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Illustration: Sisi Yu

Tiffany Bruce spends every day, all day, thinking about pain. Her own, yes, but also the thousands of people she has met online who are, like her, recovering from spine surgery and often, like her, not their first. In the “Life After Back Surgery Support Group” on Facebook, they post questions, weary updates, and long, detailed accounts of their surgeries, sometimes good, sometimes very bad. Those with long-term pain reach for the language to describe it — “radiating,” “unbearable,” “like I’ve been kicked all night long,” “little bombs.” Sometimes they post X-rays or photos of their stitched-up back. Bruce’s profile picture is a cartoon drawing of a pink-haired girl in the fetal position, cracks blooming along her body.

To hear Bruce tell it, the past 20 years of her life have been kind of a fever dream. At 18, she woke up one morning with a sharp ache in her lower back and a tingling down her leg. Since she was pregnant at the time and her doctor couldn’t prescribe stronger pain medications, he instructed her to take aspirin. After giving birth, though, Bruce’s pain persisted. A specialist eventually recommended spine surgery — specifically, spinal-fusion surgery, in which two or more vertebrae are bolted together with implants, clamping the joint as if welding beams in a collapsing building. “I felt better,” she recalled. “But not much better.” Her spine seemed to worsen in the months that followed; she struggled to stand for more than a short stretch or bend over, which posed problems in her job as a nurse. Eventually, she said, her pain was “double what it was before.” Bruce would go on to have five more fusion surgeries. After her fourth, she stopped being able to work. After her fifth this past December, she felt herself slipping into a depression. She joined the support group, she said, hoping to find community.

Members of these groups are not exactly outliers. Their pain, and their repeat surgeries, exist within a decadeslong industrywide trend.Since it entered its first boom in the early 1990s, the field of spine surgery, and specifically spinal-fusion surgery, has faced criticism over lackluster outcomes, excessive procedures, and conflicts of interest. Throughout the last couple of decades, many studies have doubted the efficacy of fusion surgery in treating back pain caused by degeneration, and the number of revision operations for spine surgery is higher than those of other orthopedic surgeries. Despite that, rates of fusion surgery in the U.S. ballooned more than 200 percent throughout the 1990s, and the number of instrumented spine surgeries being performed annually has nearly doubled since 2013. There have never been as many spine surgeries as there are now and perhaps never so much mainstream conversation about them. In December, some speculated that complications from a spinal fusion is what led Luigi Mangione to allegedly execute the CEO of United Healthcare on a Manhattan street.

Part of this rise has to do with a broader demographic shift: People are living longer and sitting longer, and by most accounts, it seems their backs are hurting more; surgery is one of only a few options for treating that pain. Other data suggests that it may be a phenomenon particular to the U.S., where spine surgery has become one of the country’s most lucrative specialties. In 2024, the first-ever longitudinal study of payments made to doctors found that U.S. orthopedic surgeons receive the most amount of money out of all specialties and rates of spine surgery are higher here than in any other developed country in the world — nearly double those of New Zealand, Australia, Canada, Norway, and Finland and about five times those of the U.K.

Much of the criticism throughout spine surgery’s history has come from surgeons disillusioned with their field. Last year, Jonathan Choi, an MIT-educated spine surgeon, went viral with a video, posted under the pseudonym Dr. Goobie, in which he laid out his reasons for abruptly quitting his job and moving to the mountains. “I knew something was not right, right away,” he said into the camera, standing against a picturesque rocky backdrop, swatting away mosquitoes. A neurosurgeon by training, Choi, like many others in the field, often performed spine surgeries, which are in much higher demand than brain surgeries. He began to notice, he said, that even if he performed a perfect surgery, its effect was variable. “Some people feel better, some people would feel the same, and some people would be worse,” he said. He described a bad spine as a house with a leak. Water had seeped into the foundation, ruining the drywall. “The surgeries that I could do were like going into that house, tearing down the drywall, ripping out the moldy insulation, putting in brand-new insulation, and rebuilding the wall,” he said. “But not fixing the leak.”

Most major surgeries present a clear etiology. An appendectomy, for instance, would most commonly be performed on patients with appendicitis. But the spine presents a kind of Choose Your Own Adventure. “There’sso much ambiguity,” said Betsy Grunch, a spine surgeon better known as @ladyspinedoc to her 1.2 million Instagram followers. “A lot of it is a judgment call. You could ask five surgeons how to treat back pain, and they’ll treat it five different ways.” Along with variations in the procedures come highly specific hardware and the techniques to use them.

There are injuries for which back surgery may be the only option: a traumatic fracture, for instance, or a severe disc herniation. Then there are the vast majority of conditions that tend to be ambiguous — a small herniation, spinal stenosis (a narrowing of the spinal canal common with age), or what Bruce was diagnosed with and what has been most often disputed regarding fusions: degenerative disc disease, which is essentially a kind of arthritis. “If you fall off a building and break your back, putting screws and rods and stuff in to hold everything in place is absolutely great,” said Eugene Carragee, the former director of the Stanford Spine Center. “But if you just have an aching back because of arthritis, that’s the stuff that, if it helps at all, it’s negligible or just not provable.” Complicating matters is that when it comes to the back, people often report symptoms and pain that diverge from tests and imaging. Many show signs of degeneration or injury on MRIs or X-rays without having pain or dysfunction; others who describe grueling symptoms show mild or no imaging changes.

Then there is a more familiar complicating factor: money. Carragee was at the beginning of his tenure as the head of the Stanford Spine Center when he began to notice more and more of his colleagues signing corporate-consulting contracts — advising on the conception and development of new devices — sometimes worth tens of millions of dollars. Their vacation homes, he recalled, appeared to be getting bigger and inching steadily further to the East in the Hamptons; industry trips became increasingly lavish. “It was a complete mind shift,” said Carragee, who is also the former editor-in-chief of The Spine Journal. He recalled an early trip he was taken on by a medical-device company to Davos, Switzerland, under the auspices of discussing new research. “I pretty quickly realized I was not there to talk about the spine,” he told me. “I was there to be picked up by a black SUV and driven to some luxury resort in the mountains and drink chocolat chaud.” Throughout the ’90s, he said, the spine community went from “holding conferences where we would get together and eat deli subs to absolute bacchanals.”

Carragee has a soft, lilting voice and a tendency toward irony. He addresses people, even his enemies, as “sir” or “ma’am.” Over the course of his long career, he became, according to Lown Institute president Vikas Saini, “practically a Savonarola” of spine, referring to the ascetic 15th-century friar. His research has been cited nearly 30,000 times, and it, for the most part, scrutinizes when and how spine surgery is most effective; often, that has meant pointing out when it is not. Throughout the aughts, he published many studies that prodded the consensus that spine surgery was a primary tool in the treatment of back pain, including one that found fusion surgery didn’t help patients with ruptured disks heal faster and another arguing that in many patients, fusion surgery wasn’t helpful long term compared with other procedures. “To a large extent, a lot of my research was just trying to figure out how valid these other, more aggressive surgeries were from a medical point of view,” he said. “Well, a lot of it was not very valid.”

Early in his career, Carragee had done a yearlong fellowship in Hong Kong, where back surgery for non-catastrophic issues was “virtually never performed,” he said (catastrophes would include tumors, major traumas, and deformities). Instead, local patients relied on things like physical therapy, acupuncture, and diet changes. It made a lasting impression on him. “I couldn’t figure how these people were doing so well without getting all the surgeries that were being done at home,” he said. His research has made him one of the most-lauded spine surgeons in the country and also one of the most reviled. (One lengthy opinion piece from a trade journal in the 2010s was headlined “Carragee Must Resign.”) In recent years, though, the tide has turned in his favor. Since he entered the field in the ’80s, he has watched the mainstream conversation about spine surgery go from one of feverish enthusiasm to tacit skepticism — though that conversation has not fully translated internally. “I mean, some surgeons’ lifestyles have just become so crazy,” he said. “As a conservative surgeon, you can’t help but make three quarters of a million dollars. But, for them, three quarters of a million dollars a year is, well, as Trump would say, ‘You’re a loser.’”

The most common spinal procedure in the U.S., and the most lucrative, is fusion surgery. The story of how fusion came to pay more than its less invasive counterparts is relatively simple. For one, U.S. health-care system values inpatient care much more than outpatient care; then there are RVUs. Insurers rely on RVUs (“relative value units”) as a kind of internal exchange rate to calculate how much a surgeon’s work is worth. In theory, RVUs weigh time, risk, and technical skill. In practice, they tend to prioritize hardware; the more implants used, the more a procedure pays. That math has, over the past few decades, tilted the field toward fusion.

The spinal-device market is currently valued at around $14 billion. Between 2000 and 2019, the annual number of new devices in spine more than tripled, outpacing growth in nearly all other sectors of the medical-device market. Where once rods and screws dominated, now there are “shape memory” cages, 3-D-printed plates, and electrical bone-growth stimulators.

Spine surgeons are divided over which devices and treatments are most effective. Carragee, though, believes fusions, in particular, have been financially exploited. The proven use cases for fusion “are really small, which does not make for a big money boom,” he told me. “Now, if you could expand it from people with a traumatic injury or instability syndromes to everybody with a backache, well, you’ve gone from maybe 20,000 people a year to 400,000 people a year.” (This isn’t to say that fusions are the only controversial spine procedures. The effectiveness of kyphoplasties and vertebroplasties, often used to treat fractures, has been contested as well.) In November 2024, a study conducted by the Lown Institute, a health-care think tank, found that more than 200,000 unnecessary — meaning that a patient’s diagnosis didn’t necessarily require surgery — fusions and laminectomies were performed on Medicare patients over a recent three-year stretch. Even as insurers are increasingly stringent about surgery approval, the number and complexity of surgeries appear to be growing largely because of the ambiguity involved in treating the spine that critics say industry groups have successfully manipulated.

To New York spine surgeon Jonathan Stieber, though, the problem isn’t inherent to the industry. Bad actors, he said, have inflated rates of back surgery across the country, and there is research that supports that belief. An update to the Lown Institute’s report, which will be published later this fall, shows that rates of spine surgery vary vastly across institutions; often, an area with extremely high rates of surgery can be traced back to one specific hospital — or one specific surgeon. Industry relationships may impact the specific implant that a surgeon uses, “like an athlete who’s sponsored by an equipment manufacturer might use a certain brand tennis racket or certain brand golf clubs.” But, he says, it is not necessarily impacting the number of surgeries they perform.

Still, others say the pressure comes from within**.** “You’re compensated by how much you do, and performance reviews are based on how productive you are,” said Ray, a Washington spine surgeon who has asked not to use his real name. For years, he said, he fought against hospital administrators who often urged him to get his numbers up — meaning to perform more surgeries. “There’s a real push to have you be as productive as possible, to the point that my supervisor, who was the general surgeon, once came to me and said, ‘You need to be more creative with your RVUs.’ I said, ‘Can I get that in writing?’” That pressure was part of the reason that, when he retired in 2022, he felt relief.

In the last few years of his tenure, Ray brought a lawsuit against a colleague of his — “a very productive surgeon who was doing things that were absolutely mind-blowing,” he said. Ray’s lawsuit claimed that, in addition to billing for surgeries he hadn’t actually done, Ray’s colleague was regularly performing fusion surgery on more parts of the spine than a patient required, without using implants, sometimes leaving their spine severely unstable as a result. At one point, the lawsuit claimed, he billed a patient’s insurer for a fusion that would not have even been possible because it was between sections of the spine that were already attached. (The lawsuit was settled without an admission of guilt from the doctor or hospital.) His productivity, however, seemed to make up for it. “He was a top producer,” said Ray. “There were several top producers who would be held out as an example of what we should all be striving for. And he was one of them.”

When people continue to experience pain in the months and years following their procedures, it’s known in the medical field as “failed back surgery syndrome.” The condition doesn’t necessarily mean anything went wrong with the surgery — some people simply don’t get better. It may be that the surgery itself wasn’t right for a patient, but it may also be that the surgical technique was flawed, or the hardware malfunctioned. In the case of fusion, the surgery itself can create the conditions for failure. Because fusions immobilize one part of the spine, the levels below or above bear added weight, which can result in more deterioration and more pain, particularly when the joints in the spine are arthritic. FBSS rates vary by procedure, but lumbarfusion sits at the high end with failure rates nearing 50 percent. (Incidentally, revision surgeries pay more than the primary surgery.)

Saini of the Lown Institute said the decision to operate is complicated not only by the many financial incentives at play but also by the fact that patients often explicitly ask for surgery. “I think there’s an expectation in the United States by the medical community, and also by the population, of ‘My back hurts every day, and something has to be done,’” said Carragee.

“I’d have special sessions with my bosses about, ‘Well, your patients aren’t happy enough,’” Ray told me. “And it’s like they’re not happy because I’m telling them, ‘I’m not going to give you Percocet and you don’t need a fifth operation.’”

Bruce has fought, she said, “for every surgery I’ve had apart from the first one.” In pain from her first fusion, she turned to a new surgeon. He told her to wait before getting another procedure and advised her to take steroid injections for the pain, but she said she was allergic to steroids; she tried physical therapy and acupuncture a few times, but none of it was helping, at least not fast enough. “I remember being in the hospital and the surgeon and his partner arguing at the foot of my bed over whether I needed surgery,” she said. She was a single mom, and she wanted to work. She believed another fusion would help her. “At that point,” she said, “you’re grasping for anything and everything to try to get any kind of relief because you’re in more pain than you could ever imagine.”

Pain continues to be a kind of black hole for the medical industry, notoriously difficult to classify and describe, still primarily graded on a scale of frowny to smiley faces. It is a term “used to group together a class of combined sensory-emotional events,” wrote the neurophysiologist and pain researcher Patrick Wall. In other words, even if it is felt most acutely in the spine, there is no real way of knowing if the origins of a person’s pain are elsewhere in the nervous system or their body or their mind. “The question is, If we all have degenerative spines as we get older, why do some people find it intolerable and some people not?” said Carragee. One study that he co-authored found that, by far, the most important factor in determining someone’s likelihood of developing lower back pain were psychosocial factors. Their prediction model was so strong, said Carragee, you could determine whether someone was likely to be able to tolerate pain “before they even report it.”

Over the course of her six surgeries, Bruce cycled through four different surgeons. Even as she maintains that her pain has only gotten worse, she has also held onto the hope that the next procedure (she’s currently undergoing a trial for a pain pump in her spine) will be the one that works. “My reasoning is that there has got to be something,” she said. “I didn’t do anything wrong. It’s not like I was out there doing stupid stuff to hurt myself. I have to have some kind of hope that something out there can fix me.”

The Spinal Surgeries That Didn’t Need to Happen

The Spinal Surgeries That Didn’t Need to Happen