Disc Replacement Debate: Is It Safer Overseas?

When it comes to back surgery — you might be surprised to know that many patients here in the U.S. hop on a plane and travel several hours to Europe and Germany — where they’ve historically done more artificial disc replacements than the U.S. But is that really necessary? I get asked several questions on this topic quite frequently, so let’s dig into it.

Why do patients go overseas for disc replacement surgery?

A lot of patients who need spine surgery are looking for options beyond a spinal fusion — the most common type of spine surgery in the U.S.. Artificial Disc Replacement can also be a good option for some. They may not limit motion as much… however — it can be harder to find doctors in the U.S. willing to do ADRs. SO — many Americans travel abroad for them.

Chad Cooper is one of my patients who seriously considered traveling to Europe for an ADR before he decided to come to me for the procedure. A college football athlete now working in the physical therapy space, he says for him it was about thoroughly investigating his options.

“As far as looking overseas, I heard from different people that’s what they were looking at because of the cost and savings. I didn’t hear so much about the outcomes,” he says. But once he started investigating his options abroad, he became concerned about how to get home after the procedure and how he would get help if he had complications.

“I know that we have some of the best spine surgeons in the world right in my backyard. And I thought, why am I not doing another search here?” he says. So he did a second search and that led him to me. We ended up doing a disc replacement to address his debilitating pain and Chad was back at work within two weeks. “As far as recovery, I was amazed,” he says.

Why are there more spinal fusions done in the U.S. than disc replacements? Is it a matter of medicine or money?

In the U.S., there are two main reasons it’s more common for patients to get a spinal fusion than a disc replacement. One is insurance companies. They don’t always approve a disc replacement because they cost more than spinal fusions. Our center, VSI, has become a leading center for many reasons — one of which is that we’re out of network. We do that on purpose so we can do what we what’s right for our patients rather than having our surgical and medical decisions dictated by what an insurance company allows.

The second reason disc replacements are more rare in the U.S. is that even as insurance companies are approving some of these replacements, surgeons are getting less reimbursement for doing a replacement. So the whole model incentivizes fusions over replacements, which are also more challenging and require more expertise. That is why historically we haven’t seen as many fusions done in the US, and why patients for many, many decades have had to travel elsewhere, especially Europe, to have their replacements done.

Change is coming but it is still pretty slow. I recently went to a spine conference and I would say only about 10% of the surgeons were routinely doing replacements. Now look, not every patient needs a disc replacement. There are situations where it might not be appropriate or the best choice. But I want to make that decision based on what’s best for the patient — not about financial reimbursement for an insurance company and my patients want that too.

Why is Germany such a popular destination for disc replacement?

Some of the earliest replacements were invented in Germany and so Germany became prominent for these procedures. But that dates back to the 90s. Since then, the U.S. has dramatically improved its ability to do disc replacements . In fact, while the earliest version of implants were made in Germany, U.S. doctors have helped develop the most recent versions. And now, in the U.S., we have so many other surgical innovations and technologies that advance surgery like augmented reality and robotic surgery that in my view, we’ve actually leaped way beyond Germany in terms of what we can do for our patients.

Another factor is that the U.S. is more strict with regulations and approvals for implants and look — I don’t think that’s a bad thing. Europe is using 8 to 9 different implants and in the U.S., it’s a smaller number. But we know the ones approved here have gone through rigorous reviews to be permitted.

How do I choose the right surgeon for a disc replacement?

Ultimately what’s important for patients to realize is that you want to go to a place where the surgeon is part of a Center of Excellence and they’re doing a lot of these surgeries. So…survey your surgeons. How many disc replacements have they done? Is this the focus of their care?

You’re also looking for an expert — not just in the surgery but also in recoveries. Care shouldn’t stop at the operating room. So I recommend choosing a place where your rehabilitation is part of the discussion. The goal is to enhance recovery after surgery. We do that in a number of ways from getting patients up and moving within hours of a procedure to working with our in-house physical therapists to rehab patients and ensure we are mobilizing joints, maintaining and growing range of motion, building balance and more.

That’s another reason I don’t advise patients to go out of the country for procedures because unless you have an unlimited budget to stay in Europe long-term, you’re coming home soon after surgery and will miss out on important recovery assistance afterwards.

Research is key. Support groups on Facebook and other places can be very helpful. Patients are very, very smart. See what surgeons and their centers are saying on their websites and social media. Talk to different surgeons in person to see if you get different opinions. One other thing to keep in mind. At our practice, we work to customize these surgeries so we’re not married to a specific implant company. I think that’s an important conversation to have with your surgeon as you’re deciding where to go. Also ask about their outcomes. Top centers should be measuring those and should be willing to share them.