When the Best Surgical Outcome is No Surgery

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When a patient has ongoing back or joint pain, getting an MRI is often one of the first steps in diagnosing the issue. If the MRI shows spine degeneration or a bulging disc, some doctors recommend surgery based on those findings. The problem is an MRI alone doesn’t provide enough information about whether someone is a good candidate for surgery.

“There are too many spine surgeons who recommend spine surgery based on an MRI with very little direct engagement in the story behind the MRI,” says Dr. Robert Masson, medical director and founder at Masson Spine Institute and member of Employer Direct Healthcare’s medical advisory board.

Degenerative findings are common even in asymptomatic patients. In a study of around three thousand people with no back pain, 37% of the 20 to 30-year-olds had an MRI that met the criteria for disk degeneration—and that number increased with age. In other words, an MRI alone can’t tell you whether someone is experiencing pain. For this reason, international guidelines recommend against the use of imaging for routine diagnostic tests of lower back pain. Despite this, the use of MRI diagnostics continues to rise.

Ideally, surgeons should consider several factors when deciding whether a patient is a good candidate for surgery. Masson starts patient encounters by asking about goals. “They look at me like I have three heads because no one’s ever asked them what their goals are,” he says. “When you start with goals, you can figure out what’s holding them back. The deeper you get into the storytelling, the clearer you are on the extent of the surgery, the type of surgery, the value of surgery or the lack thereof.”

A quality surgeon identifies the right treatment approach through shared decision-making with their patient, which may or may not involve surgery.

The overprescription of surgery

Studies show U.S. physicians overprescribe surgery, particularly musculoskeletal (MSK) and orthopedic procedures. An observational study of around 500 patients found that 60% were recommended unnecessary spine surgery. A similar study found 34% of knee replacement surgeries were deemed inappropriate.

In some cases, physical therapy is a more appropriate path, but patients either never hear about this option or aren’t able to pursue it. In a State of MSK report released by Hinge Health, 50% of respondents strongly agreed that physical therapy was too expensive.

MSK issues account for the second-largest cost concern for employers, and as a result, many employers have implemented virtual physical therapy programs or surgical center of excellence models to help curb costs.

But the rise in point solutions has caused fatigue among benefits leaders, while many employees don’t fully understand the benefits available to them. Offering employees a connected ecosystem of wellness solutions helps raise awareness of available resources while creating a collaborative care environment.

For example, SurgeryPlus Care Advocates guide members to other solutions in their benefits ecosystem for digital PT programs, such as Hinge Health, if their surgeon recommends against surgery or the member needs PT for pre- or post-surgical exercise.

When surgery is the right option

When used appropriately, MSK and orthopedic surgeries vastly improve quality of life.

“Do I think too much spine surgery is done? Absolutely,” Masson says. “Does that put a scar on spine surgery? No way. So many people are critically dependent on spine surgery to get back to who they want to be.”

Appropriate care requires shared decision-making (SDM) and the evaluation of other pain mitigation strategies, like supervised exercise and physical therapy.

An article in the Journal of the American Academy of Orthopaedic Surgeons describes SDM as, “the process by which the physician and the patient collaborate to arrive at the evidence-based treatment that best aligns with the patient’s individual goals of care.”

This approach improves patient outcomes and reduces costs. Masson actively engages with SDM by focusing on education and goals with his patients. The matrix he uses to decide if someone needs surgery involves testing their functional limitations relative to their goals.

“A lot of people have expectations that surgery will completely fix their problem,” Masson says “They should be aiming toward functional performance, movement, independence, productivity, capacity and consistency. People who don’t have that in their goal structure aren’t great surgical candidates because they’ve missed the point of what their goals should be, which is functional recovery.”

When creating a care plan, Masson works with clients to create physical activity, nutrition and rest recovery maps.

“There’s a tendency to put conservative care and surgical care into polar extremes of a spectrum when the best application of surgery is with them tightly intertwined. Surgery by itself is a tiny piece of the puzzle,” Masson says. “Surgery optimized with all the pieces of holistic care creates a top 1% strategy.”

Offering high-quality care

Employers should offer access to physical therapy and excellent surgical care to provide employees with the most appropriate care at the right time. When evaluating surgery centers of excellence, focus on providers. Ask the questions:

  • What is their pre- and post-surgery education protocol?
  • How often do they recommend against surgery?


SurgeryPlus offers a network of individually vetted surgeons who provide a 20 to 30% surgical avoidance rate.

“Surgery is the easy part. The most important ingredient for a high-quality surgeon is understanding why we are there in the first place and what we want to achieve for our community,” Masson says. “Any environment that puts themselves through the rigors of qualifying the professionals who are going to be serving their community is inherently going to be more successful at delivering appropriate care.”

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