a millimetre or two,” he said.

After McQueen was wheeled into the operating theatre, Dr McEntee reviewed the rugby player’s films one last time. The images that showed the bulging discs and bony spurs that were causing pain and numbness down both his arms and were stopping him from playing his beloved game.

Once McQueen was asleep, Dr McEntee secured his head to the operating table with long strips of duct tape. Then he put on a mask and scrubbed his hands and gowned and gloved and, taking a scalpel, made his first incision.

Although McQueen, at 29, was relatively young to be having this kind of surgery he was far from unique. In fact, McEntee himself had had a similar operation when he was only 28. “People don’t realise that spinal deterioration begins from their late teenage years onwards,” Dr McEntee said. “Generally, it’s a non-painful process with everyone’s spine wearing out at different rates.”   

According to the Australian Institute of Health and Welfare, chronic back pain affects 3.7 million people and is the third leading cause of disease burden in Australia[1]. In 2009 the direct healthcare expenditure on back pain alone was $1.2bn[2].    

Dr McEntee calls it a massive problem. “It’s probably the number one leading cause of musculoskeletal disability, certainly in working-age people,” he said.

The causes of back pain are myriad including muscle and ligament strain, inflammation, osteoarthritis, scoliosis and compression fractures secondary to osteoporosis. However, McQueen was suffering from another common cause: radiculopathy, also known as nerve compression.

This condition arises from the spine’s complex anatomy. The spinal column consists of 24 vertebrae or backbones, along with the sacrum and coccyx. There are two main parts of a vertebrae: the body; and the vertebral arch – which projects posteriorly to form a bony tunnel through which the spinal cord runs.  

The vertebrae are joined to each other by intervertebral discs, which are composed of an outer fibrous ring and an inner gel-like centre. As we age the discs become more fibrous and less elastic leading to disc shrinkage and bulging which can compress on nerves. With trauma the fibrous ring can rupture, leading to extrusion of the gel-like centre and further nerve impingement.    

With ageing and degeneration, osteophytes, or bony spurs, can grow out from the edges of vertebral bodies also causing nerve compression. Management includes activity modification such as avoiding heavy lifting or prolonged sitting. Paracetamol and non-steroidal anti-inflammatory drugs can be used to help with pain. Most episodes of radiculopathy are self-limiting. However, if severe symptoms persist, surgery may be required to help relieve pressure on the nerves.

There are multiple types of spinal surgery involving either removing part of a damaged disc (discectomy), removing an entire damaged disc (disc replacement) or joining vertebrae together to prevent movement and nerve impingement (spinal fusion).

“With the proper approach to the diagnosis and treatment of people and then the right operation on the right person for the right reason, the results can be spectacular and really change people’s lives,” says Dr McEntee.

There is limited evidence for surgery for chronic, non-specific, lower back pain and it is generally not recommended[3]. But when nerve compression is involved there is evidence that surgery may be of benefit. In the 2006 landmark Spine Patient Outcome Research Trial (SPORT), patients who were suffering from disc herniation, spinal stenosis or spondylolisthesis (vertebral slippage) were randomised with either surgery or conservative management. Those who had surgery showed better improvement in function and patient satisfaction four years after treatment compared to those who didn’t[4].

However, even if surgery is warranted, it is often no easy task to have it. Waiting times to be seen in a public orthopaedic outpatient clinic are often substantial, with equally long waits once patients are seen before they can actually have surgery[5].

As a result, many, who can afford to, have turned to the private health care system to have their spinal surgery done. In the 2016-2017 financial year, more than 13,000 spinal surgeries were covered privately, costing health funds over $380m[6].

But with the federal government’s private health insurance reforms that took effect on April 1 this year, some have expressed concern that it will now be harder to have spinal surgery performed privately. Private health policies have been classified into either Gold, Silver, Bronze or Basic tiers. A number of procedures have been restricted to the highest tiers, including back, neck and spine surgery, now only covered by Gold and Silver tiers[7].

Spine Society of Australia president, Dr Michael Johnson, is concerned the new categorisations will have the potential to drive inappropriate practice. “It seems to be more about what insurers are prepared to provide within certain actuarial constraintas, rather than what patients with private health cover require,” he said.

Dr Johnson warned that many patients without Gold-tier insurance will only discover they are inadequately insured when they reach the stage where surgery is required.

“An example of this is nerve compression in the neck, known as cervical radiculopathy, which leads to pain and upper limb weakness,” he said. “The two most common surgical treatments of this condition are anterior cervical decompression and fusion or cervical total disc replacement.

“Under the new clinical categories, patients with Silver cover are only covered for a posterior cervical decompression to treat this problem. In most cases, this is an inferior option as the dissection of the paraspinal muscles leads to increased pain, higher infection rates and longer hospital stays.

“Patients who can’t afford to increase their cover to Gold or pay for the surgery themselves will be forced into the public system,” he said. “The result will be an enormous cost shift from the private health system to the state-run public system.”  

Private Healthcare Australia chief executive Dr Rachel David disagrees, saying the changes will eliminate features of the system that consumers have found confusing, improving transparency and making it simpler to use their private health insurance.

“Keeping private health sustainable ultimately benefits all Australians by keeping pressure off the public hospital system,” she said.

“The whole point of the private health insurance reform legislation is to standardise across all health funds, so not only do you have the Gold, Silver, Bronze and Basic tiers, but now you’ve got standardised clinical definitions. That means that if orthopaedic or spine surgery is covered by one fund, exactly the same range of treatments will be covered by the other funds.”

Thankfully, up to 90 per cent of patients who see an orthopaedic surgeon don’t require surgery, says Dr McEntee. “The vast majority of people can generally manage with regular exercise, maintaining good weight and posture, core muscle and back muscle strengthening exercises, and from physiotherapy,” he says.

[1] https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/back-problems/contents/what-are-back-problems

[2] https://www.apsoc.org.au/PDF/Publications/20160816_AIHW_Impacts_of_Chronic_Back_Pain.pdf

[3] https://www.ncbi.nlm.nih.gov/pubmed/16462440

[4] https://www.dartmouth-hitchcock.org/spine/sport_results.html

[5] https://theconversation.com/getting-an-initial-specialists-appointment-is-the-hidden-waitlist-99507

[6] These figures supplied to me by Private Healthcare Australia CEO Dr Rachel David

[7]http://www.health.gov.au/internet/main/publishing.nsf/Content/89DCC17F86C24B4ACA2581BA007A2DC7/$File/GSBB%20fact%20sheet%20V02.pdf