Three years ago, Amy Leyden took her 10-year-old son, Luke, on a vacation to Oregon. Her back hasn't been the same since.
In a furious game of touch football, Leyden made a spectacular catch but landed flat on her back. That night, she slept on a friend's couch, and the next day, the fearless duo went on an ill-advised dune buggy ride on the Oregon coast.
Within a month, the "40-something" marketing manager at the University of Minnesota was diagnosed with a herniated disk, a condition so painful she had to conduct meetings lying flat on her belly in her office. "It was excruciating," she said.
Leyden's story is an increasingly familiar one in American medicine. Four out of five Americans will suffer from disabling back pain during their lifetimes, according to the National Institutes of Health. Spending on back care soared between 1997 and 2005, reaching $86 billion — just shy of what Americans spent battling cancer.
As those numbers have multiplied, so have questions about the more aggressive forms of back treatment. A 2008 study in the Journal of the American Medical Association, for example, noted that the increase in back-care spending occurred "without evidence of corresponding improvement" in patients' health.
"Intense pain is not necessarily an indication for surgery," said Richard Deyo, a professor of family medicine at Oregon Health and Science University and one author of the study. "You can't fix everything with a knife."
Fusion surgeries proliferating
Perhaps the biggest controversy involves an invasive surgery called spine fusion, which attempts to relieve back pain by permanently connecting (or fusing) several levels of bone in the spine. While the overall number of back operations has flattened out in recent years, complex fusion surgeries, which can cost upward of $80,000, continue to proliferate. American surgeons now perform twice as many of these operations as their counterparts in most European countries, Australia and New Zealand, and five times more than the United Kingdom, despite similar patient populations.
This debate is likely to intensify under the sweeping new federal health legislation that President Obama signed in March, which will gradually require doctors and hospitals to demonstrate that their services are cost-effective. In that vein, the New England HealthCare Institute estimates the United States could save $1 billion a year by eliminating unnecessary back surgeries.
Minnesota is likely to be a crucible in this debate. The state is home to Medtronic Inc., the world's largest maker of devices used in spine surgery, as well as Abbott Northwestern Hospital, which performs more spine fusion surgeries on Medicare patients than any other hospital in the country, according to the industry publication Orthopedic Network News.
Fusion surgery has historically been used to correct deformities, fractures, complications related to tumors and other rare conditions. The surgical results have been good, and largely noncontroversial.
But in recent years, more and more of these procedures have been used to treat back pain related to aging, prompting several studies to question whether the expensive intervention is worth it.
Fusion involves a surgical tool kit consisting of screws, rods, cages and plates, and sometimes a biologic product made by Medtronic called Infuse, which grows bone between the vertebrae in an effort to stabilize the spine.
A painful journey
In 2006, American doctors performed approximately 343,000 spine fusion operations, up 82 percent from 1999, according to the National Center for Health Statistics, which tracks Medicare data, omitting perhaps thousands more paid by other sources.
Since then, the number has continued to rise, though not as explosively. The Millennium Research Group estimates 445,300 spine fusion surgeries were done last year.
Some claim the increase in fusion surgery may be related to improvements in technology and the simple fact that baby boomers are aging.
"Americans think longevity is a right and death is optional," said Sam Ho, chief medical officer for UnitedHealth Group, the nation's largest insurer. "We all want to be as active as we can — and for as long as possible."
Critics argue that influence by big medical device companies — including lucrative royalty and consulting arrangements bestowed on top surgeons whose opinions hold sway among their colleagues — is one reason the number of spine fusion surgeries has skyrocketed.
Medtronic and others insist that collaboration with doctors is crucial for creating and perfecting innovative new tools to treat patients.
But Charles Rosen, a California spine surgeon and the head of the Association for Ethics in Spine Surgery, says these financial incentives create demand for certain brands of product.
"That's one reason why you're seeing so many fusion surgeries," he said.
Other specialists say the situation is more nuanced. Each patient is different, they say.
"Is there too much back surgery? Yes," said John Sherman, an orthopedic surgeon with Twin Cities Orthopedics, one of the nation's biggest practices of its kind.
"But it's not as dark as (Dr.) Deyo portrays it, nor is surgery a panacea for curing all back pain."
The truth is, up to 90 percent of people with acute low back pain will heal on their own, no matter what they do, according to several studies.
Some doctors have embraced doubts about surgery and are exploring nonsurgical options.
For example, Physicians Neck and Back Clinic, a Twin Cities chain of clinics, has gained national attention for its sports medicine approach to treating back pain.
The clinic offers its patients an aggressive rehabilitation program aimed at strengthening the back.
It can be a painful journey, according to CEO Dave Carpenter. "Generally patients tend to get worse before they get better," he said.
One satisfied patient is Amy Leyden, who turned down surgery "out of pure fear" and went to 24 rehab sessions at Physicians Neck & Back Pain instead.
"You're pushed," she said. "It's like having a personal trainer. But I would have never done it on my own. As soon as it got painful, I would have quit."
It worked. Today, Leyden keeps up with two kids, plays tennis and goes to the Y a couple of times a week.