Tapping into controversial back surgeries


Surgeons we looked into

Barbara Jo Smith has lived in Clarksville, Tennessee for her whole life. She grew up on a farm, riding horses and chasing her two brothers around. In 1999, she married her childhood sweetheart.

By age 45, Smith had developed debilitating back pain. She saw a chiropractor and a physical therapist, but neither seemed to help. So she went to Nashville spine surgeon Dr. David McCord.

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Dr. David McCord
YouTube
Dr. McCord's website calls him "A True Medical Pioneer in the Treatment of Spine Pain." A video claims "his insight is highly prized across the world," before patients offer praise, like "I have no idea where I would be today, had I not met Dr. McCord."

Dr. McCord recommended two spinal fusion surgeries for Barbara Jo Smith, two days apart. In May of 2010 he operated on her, using plates and screws to join three of her vertebrae. Five months later, she says her pain had only worsened. So she went back to Dr. McCord and he performed another spinal fusion.

Today, Barbara Jo Smith says her pain is "a hundred times worse" than before the surgeries, and that she has nerve problems she did not have before. "One foot feels like it's burning, the other feels like it's on ice," she says. "I'm 49 years old and I can't lift anything without dying."

There are always risks with surgery and a bad outcome is not necessarily the doctor's fault. But if an operation wasn't needed to begin with, it's a different story. When it comes to individual cases, surgeons can disagree about whether a spinal fusion is appropriate. So we asked two doctors to tell us, without commenting on Smith's case in particular, whether they generally recommend the procedure for the diagnosis she was given. Both said they do not.

Dr. Daniel Resnick, Vice Chair of Neurosurgery at the University of Wisconsin School of Medicine and President of the Congress of Neurological Surgeons, helps shape national guidelines for spine surgery. Dr. Sohail Mirza, Chair of Orthopaedics at Dartmouth-Hitchcock Medical Center, has published studies on spine surgery and what he considers the overtreatment of back pain. Both doctors said they generally recommend more conservative treatments for patients with Smith's diagnosis.

According to the Medicare database, Dr. McCord performed fusions on 96 patients from 2011-2012. He did them on 34 percent of patients he saw, almost the highest rate in the entire country. And he performed three or more of these surgeries on 20 different patients over that period - the most of any surgeon nationwide.

The number of patients that Dr. McCord has repeatedly operated on may be higher in part because he often performs "360 degree" fusions (as he did on Barbara Jo Smith). The technique involves two surgeries, through the front and back. But other doctors also use this method, and the 20 patients that Dr. McCord operated on three or more times was twice as many patients as any other surgeon nationwide, according to the Medicare database.

In 2012, Dr. McCord was banned from operating at Centennial Medical Center. A confidential report by the hospital reveals that a "hearing committee found that [Dr. McCord] had a pattern of performing spine surgeries on patients for whom surgery is not indicated." Internal and external reviews concluded that he was performing unnecessary hardware removal operations. Dr. McCord sued the hospital, accusing it of conducting a sham review process led by a surgeon that saw him as competition. The case was dismissed.

Dr. McCord's attorney says he will appeal. But it wasn't the first time his surgeries had come under scrutiny at Centennial. CBS News has learned that after a separate review in the late 1990s, Dr. McCord agreed to limit his number of surgeries and get second opinions before operating. He is still practicing at another hospital just blocks away.

Dr. McCord invited CBS News to his office but declined repeated requests for an on-camera interview. He introduced us to three patients and each spoke about how he dramatically improved their lives. In an email, his attorney wrote: "we will not verify many of the[se] misstatements and ill-founded allegations...of the hundreds of patients Dr. McCord has treated, the vast majority of them are much improved."

The lawyer also said Dr. McCord has not settled or lost a malpractice lawsuit, and highlighted Dr. McCord's degrees from top universities. He said Dr. McCord was banned from Centennial because as an orthopedist, the neurosurgeons there did not like him (both specialties perform spine surgery).

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Dr. Omar Jimenez
rwmc.com
The Medicare database indicates Dr. Omar Jimenez of Scottsbluff, Nebraska performed 325 spinal fusion surgeries - the third most nationwide. Through an attorney, Dr. Jimenez declined multiple interview requests for this story. The lawyer said that Dr. Jimenez performs many procedures because he works in a part of the country with few spine surgeons and receives many referrals. She also pointed out that some of the fusions he performs require two surgeries, but should not be counted as such.

"Dr. Jimenez is well aware of and shares the general concern about unnecessary spinal surgeries," a statement reads. "Before a fusion is considered, he treats his patients conservatively with a course of care that might include NSAIDs, physical therapy and injections."

The attorney also objected to the use of billing codes to count spinal fusions for "degenerative" conditions that cause lower back pain. "It is simply not possible to discern the diagnosis(es) from the CPT code alone," she wrote.

It is true that the billing codes describe a technique - not a diagnosis. Some widely accepted fusions are billed for using these same codes. But while the data does not reveal whether any of the fusions that a doctor performed were inappropriate, experts say high numbers raise questions and serve as starting points for further investigation.

When we looked into Dr. Jimenez, we found that in 2006 he was suspended indefinitely by a network of five hospitals in Georgia. According to a confidential report obtained by CBS News, it concluded that he "pose[d] a threat to the life, health and safety of patients." There were concerns about, among other things, his "surgical competency and selection of procedures." Dr. Jimenez eventually left the hospital system and sued it for racial discrimination. He claimed the review committee made up lies to oust him and did not give him a hearing. The case was eventually dismissed.

Dr. Jimenez also settled two malpractice suits in Georgia, for $950,000 in 2006 and $375,000 in 2010, according to the state's medical board. One of the cases was brought by James McCall, a 44-year-old man with back and leg pain, McCall's attorney said. After Dr. Jimenez performed a fusion on three of his vertebrae, McCall suffered permanent nerve damage in his right leg, the complaint says. He could no longer lift his foot and would trip when walking, and his back and leg pain also remained. Dr. Jimenez denied wrongdoing.

We mentioned the hospital suspension and malpractice settlements to the attorney representing Dr. Jimenez, but she chose not to comment on them.

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Dr. Mathew Alexander
Deposition

Some of the biggest concerns surround more complex fusions, on four or more vertebrae. A 2010 study in the Journal of the American Medical Association looked at complex fusions for lower back stenosis (a narrowing of the spinal canal) and found 1 in 20 led to life-threatening complications. The Medicare database indicates Dr. Mathew Alexander of Corpus Christi, Texas performed 97 fusion surgeries on four or more vertebrae - the sixth most in the country.

One of Dr. Alexander's patients, a 63-year-old hairdresser named Kimberly Keith, had pain in parts of her head, neck, and left arm. She tried physical therapy and a steroid injection, but neither helped. So in 2010, Dr. Alexander performed a spinal fusion from her skull through six of her vertebrae. The operation took five hours and in a deposition, Dr. Alexander said he had one or two other procedures earlier that day. Keith was billed more than $56,000 in surgical fees, but Dr. Alexander said they likely collected about a third of that amount.

Keith is now suing Dr. Alexander for allegedly aligning her neck crookedly and performing a more aggressive surgery than necessary. She has virtually no movement of her head, and it is stuck in a tilted position looking down and off to the right. Multiple doctors have said a corrective surgery would involve removing rods and screws that Dr. Alexander put in and entail significant risk. The case is ongoing.

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Kimberly Keith's x-ray after surgery
Hilliard Munoz Gonzales LLP
Through a spokesperson, Dr. Alexander declined multiple interview requests. Even after we shared specific points for him to address, he chose not to respond. In a deposition, he said he believed Keith's spine was unstable, and without such an extensive operation she could have been paralyzed. He added that she had severe stenosis (a narrowing of the spinal canal) and a fracture in her second vertebra.

Dr. Alexander also said an imperfectly aligned neck is a risk of the surgery that cannot always be avoided. "There's no way you can hundred percent put a patient in neutral position...that's the best we can do for this type of operation."

In the deposition, Keith's attorney pressed Dr. Alexander on why he believed she had severe stenosis (a narrowing of the spinal canal) when multiple radiologists considered it mild or moderate. Dr. Alexander said he disagreed with their readings of the images. "I rely on the radiologist," he said. "But also as a neurosurgeon, we interpret the films, too."

Keith's attorney also asked why he fused the second, third, and fourth vertebrae in her neck, when none of the radiologists mentioned problems in that area. He said that when fusing two separate parts of the spine, it is common practice to include the vertebrae between them. "You have to incorporate the whole thing," he said, or she would "require further surgery down the road."

The Medicare data indicates that Dr. Richard Hynes of Melbourne, Florida performed 107 fusions on four or more vertebrae--the third most in the country. In 2006, a private health insurer dropped him and The B.A.C.K. Center (of which he is president) from its coverage network. "They say we're too aggressive, too expensive," he reportedly told a newspaper at the time. "Medical technology is expensive."

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Dr. Richard Hynes
thebackcenter.net
Dr. Hynes filed an anti-trust lawsuit against the insurer's parent company, accusing it of excluding him because he was performing surgeries at a competing hospital. The case is ongoing.

In 2008, Dr. Hynes was sued for allegedly performing an unnecessary spinal fusion. After the operation, his 32-year-old patient developed an infection and required another spinal fusion, medical records show. According to her legal complaint, one of the surgeries damaged her intestine, forcing her to have part of it removed. Dr. Hynes settled the case, but denied wrongdoing.

According to the Florida Office of Insurance Regulation, five payments totaling more than $500,000 were made to former patients of Dr. Hynes by his insurance company from 2005-2012. Three of the cases challenged the necessity of spinal procedures performed by Dr. Hynes.

Through an attorney, Dr. Hynes declined our interview requests for this story. Even after we shared our specific findings, he chose not to respond. His lawyer only suggested we review a separate anti-trust lawsuit filed against Health First, the parent company of the insurer that dropped him from its network.

That case was filed by several physicians and group practices (not including Dr. Hynes). It alleges that the company has a near monopoly on healthcare services in the area, and intimidates doctors or obstructs their ability to practice medicine if they do not refer patients exclusively to its facilities. Health First has denied the allegations.

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