As the nation rapidly grays, not only are middle-aged and older patients undergoing increasing numbers of knee, hip, ankle, and shoulder surgeries, back operations also have spiked — and a significant number of these procedures may be unwarranted and harmful.

Spinal surgery is a booming business for orthopedic surgeons and hospitals, with  Wall Street analysts forecasting, according to one report, that the “sales of spinal surgery implants, instruments, pharmaceuticals and other novel treatments for chronic and disabling back pain will … rise from $10 billion in 2020 to $14 billion -$ 16 billion by 2030.”

While rising numbers of patients, starting around age 42, complain of back pain and many eventually seek surgical relief, skepticism and concern may be deserved for the common, costly, and lucrative spinal fusion surgery, Modern Healthcare, an industry trade publication reported in its Oct. 5 edition.

(The Modern Healthcare article requires a subscription, available at low-cost on a trial basis. The magazine also is available through databases that can be accessed via research and public libraries — if you do not have a local library card, consider getting one because they provide invaluable information services. For free.)

Here is what the trade journal reported about spinal fusions:

“The surgery can be great for people who suffer traumatic injuries, such as from car crashes, or who have congenital disorders or even arthritis in the back with some slippage of vertebrae in the spine. But the procedure is also potentially one of the most overused and unnecessary, and surgeons often recommend it for a host of conditions despite unclear evidence of its effectiveness. The lack of rigorous clinical trial evidence is apparent in a recent study, which raises questions about why surgeons are cutting into so many backs without clearly knowing whether it works, and about a health care industry that relies on expensive medical devices that don’t undergo the same stringent regulatory reviews as prescription drugs. For hospital administrators, expensive procedures and devices used by doctors may seem par for the course in the U.S. health care system.

“But the rising frequency and cost of spinal fusions suggest a closer look at orthopedic departments may be needed. Spinal fusions can, on average, cost between $60,000 to $110,000. A British Medical Journal review of randomized controlled clinical trials on several elective orthopedic surgeries found little evidence to support spinal fusions on patients with degenerative disk disease. There was also little evidence to justify surgery over nonoperative treatments for five other orthopedic procedures, including rotator cuff repairs.”

Modern Healthcare explains that spinal fusions often encompass two elements:

“Surgical treatment usually has two components: decompression and spinal fusion. For the former, physicians open patients’ backs and cut out arthritic bone that pinches the nerves that run from the back to the leg. For the latter, surgeons use a bone graft to weld vertebrae together, often with a medical device to stabilize the area.”

The evidence is spare as to beneficial outcomes of fusions, which can end up leaving patients worse rather than better off, especially because surgeons have created a solid bony area that lacks movement. And this often is done based on light evidence but at the promotion of medical device makers.

Dr. Eugene Carragee, a professor of orthopedic surgery at the Stanford University School of Medicine and former chief of the spinal surgery division, had this tough observation for the magazine about the operations:

“In the absence of there being some plague that has caused spines to start dissolving — the spines of aging people are not much different than they were in last 50 to 60 years. The gross increase in reported pathology and reported necessity of involved surgeries, it’s not a smoking gun, but certainly something smells rotten, that’s for sure.”

Modern Healthcare interviewed experts who give medical specialists the benefit of the doubt in performing so many spinal fusions, noting that busy surgeons may be unduly influenced by the big-spending medical device industry:

“The rise of spinal fusions is … complicated by an industry built up around these procedures. The implantable medical device market was worth $211.3 billion between 2014 and 2017. About 75% of neurosurgeons and orthopedic surgeons received payments from device manufacturers and were among the 20 specialties that attracted the most device company dollars, according to a Health Affairs article published in April. Orthopedic surgeons received almost 35% of device payments from the top 10 manufacturers from 2014 to 2017, the largest share among all medical specialties and equaling about $828 million.”

Hospitals, too, may have been over-eager for the revenues generated by spinal fusions and other back surgeries, though this may be changing, the magazine has reported earlier, quoting Dr. Richard Deyo, a professor of evidence-based medicine at Oregon Health & Science University who has published studies of spine surgery appropriateness and outcomes:

“Hospitals have relied on spine surgery as a top-performing service line, and it’s still a major source of revenue. But they are rethinking their approach. ‘Until now, spine surgery was a big winner for generating revenue for hospitals and surgeons. That hasn’t completely changed,’ Deyo said. But ‘with health care reform and more health plans going to some form of a capitated model [a cost-sharing approach in which fees are fixed in advance and split among various providers], the financial incentives are changing.’

“With the growing consensus about overutilization of surgery, some hospitals are turning surgical programs into comprehensive spine care programs that offer an array of treatments, including physical therapy, pain management, psychological care, and different types of surgical procedures. It’s estimated that only one in 10 patients with low back pain will need surgery, surgeons and experts say. These comprehensive spine programs ‘are not as lucrative as surgery but the volume is there,’ said Shruti Tiwari, a consultant for the Advisory Board Company’s research and insights division.”

A separate, earlier Modern Healthcare article reported that technology and advances in medical science may change current practices, giving patients and specialists alternatives to procedures now used and that soon may be regarded as too harsh and invasive. Therapies may be around the corner to allow regrowth of critical tissues that degrade or disappear with age, causing back pain. As has occurred with hips and knees, surgeons also soon may not tinker with discs or bone but substitute replacements for them entirely.

Hmm, we will see. In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, effective, and excellent medical care. All medical procedures carry risks, and surgeries — even operations like knee and hip replacements that doctors and hospitals insist have become almost routine — should never be undertaken without extensive discussion, preparation, investigation, and care.

It may benefit back patients, in particular, to investigate deeply and try the many other, available options before undergoing costly, invasive, and risky surgeries. As the nation tries to quell a lethal opioid abuse and drug overdose crisis, use caution if your doctor prescribes painkillers for your back condition. Be sure before going under the knife that your doctor has provided you with a full detailed explanation of the proposed procedure’s risks and benefits, giving you the fundamental and needed right of informed consent, so you can make intelligent choices about who will do what to them, when, and how.

We have lots of work to do to understand better and to relieve the pain, discomfort, and debilitation caused by bad backs — without leaving patients in worse shape than they were before they received medical care.