Back surgery overuse

Back surgery overuse
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VIDEO: Our October 7th panel discussion featuring
David Auerbach, Ph.D
, Massachusetts Health Policy Commission;
Eugene Carragee, MD
, Stanford University; and
Vikas Saini
MD
, president of the Lown Institute.
The Lown Institute Hospitals Index is the first to evaluate how well individual hospitals avoid overuse of common low-value tests and procedures. The Institute measured overuse of spinal fusion/laminectomy and vertebroplasty at hospitals with the capacity to perform the procedure using Medicare fee-for-service (2021-2023) and Medicare Advantage (2020-2022) claims data.
press release
methodology
Key Takeaways
U.S. hospitals performed more than 200,000 unnecessary back surgeries on Medicare beneficiaries. That’s one low-value back procedure every eight minutes.
These low-value back procedures cost Medicare more than $1.9 billion over three years.
Complications of spinal fusion occur in up to 18% of patients and include infection, blood clots, stroke, pneumonia, heart and lung problems, and even death.
California, Florida, Texas, and Pennsylvania had the highest volume of spinal fusion overuse, with at least 5,000 unnecessary procedures done in each state.
Texas, Florida, and Ohio had the highest volume of vertebroplasty overuse, with at least 6,000 unnecessary procedures done in each state.
Variation among U.S. News hospitals: Cleveland Clinic has a 0.5% rate of unnecessary vertebroplasty, while AdventHealth Orlando has a rate of 22.7%.
The top 10% of physicians by spinal fusion overuse volume accounted for 60% of the total overuse.
Lowest spinal fusion overuse hospitals
These are the hospitals with the
lowest rates
of spinal fusion/laminectomy overuse, including all hospitals that performed at least 500 procedures over three years. The rate of overuse is measured as the proportion of total procedures performed that meet overuse criteria.
The average overuse rate for all U.S. hospitals is 13%.
Name
State
Overuse rate
Overuse procedures
Total procedures
AVALA
LA
0.1%
(see note)
NORTHWEST SPECIALTY HOSPITAL
ID
0.9%
BAYLOR SURGICAL HOSPITAL AT LAS COLINAS
TX
1.2%
FRESNO SURGICAL HOSPITAL
CA
1.4%
CHRISTUS Mother Frances Hospital – Tyler
TX
1.5%
17
1134
MCBRIDE ORTHOPEDIC HOSPITAL
OK
1.5%
11
728
CaroMont Regional Medical Center
NC
2.1%
17
823
ERLANGER Baroness Hospital
TN
2.1%
20
934
HENDRICK MEDICAL CENTER
TX
2.1%
20
931
St. Francis Hospital & Heart Center
NY
2.2%
12
539
SOUTH TEXAS SPINE AND SURGICAL HOSPITAL
TX
2.2%
29
1300
LEGENT ORTHOPEDIC + SPINE
TX
2.3%
32
1392
CHRISTUS SANTA ROSA Hospital -MEDICAL CENTER
TX
2.4%
15
634
METHODIST HOSPITAL FOR SURGERY
TX
2.4%
19
801
UC San Diego Medical Center
CA
2.4%
20
840
MERCY SPECIALTY HOSPITAL SOUTHEAST KANSAS
KS
2.4%
16
671
MORRISTOWN MEDICAL CENTER
NJ
2.5%
26
1023
CHRISTUS OCHSNER ST PATRICK HOSPITAL
LA
2.5%
13
510
LOS ROBLES HOSPITAL & MEDICAL CENTER
CA
3.0%
15
500
PROVIDENCE REGIONAL MEDICAL CENTER
WA
3.0%
22
724
NOTE: Data omitted to avoid sharing information that could be personally identifiable.
Highest spinal fusion overuse hospitals
These are the hospitals with the
highest rates
of spinal fusion/laminectomy overuse, including all hospitals that performed at least 500 procedures over three years. The rate of overuse is measured as the proportion of total procedures performed that meet overuse criteria.
Most of these hospitals have overuse rates of
33% or above
, meaning at least one in three procedures are unnecessary.
The average overuse rate for all U.S. hospitals is 13%.
Name
State
Overuse rate
Overuse procedures
Total procedures
MOUNT NITTANY MEDICAL CENTER
PA
57.2%
289
505
CONCORD HOSPITAL
NH
39.5%
204
517
LUTHERAN HOSPITAL OF INDIANA
IN
38.6%
475
1232
HERITAGE VALLEY SEWICKLEY
PA
37.7%
229
607
HCA HealthONE Aurora
CO
37.6%
272
723
Jefferson ABINGTON HOSPITAL
PA
37.5%
291
777
Springfield MEMORIAL Hospital
IL
37.3%
315
844
MOBILE INFIRMARY
AL
36.6%
213
582
BAYSTATE MEDICAL CENTER
MA
36.0%
354
983
CRYSTAL CLINIC ORTHOPAEDIC CENTER
OH
34.5%
514
1490
ROCHESTER GENERAL HOSPITAL
NY
33.8%
213
630
PRESBYTERIAN HOSPITAL
NM
33.8%
184
545
UNITYPOINT HEALTH – Iowa Methodist Medical Center
IA
33.5%
267
796
CAPE CORAL HOSPITAL
FL
33.3%
186
558
HOSPITAL OF the UNIVersity OF PENNSYLVANIA
PA
33.3%
220
661
THE ORTHOPAEDIC HOSPITAL OF LUTHERAN HEALTH NETWORK
IN
32.7%
358
1096
Advocate Condell Medical Center
IL
31.5%
178
565
Riverside Methodist Hospital
OH
30.4%
622
2045
Unity Hospital
NY
29.4%
239
814
BLACK HILLS SURGICAL HOSPITAL LLP
SD
28.7%
241
840
Lowest vertebroplasty overuse hospitals
Many of these hospitals performed
zero unnecessary vertebroplasties
for patients with osteoporotic fracture, despite having opportunities to do so. The list includes hospitals with at least 500 eligible patient visits over three years.
The average overuse rate for all U.S. hospitals is 10%.
Name
State
Overuse rate
Patient visits
METROHEALTH Medical Center
OH
0.0%
1616
HARBORVIEW MEDICAL CENTER
WA
0.0%
1354
Mayo Clinic Health System – La Crosse
WI
0.0%
1091
ESSENTIA HEALTH – ST JOSEPH’S MEDICAL CENTER (Brainerd)
MN
0.0%
1026
MARSHALL Hospital
CA
0.0%
934
NYC Health + Hospitals/Lincoln
NY
0.0%
605
ST JOSEPH HOSPITAL
ME
0.0%
590
CAYUGA MEDICAL CENTER
NY
0.0%
575
ADVENTHEALTH SEBRING
FL
0.0%
549
MID COAST HOSPITAL
ME
0.0%
545
SAMARITAN HOSPITAL
NY
0.0%
503
Logan Health Medical Center
MT
0.1%
(see note)
Essentia Health – Duluth (Miller-Dwan Building)
MN
0.1%
MultiCare Yakima Memorial Hospital
WA
0.1%
Johns Hopkins Bayview Medical Center
MD
0.1%
Trinity Hospital
ND
0.2%
St. Luke’s Magic Valley Medical Center
ID
0.2%
Saratoga Hospital
NY
0.2%
Boston Medical Center
MA
0.2%
Note: Data omitted to avoid sharing information that could be personally identifiable.
Highest vertebroplasty overuse hospitals
These are the hospitals with the
highest rates
of vertebroplasty overuse, including all hospitals with at least 500 eligible patient visits over three years. The rate of overuse is measured as the proportion of patient visits with osteoporotic fracture that resulted in an unnecessary vertebroplasty.
For the three hospitals with the highest rates of overuse,
every other
patient visit for spinal fracture resulted in an unnecessary vertebroplasty.
The average overuse rate for all U.S. hospitals is 10%.
Name
State
Overuse rate
Overuse procedures
Patient visits
Kettering Health Miamisburg
OH
56.1%
324
578
Shannon Medical Center
TX
54.6%
379
694
St. Elizabeth Florence Hospital
KY
50.1%
335
668
AdventHealth Shawnee Mission
KS
47.9%
268
559
CHI St. Vincent Infirmary
AR
46.7%
250
535
Lutheran Hospital of Indiana
IN
44.1%
248
562
Halifax Health Medical Center
FL
43.2%
220
509
Jackson-Madison County General Hospital
TN
42.1%
266
632
Henry Ford Providence Southfield Hospital
MI
42.0%
216
514
Swedish Cherry Hill Campus
WA
40.1%
249
621
Northside Hospital Forsyth
GA
39.3%
291
740
Lakeland Regional Health Medical Center
FL
38.9%
210
540
Washington Regional Medical Center
AR
38.7%
299
773
Liberty Hospital
MO
38.4%
358
933
Blanchard Valley Hospital
OH
37.6%
193
513
Ascension Borgess Hospital
MI
37.6%
375
997
Parkview Regional Medical Center
IN
37.1%
358
965
Mather Hospital
NY
36.8%
254
690
Northside Hospital Cherokee
GA
36.7%
212
577
Gulf Coast Medical Center
FL
36.5%
189
518
U.S. News honor roll hospitals
Overuse varied
even among large academic medical centers such as the  2025-26 US News Honor Roll hospitals. For example, at the
Cleveland Clinic, fewer than 1%
of patient visits with osteoporotic fracture resulted in an unnecessary vertebroplasty, compared to more than
22% at AdventHealth Orlando
Spinal fusion
Vertebroplasty
Hospital
State
Overuse procedures
Total procedures
Overuse rate
Overuse procedures
Total patient visits
Overuse rate
AdventHealth Orlando
FL
397
1789
22.2%
519
2287
22.7%
Brigham and Women’s Hospital
MA
302
1719
17.6%
67
4074
1.6%
Cedars-Sinai Medical Center
CA
382
2278
16.8%
64
2640
2.4%
Cleveland Clinic Main Campus
OH
228
1982
11.5%
55
10541
0.5%
Hackensack University Medical Center
NJ
124
717
17.3%
38
697
5.5%
Hospital of the University of Pennsylvania
PA
220
661
33.3%
32
1950
1.6%
Houston Methodist Hospital
TX
241
2408
10.0%
261
1483
17.6%
Massachusetts General Hospital
MA
308
1491
20.7%
501
5896
8.5%
Mayo Clinic Hospital, Phoenix
AZ
55
878
6.3%
144
799
18.0%
Mayo Clinic Hospital, Saint Marys Campus
MN
246
2205
11.2%
264
2919
9.0%
New York-Presbyterian Hospital
NY
278
1641
16.9%
196
2746
7.1%
Northwestern Memorial Hospital
IL
81
848
9.6%
27
1978
1.4%
Ronald Reagan UCLA Medical Center
CA
(see note)
32
2651
1.2%
Rush University Medical Center
IL
161
1405
11.5%
53
2153
2.5%
Stanford Hospital
CA
358
1579
22.7%
165
3943
4.2%
The Johns Hopkins Hospital
MD
159
1185
13.4%
53
827
6.4%
The Mount Sinai Hospital
NY
115
911
12.6%
170
1226
13.9%
Tisch Hospital
NY
192
2306
8.3%
292
3754
7.8%
UCSF Helen Diller Medical Center at Parnassus Heights
CA
328
1778
18.4%
65
3122
2.1%
University of Michigan Health System
MI
169
973
17.4%
38
5544
0.7%
Note: Data omitted to avoid sharing information that could be personally identifiable.
Highest/lowest spinal fusion overuse hospitals in each state
Spinal fusion/laminectomy
State
Lowest overuse hospital
Overuse volume
Overuse rate
Highest overuse hospital
Overuse volume
Overuse rate
Alaska
n/a*
n/a*
Alabama
Baptist Medical Center South
38
5.9%
Mobile Infirmary
213
36.6%
Arkansas
Baxter Regional Medical Center
24
3.4%
CHI St. Vincent Infirmary
250
19.2%
Arizona
HonorHealth Scottsdale Thompson Peak Medical Center
19
3.7%
Saint Joseph’s Hospital – Tucson
157
23.1%
California
FRESNO SURGICAL HOSPITAL
<11
1.4%
Kaiser Permanente Los Angeles Medical Center
180
27.1%
Colorado
AdventHealth Avista
17
3.1%
HCA HealthONE Aurora
272
37.6%
Connecticut
St. Vincent’s Medical Center
40
6.3%
St. Francis Hospital & Medical Center
134
16.8%
District of Columbia
n/a*
n/a*
Delaware
n/a*
n/a*
Florida
Tallahassee Memorial Hospital
26
4.0%
Cape Coral Hospital
186
33.3%
Georgia
Piedmont Augusta
32
3.1%
Emory University Hospital
233
18.7%
Hawaii
n/a*
n/a*
Iowa
University of Iowa Hospital & Clinics
121
11.8%
UnityPoint Health – Iowa Methodist Medical Center
267
33.5%
Idaho
NORTHWEST SPECIALTY HOSPITAL
<11
0.9%
Saint Alphonsus Regional Medical Center
157
20.7%
Illinois
Elmhurst Hospital
56
5.2%
Springfield Memorial Hospital
315
37.3%
Indiana
ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH
67
6.1%
Lutheran Hospital of Indiana
475
38.6%
Kansas
MERCY SPECIALTY HOSPITAL SOUTHEAST KANSAS
16
2.4%
The University of Kansas Hospital – Bell Hospital Tower
129
10.8%
Kentucky
Baptist Health Paducah
51
8.0%
Baptist Health Lexington
135
19.1%
Louisiana
AVALA
<11
0.1%
Willis Knighton North
227
23.8%
Massachusetts
Lahey Hospital & Medical Center
63
9.3%
Baystate Medical Center
354
36.0%
Maryland
Luminis Health Anne Arundel Medical Center
49
7.9%
University of Maryland Medical Center
109
15.8%
Maine
Maine Medical Center**
191
15.5%
Northern Light Mercy Hospital**
130
17.4%
Michigan
Beaumont Hospital, Troy
74
5.0%
Trinity Health Grand Rapids Hospital
151
24.9%
Minnesota
M Health Fairview University of Minnesota Medical Center
28
4.5%
CentraCare – St. Cloud Hospital
256
24.9%
Missouri
Cox Medical Center South
48
3.6%
North Kansas City Hospital
346
27.7%
Mississippi
n/a*
n/a*
Montana
St. Vincent Regional Hospital
29
5.0%
Billings Clinic
102
18.2%
North Carolina
CaroMont Regional Medical Center
17
2.1%
UNC Health Rex
275
18.9%
North Dakota
Sanford Medical Center Fargo**
31
5.7%
CHI St. Alexius Health Bismarck Medical Center**
98
17.0%
Nebraska
Bryan Medical Center
119
10.6%
MIDWEST SURGICAL HOSPITAL LLC
251
27.7%
New Hampshire
Dartmouth Hitchcock Medical Center**
121
23.3%
Concord Hospital**
204
39.5%
New Jersey
Morristown Medical Center
26
2.5%
Hackensack University Medical Center
124
17.3%
New Mexico
Lovelace Medical Center**
97
18.7%
Presbyterian Hospital**
184
33.8%
Nevada
Renown Regional Medical Center**
81
6.3%
Southern Hills Hospital & Medical Center**
49
6.9%
New York
St. Francis Hospital & Heart Center
12
2.2%
Rochester General Hospital
213
33.8%
Ohio
UC Medical Center
29
4.4%
CRYSTAL CLINIC ORTHOPAEDIC CENTER
514
34.5%
Oklahoma
McBride Orthopedic Hospital
11
1.5%
Saint Francis Hospital
96
13.5%
Oregon
Providence St. Vincent Medical Center
47
4.1%
Salem Hospital
80
11.4%
Pennsylvania
WellSpan York Hospital
45
7.4%
Mount Nittany Medical Center
289
57.2%
Rhode Island
The Miriam Hospital**
41
7.0%
Rhode Island Hospital**
106
9.7%
South Carolina
Pelham Medical Center
45
4.7%
McLeod Regional Medical Center
177
16.2%
South Dakota
SIOUX FALLS SPECIALTY HOSPITAL
64
10.1%
BLACK HILLS SURGICAL HOSPITAL LLP
241
28.7%
Tennessee
Erlanger Baroness Hospital
20
2.1%
Saint Francis Hospital – Memphis
158
27.9%
Texas
BAYLOR SURGICAL HOSPITAL AT LAS COLINAS
<11
1.2%
Methodist Hospital | Stone Oak
249
23.1%
Utah
McKay-Dee Hospital
36
4.3%
Intermountain Medical Center
92
12.0%
Virginia
Winchester Medical Center
28
4.1%
Reston Hospital Center
133
18.1%
Vermont
n/a*
n/a*
Washington
Providence Regional Medical Center
22
3.0%
Confluence Health Hospital | Central Campus
151
22.5%
Wisconsin
Froedtert Hospital
55
7.5%
Aurora BayCare Medical Center
180
25.9%
West Virginia
St. Mary’s Medical Center**
77
14.6%
J.W. Ruby Memorial Hospital
116
14.6%
Wyoming
n/a*
n/a*
*Fewer than two hospitals in this state with high volume
**Only two hospitals in this state with high volume
Highest/lowest vertebroplasty overuse hospitals in each state
Vertebroplasty
State
Lowest overuse hospital
Overuse volume
Overuse rate
Highest overuse hospital
Overuse volume
Overuse rate
Alaska
n/a*
n/a*
Alabama
UAB Hospital**
29
3.6%
Huntsville Hospital**
225
22.2%
Arkansas
Unity Health – White County Medical Center
41
6.6%
CHI St. Vincent Infirmary
250
46.7%
Arizona
HonorHealth John C. Lincoln Medical Center
<11
0.3%
Mayo Clinic Hospital, Phoenix
144
18.0%
California
Marshall Hospital
0.0%
Saint Barbara Cottage Hospital
180
35.2%
Colorado
Denver Health Main Campus
<11
0.3%
CommonSpirit – Penrose Hospital
97
18.5%
Connecticut
UConn John Dempsey Hospital
16
1.9%
Hartford Hospital
103
14.5%
District of Columbia
n/a*
n/a*
Delaware
Beebe Medical Center**
<11
1.6%
Christiana Hospital**
280
16.0%
Florida
AdventHealth Sebring
0.0%
Halifax Health Medical Center
220
43.2%
Georgia
Wellstar Cobb Medical Center
42
5.5%
Northside Hospital Forsyth
291
39.3%
Hawaii
Straub Medical Center
30
2.4%
Pali Momi Medical Center
53
8.6%
Iowa
University of Iowa Hospital & Clinics
25
1.6%
UnityPoint Health – Iowa Methodist Medical Center
108
20.6%
Idaho
St. Luke’s Magic Valley Medical Center
<11
0.2%
Kootenai Health
185
15.5%
Illinois
Advocate Illinois Masonic Medical Center
<11
0.4%
Northwestern Medicine Kishwaukee Hospital
198
31.4%
Indiana
IU Health Methodist Hospital
36
3.5%
Lutheran Hospital of Indiana
248
44.1%
Kansas
The University of Kansas Hospital – Bell Hospital Tower
121
2.8%
AdventHealth Shawnee Mission
268
47.9%
Kentucky
Baptist Health Hardin
<11
0.9%
St. Elizabeth Florence Hospital
335
50.1%
Louisiana
Ochsner Medical Center – Baton Rouge
32
2.7%
Our Lady of Lourdes Regional Medical Center
239
32.0%
Massachusetts
Boston Medical Center
<11
0.2%
MelroseWakefield Hospital
131
24.8%
Maryland
Johns Hopkins Bayview Medical Center
<11
0.1%
TidalHealth Peninsula Regional
110
19.9%
Maine
St. Joseph Hospital
0.0%
Maine Medical Center
221
8.6%
Michigan
Bronson Battle Creek Hospital
<11
0.5%
Henry Ford Providence Southfield Hospital
216
42.0%
Minnesota
Essentia Health – St. Joseph’s Medical Center (Brainerd)
0.0%
CentraCare – St. Cloud Hospital
120
18.4%
Missouri
University Hospital
31
2.9%
Liberty Hospital
358
38.4%
Mississippi
Mississippi Baptist Medical Center
<11
1.6%
North Mississippi Medical Center – Tupelo
712
26.7%
Montana
Logan Health Medical Center
<11
0.1%
St. Peter’s Health Regional Medical Center
82
15.6%
North Carolina
UNC Medical Center
38
1.6%
Novant Health Presbyterian Medical Center
315
34.8%
North Dakota
Trinity Hospital
<11
0.2%
CHI St. Alexius Health Bismarck Medical Center
102
17.1%
Nebraska
Nebraska Medical Center
38
1.7%
Methodist Hospital
161
27.8%
New Hampshire
Dartmouth Hitchcock Medical Center
102
4.2%
Elliot Hospital
229
18.2%
New Jersey
Englewood Hospital
<11
0.5%
Overlook Medical Center
76
14.8%
New Mexico
UNM Hospital**
21
1.0%
Presbyterian Hospital
41
4.2%
Nevada
Renown Regional Medical Center**
116
10.5%
Carson Tahoe Regional Medical Center
115
15.7%
New York
NYC Health + Hospitals/Lincoln
0.0%
Mather Hospital
254
36.8%
Ohio
MetroHealth Medical Center
0.0%
Kettering Health Miamisburg
324
56.1%
Oklahoma
McBride Orthopedic Hospital
<11
1.0%
INTEGRIS Baptist Medical Center
125
23.8%
Oregon
Asante Rogue Regional Medical Center
<11
0.5%
Adventist Health Portland
97
16.9%
Pennsylvania
St. Luke’s Hospital – Anderson Campus
<11
0.3%
St. Clair Hospital
159
29.6%
Rhode Island
The Miriam Hospital
50
5.8%
Newport Hospital
119
21.2%
South Carolina
Anmed Health
25
2.8%
Lexington Medical Center
162
30.7%
South Dakota
Monument Health Rapid City Hospital
74
4.0%
Avera McKennan Hospital & University Health Center
189
13.6%
Tennessee
Vanderbilt University Medical Center
34
0.9%
Jackson-Madison County General Hospital
266
42.1%
Texas
Parkland Health and Hospital System
<11
0.4%
Shannon Medical Center
379
54.6%
Utah
University of Utah Hospital
46
1.2%
St Mark’s Hospital
116
17.3%
Virginia
VCU Medical Center Main Hospital
19
1.3%
Henrico Doctors’ Hospital
154
27.5%
Vermont
n/a*
n/a*
Washington
Harborview Medical Center
0.0%
Swedish Cherry Hill Campus
249
40.1%
Wisconsin
Mayo Clinic Health System – La Crosse
0.0%
ProHealth Waukesha Memorial Hospital
140
15.4%
West Virginia
United Hospital Center
18
1.0%
CAMC General Hospital
50
7.2%
Wyoming
n/a*
n/a*
*Fewer than two hospitals in this state with high volume
**Only two hospitals in this state with high volume
Methodology
Hospital overuse was measured using Medicare fee-for-service and Medicare Advantage claims data for three years of the most recently available data (2021-2023 for Medicare FFS and 2020-2022 for Medicare Advantage). The nationwide counts of low-value procedures includes all hospitals with Medicare claims data available (n=2,547 for spinal fusion/laminectomy, n=2,412 for vertebroplasty).
The cost of low-value back surgeries was calculated using Medicare’ procedure price lookup tool for outpatient procedures, using the most frequent CPT code for the procedure. The cost of inpatient procedures was calculated using the average Medicare cost of the most frequent Diagnosis Related Group (DRG) code for the procedure, using Medicare FFS claims data. We assume that the cost of these procedures is similar for Medicare FFS and Advantage patients.
The lists of hospitals with highest and lowest overuse rates are limited to hospitals with high volumes, defined as performing at least 500 total spinal fusions/laminectomies (when measuring spinal fusion/laminectomy) or having at least 500 patient visits for osteoporotic fracture (when measuring vertebroplasty) over three years. An additional capacity filter was used to ensure that hospitals with no vertebroplasties had the capacity to perform the procedure.
Spinal fusion and/or laminectomy was defined as overuse for patients with low-back pain, excluding patients with radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain or scoliosis. For spinal fusion only cases, patients with stenosis with neural claudication and spondylolisthesis were excluded. For laminectomy only cases, patients with stenosis with neural claudication were excluded. Overuse rates of spinal fusion/laminectomy were measured as a ratio of low-value procedures as a proportion of total spinal fusion/laminectomy procedures.
Vertebroplasty was defined as overuse for patients with spinal fractures caused by osteoporosis, excluding patients with bone cancer, myeloma, or hemangioma. Overuse rates of vertebroplasty were measured as a ratio of low-value procedures as a proportion of total patient visits with osteoporotic spinal fracture.
Advisory Committee
Jane Ballantyne, MD
Anesthesiologist and director of the University of Washington Medicine Pain Fellowship
Rachelle Buchbinder, MBBS, PhD
Rheumatologist, clinical epidemiologist, and professor at Monash University
Eugene Carragee, MD
Professor of Orthopaedic Surgery, Emeritus at Stanford Medicine
Ian Harris, MBBS, PhD
Professor of Orthopaedic Surgery, School of Clinical Medicine, University of New South Wales (UNSW) Medicine and Health, UNSW Sydney
Sohail Mirza, MD
Orthopedic surgeon and professor at Dartmouth College
Facts about back surgery overuse
Spinal fusion/laminectomy
What is a spinal fusion or laminectomy?
Spinal fusions and laminectomies are performed to treat back pain, either by fusing vertebrae together (spinal fusion) or removing part of a vertebra (laminectomy). These procedures are frequently performed together.
When is it overuse?
Lumbar spinal fusion is recommended for patients that have low-back pain caused by issues such as traumatic injury, sciatica, slipped spinal bone, or spinal deformity. However, for patients who have low back pain caused by aging, there is not sufficient evidence of a benefit from these procedures compared to non-surgical alternatives. Unlike with vertebroplasty, there have been no randomized controlled trials comparing spinal fusion/laminectomy to a placebo surgery (known as “sham trials”).
For this study, spinal fusion and/or laminectomy was defined as overuse for patients with low-back pain, excluding patients with radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain, scoliosis. Patients with neural claudication and spondylolisthesis were also excluded in certain cases. Our exclusion criteria is based on a previously validated
overuse measure
and consultations with physicians.
Systematic reviews/meta-analyses
2016 Cochrane review
including 5 randomized controlled trials concluded that “no clear benefits were observed with surgery versus non‐surgical treatment.”
2018 summary of systematic reviews
found that “the available evidence does not support a benefit from spine fusion compared to non-operative alternatives for back pain associated with degeneration.”
2021 meta-analysis
including 34 RCTs of various surgical and non-surgical interventions found that “there were no significant differences among the different interventions in improving patient function.”
See also:
Choosing Wisely Canada,
Canadian Spine Society
Lumbar spinal fusion guidelines,
North American Spine Society
What are the harms?
The complication rate for lumbar spinal fusion is 17.8% according to a
2010 systematic review
of spinal fusion complications.
More recent
studies
also found complication rates over 15%.
Specific complications and their prevalence include:
Unplanned admission after outpatient procedure: 4.8% (
Chalmers, 2021
Hospital acquired infection: 1.3% (
Chalmers, 2021
Patient safety incident: 10.4% (
Chalmers, 2021
Infection: 1.5%-5.6% (
Liu, 2023
Son, 2021
Failed back surgery syndrome: 10%-40% (
Sebaaly, 2018
Blood clot: 1.6%-3.5% (
Nasser, 2010
Cardiovascular event: 4%-5% (
Nasser, 2010
Vertebroplasty
What is a vertebroplasty?
Vertebroplasty is a procedure to treat spinal fractures caused by osteoporosis, bone cancer, and other conditions. A medical-grade cement is injected into the fractured vertebra through a needle, under light sedation or general anesthesia, and the cement hardens in the bone space to form an internal cast. Vertebroplasty may include a kyphoplasty, in which a balloon is inserted into the fractured vertebra and inflated to create space before the cement is injected.
When is it overuse?
For this study, vertebroplasty was defined as overuse for patients with spinal fractures caused by osteoporosis, excluding patients with bone cancer, myeloma, or hemangioma. Overuse rates of vertebroplasty were measured as a ratio of low-value procedures as a proportion of total patient visits for osteoporotic spinal fracture. This overuse definition is based on a previously validated
overuse measure
For a review of vertebroplasty research, see the “
Vertebroplasty Research Timeline
” section below.
What are the harms?
The rate of vertebroplasty complications ranges from 5.2% – 9.5% (
Galivanche, 2021
).
Specific complications and their prevalence include:
Unplanned admission after outpatient procedure: 2.9% (
Chalmers, 2021
Hospital acquired infection: 2.9% (
Chalmers, 2021
Patient safety incident: 3.2%  (
Chalmers, 2021
Infection: 1.4-1.8% (
Deng, 2025
Galivanche, 2021
Intradiscal cement leakage: 2.8%-8% (
Deng, 2025
Saracen, 2016
Pulmonary embolism: 0.7% – 1.4% (
Kim, 2020
Deng, 2025
Cardiovascular event: 0.1% – 0.6% (
Kim, 2020
Galivanche, 2021
Vertebroplasty research timeline
Below we review some of the important events and studies in the history of vertebroplasty and kyphoplasty. See also: Recent posts from
Dr. Vikas Saini
and
Dr. Eugene Carragee.
1984
– Neurosurgeon Galibert and neuroradiologist Deramond at the University Hospital of Amiens in France
perform the first percutaneous vertebroplasty
on a patient experiencing pain from hemangioma (a tumor that forms from blood vessels).
1997 –
Vertebroplasty (injection of bone cement into the spine)
first performed in the U.S.
for osteoporotic vertebral compression fractures.
1998 –
Kyphoplasty (use of inflatable balloon before injection of cement)
first performed
for osteoporotic vertebral compression fractures. The insertion of the balloon was designed to make the procedure safer and restore vertebral height.
2001 –
Vertebroplasty and kyphoplasty become
much more widespread
, despite no evidence from controlled trials showing a benefit for these procedures. Medicare billing codes were created for the procedures and insurers started paying for them.
From 2001 through 2005, the rate of vertebroplasties performed for Medicare enrollees
almost doubled
, from 45 to 87 per 100,000 people.
2003 –
The
first controlled trial
of vertebroplasty versus conservative therapy is published. The trial found that the vertebroplasty group reported improvements in pain relief and functioning. However this trial was not randomized or blinded, nor was there a placebo procedure in the control group.
2005 –
Use of vertebroplasty and kyphoplasty
continues to increase
, with volume rising by 135% from 2005-2008.
2007 –
Medtronic buys Kyphon, which held the patent for the kyphoplasty device, for
$3.9 billion
2009 –
Two
randomized
controlled studies
published in NEJM using a “sham” procedure find no benefit of vertebroplasty for compression fractures compared to the placebo procedure. For the “sham” procedures, doctors used physical cues such as putting pressure on the back and simulating the smell of the bone cement, but no cement was injected.
One trial
of 78 patients found significant reductions in overall pain in both the vertebroplasty and control groups at each follow-up assessment (1 week, 1 month, 3 months, 6 months). There were similar improvements in both groups for functioning and quality of life.
The
INVEST trial
randomized 131 participants to either vertebroplasty or sham procedure. The study found no significant difference in pain scores between the vertebroplasty group and the control group after one month. Because this study allowed patient “crossover” after one month (patients who didn’t receive a vertebroplasty were given the option to receive it), this limited the ability of researchers to evaluate long-term efficacy.
2009 –
Following the publication of two trials showing no benefit to vertebroplasty over placebo, several specialty organizations put out guidance recommending that doctors avoid vertebroplasty for osteoporotic spinal fracture, and some payers announced they would no longer cover the procedure.
From 2008-2010, the volume of vertebroplasties in the Medicare population
decreased by 16%
From 2010 to 2018
eleven more studies are performed
, three with sham interventions. Of these, five did not find a difference in their primary outcome. A few of these studies are explained below in more detail.
2010 –
VERTOS II trial
finds a significant improvement in pain relief from vertebroplasty compared to conservative treatment. However, this study was not blinded and did not include a sham control. The study was funded in part by a medical device company.
In a review of vertebroplasty research, Lown Institute president
Vikas Saini noted
, “Of 431 originally eligible [for the study], 53% had pain relief before they could be randomized. This indicates that many painful vertebral fractures resolve on their own.”
2016 –
The
VAPOUR trial
, a double-blind placebo-controlled trial of 120 patients is published. This study focused on patients who had painful fractures for six weeks or less. After two weeks a significantly larger proportion of patients in the vertebroplasty group had pain scores below 4 (out of a 10 point scale) compared to the sham controlled group. However, there was not a significant difference in pain intensity or disability scores after two weeks, or in use of painkillers. The study was funded by a medical device company.
Stanford Emeritus professor of orthopedic surgery
Eugene Carragee says
, “The outcomes at 14 days show some differences between groups, but all inter-group differences are very small, and well below the minimal clinically important difference for each outcome measure.”
2018 –
The
VERTOS IV trial
, a randomized, sham controlled trial of 180 patients, is published. The study did not show a statistically significant difference in pain relief for patients in the vertebroplasty group compared to placebo, after one month or one year. The study was funded by a medical device company.
Dr. Saini wrote
, “The effectiveness of the sham was impressive, with 80% of subjects believing they had the active treatment.”
2023 –
In the
VERTOS V trial
, 80 patients with painful fractures lasting over three months were randomized to either vertebroplasty or an injection of local anesthesia. The study was funded by a medical device company.
The results showed statistically differences in pain scores at the 3 and 12 month marks, but no clinically important difference. Pain medication use was not significantly better for the vertebroplasty group compared to the control group at any time points.
Dr. Carragee commented
, “At no time point was there a better outcome for the vertebroplasty group greater than the minimally clinically important difference (MCID) compared to a sham procedure. Not one. The same findings held for the secondary functional outcomes.”
2025 –
Lown Institute report shows that vertebroplasty overuse is still relatively common among Medicare patients. Over three years, U.S. hospitals delivered over 100,000 vertebroplasties for patients with osteoporotic fracture that met criteria for overuse. Overall, 10% of patients that came to hospitals with an osteoporotic fracture received an unnecessary vertebroplasty.
Media inquiries
should be directed to Aaron Toleos, vice president of communications for the Lown Institute, at
atoleos@lowninstitute.org