An Interview with Dr. Edward Benzel
BY JOHN MCCORMICK, OCTOBER 19, 2005
Last week, we had the good fortune of catching up with Dr. Edward Benzel, Chairman of the Cleveland Clinic Spine Institute. We spent a few minutes with him at this year's Congress of Neurological Surgeons in Boston. At The Cleveland Clinic, Dr. Benzel is also Vice Chairman of the Department of Neurosurgery, and the Program Director for the Neurosurgery Residency. Dr. Benzel is well known in the field as a formidable scientist with a focused empirical approach to questions surrounding the efficacy of various spine treatments.
HealthpointCapital: Fusions have an approximate 70% success rate. Is that an ambiguous result? What is the real clinical benefit of a fusion?
Dr. Edward Benzel: The fusion rate may truly be 70%, but actual success rates can vary significantly from that. Dr. [Peter] Fritzell from Sweden recently published a study in which the fusion rate was quite high but the actual success rate of fusion did not necessarily depend upon the acquisition of fusion. So we must be very cognizant of the fact that we do not fully understand the variables and their effects, and that clinical success may deviate significantly from "acquisition-of-fusion" success.
HC: If you were to design a study on the clinical efficacy of fusion, what would be the ideal measurement criteria of success?
EB: Outcome assessment instruments, such as the SF-36, Oswestry disability scale, and the visual analog pain scale, or equivalent instruments.
HC: Do you view fusion as a last resort?
EB: Absolutely.
HC: What other methods or devices are becoming available to surgeons in the continuum of care to prevent or delay fusion?
EB: This is a leading question. I believe "we" do too much surgery. The alternatives to fusion are not necessarily surgical. They may be non-operative in nature. In my opinion, we should be very, very surgically selective. Having said that, the surgical alternatives to fusion include nuclear replacement strategies, total disc arthroplasty, and dorsal motion preservation techniques, such as the Dynesys. From the information available to-date, these devices provide a limited advantage in a selected portion of the patient population that normally would have undergone a fusion procedure.
HC: What non-operative procedures do you view as attractive, say, for degenerative disc disease?
EB: Operations may not be the answer. Aggressive attempts at physical restoration, and rehabilitation are the most attractive to me. The treatment of spinal disorders is not a simple process. It encompasses a complex psychosocial, physiological, and physical milieu that the patient and physician must come to grips with. We must better define the patient population that are candidates for surgery. Simply defining an appropriate patient as one having back pain that is refractory to non-operative management is not enough. We must more clearly define the character of the pain and the imaging findings that are consistent with a good surgical and clinical outcome.
We, as surgeons, all too often assume that if nothing else has worked, surgery will. On the contrary, the fact that nothing else has worked does not justify an indication for surgery. Therefore, one should never assume there is a surgical or interventional alternative for the management of the patient's pain syndrome. Many other psychosocial factors may be involved. The patient's pain syndrome may be related to secondary gain issues. After all, back pain is a compensable disorder in the United States. Therefore, secondary gain plays a major role in the indications for and outcome of interventions.
HC: Do you consider back pain to be a fundamentally modern disorder then? We don't read about back pain being a major public health problem in Colonial times, for example.
EB: Back pain has not changed over the centuries. People dealt with back pain and didn't comment on it in days gone by. Back pain was a fact of life, like the common cold. People are affected by a cold or two every year. They simply deal with it. Today, people with back pain expect to be cured. This emerges from attitudes of the days gone by. Back pain is compensable and not tolerated. People, in general, are not willing to expend great effort to deal with it through active means such as weight loss, cessation of smoking, and aggressive physical restoration and rehabilitation activities.
HC: Why are surgeons so aggressive about surgical intervention then?
EB: If you hold a hammer in your hand, you look for nails. Surgeons are very impulsive individuals, and they seek to practice their craft. I believe that we perform far too many spinal surgical procedures, particularly lumbar fusion procedures. Some have been critical of this opinion, but most thoughtful surgeons agree.
HC: Dr. Benzel, thank you for your time.
EB: You're welcome.
