Resources to Fight BMI-Based Denials for Lumbar Spinal Surgery

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BMI-Based denials of care are about holding healthcare hostage for a weight loss ransom. A ransom that most people won’t be able to pay.

I wrote about fighting these denials in a two-part series here

I have a collection of resources to fight joint surgery denials here

I have a collection of resources to fight gender-affirming surgery denials here

Today I’m writing about resources that can be used to fight BMI-based denials for lumbar spinal surgery.

Please note that most if not all of these studies are coming from a place of weight stigma – pathologizing body size, blaming higher-weight bodies for the harms that come from a healthcare system rooted in weight stigma etc. Still, from a harm reduction perspective they can and have been used to fight BMI-based denials of surgery.

An important point in discussing these denials with providers is the idea that if higher-weight people have higher rates of complications then denial of the procedure is justified. This is a point of view that is based in weight stigma for several reasons. First of all, because the healthcare system is quick to blame any higher rates of complications or negative outcomes on “weight” when the actual cause might be the fact that higher-weight people are being treated by a healthcare system where tools, best practices, pharmacotherapy and more are created for thin people. So the idea that fat people (who were largely excluded from the creation of the healthcare system) only deserve care if they have the same outcomes as thin people (for whom the system was created) only perpetuates the weight stigma upon which the system is based. Further, often the complications that occur at a higher rate are minor. I would argue, for example, that a higher rate of urinary tract infections (UTIs) should not be used to justify the refusal of a life-improving/saving procedure. Overall, a higher rate of complications or negative outcomes may well warrant an informed consent discussion and shared decision-making process, not a denial of care.

Of course, overall, if higher-weight patients have more complications then the goal should be to get better at performing surgical procedures and aftercare on higher-weight patients, not to exclude these patients from care. Healthcare should fit patients, patients shouldn’t have to change their bodies to fit healthcare.

Willems, S. J., Coppieters, M. W., Rooker, S., Orzali, L., Kittelson, A. J., Ostelo, R. W., Kempen, D. H. R., & Scholten-Peeters, G. G. M. (2024). The impact of being overweight or obese on 12 month clinical recovery in patients following lumbar microdiscectomy for radiculopathy. The spine journal : official journal of the North American Spine Society, 24(4), 625–633. https://doi.org/10.1016/j.spinee.2023.10.023

Multivariable and univariable logistic regression revealed no significant associations between the BMI categories and poor recovery from back pain, leg pain, and disability.

Singh, A. K., Ramappa, M., Bhatia, C. K., & Krishna, M. (2010). Less invasive posterior lumbar interbody fusion and obesity: clinical outcomes and return to work. Spine, 35(24), 2116–2120. https://doi.org/10.1097/BRS.0b013e3181cf0980

Although surgery is technically more demanding, our experience with less invasive posterior interbody fusion has shown less incidence of postoperative complication, less intraoperative blood loss, and short in-patient hospital stay. Furthermore (66.6%) returned to their normal preoperative employment within 12 months of the index procedure. We conclude that a high BMI should not be a contraindication to surgery in patients with degenerative low back pain. (emphasis mine)

Lingutla, K. K., Pollock, R., Benomran, E., Purushothaman, B., Kasis, A., Bhatia, C. K., Krishna, M., & Friesem, T. (2015). Outcome of lumbar spinal fusion surgery in obese patients. The Bone & Joint Journal, 97-B(10), 1395-1404. https://doi.org/10.1302/0301-620X.97B10.35724

Ob*se patients have greater intra-operative blood loss, more complications and longer duration of surgery but pain and functional outcome are similar to non-ob*se patients. Based on these results, ob*sity is not a contraindication to lumbar spinal fusion. (emphasis mine)

Jackson, K. L., 2nd, & Devine, J. G. (2016). The Effects of Obesity on Spine Surgery: A Systematic Review of the Literature. Global spine journal, 6(4), 394–400. https://doi.org/10.1055/s-0035-1570750

“given the equivalent or greater treatment effect of surgery, this comorbidity should not prohibit ob*se patients from undergoing operative intervention” (emphasis mine)

Abbasi, H., & Grant, A. (2018). Effect of Body Mass Index on Perioperative Outcomes in Minimally Invasive Oblique Lateral Lumbar Interbody Fusion versus Open Fusions: A Multivariant Analysis. Cureus, 10(3), e2288. https://doi.org/10.7759/cureus.2288

“In OLLIF [oblique lateral lumbar interbody fusion ], BMI does not affect perioperative outcomes. Therefore, OLLIF may reduce the disparity in outcomes and cost between ob*se and non-ob*se patients.”

In an article about this study (note that the article is for his practice website, NOT a peer reviewed journal)  the lead author wrote “a recent research study shows that oblique lateral lumbar interbody fusion (OLLIF) is just as safe for ob*se patients as it is for slimmer ones.”

Cofano F, Perna GD, Bongiovanni D, et al. (2022) Obesity and Spine Surgery: A Qualitative Review About Outcomes and Complications. Is It Time for New Perspectives on Future Researches? Global Spine Journal. 2022;12(6):1214-1230. doi:10.1177/21925682211022313

“Evidence suggest that ob*se patients could benefit from spine surgery and outcomes be satisfactory.”

Remember that if you are facing a BMI-based denial of care medical weight stigma is becoming your problem, but it is not your fault. This should not be happening and you deserve care in the body you have now.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.