Articles by JCS

Bad Disk Scam

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Bad Disk Scam

Back surgery is now rated among the worst of unnecessary, expensive and ineffective surgeries, yet few, if any, spine surgeons will admit this to their patients. Nor has Sanjay Gupta at CNN ever mentioned the “bad disk” scam his fellow spine surgeons perpetrate upon the unsuspecting public.

An article in USA TODAY warned “Caution: Six common surgeries are often done unnecessarily, including stents, pacemakers and spinal fusions, according to medical research and government databases.”[1] According to this article, there are six common yet unnecessary surgeries that carry significant risks of being done without medical necessity:

  • Cardiac angioplasty, stents:
  • Cardiac pacemakers:
  • Hysterectomy (surgical removal of the uterus):
  • Knee and hip replacement:
  • Cesarean section:
  • Back surgery, spinal fusion:

Unfortunately, the editors failed to explain why disk fusions are unnecessary and ineffective, which is essential for the public to understand if chiropractors are to become the portal of entry (POE) for musculoskeletal disorders (MSDs) and spine-related disorders (SRDs).

This criticism of spinal fusions is not new by any means; not only are they ineffective, researchers agree fusions are based on a debunked “bad disk” premise, an issue well known in the research journals, but rarely mentioned in the public media.

Beginning in 1990, MRI researcher Scott Boden, MD, now director of the Spine Center at Emory University, found ‘bad disks’ in pain-free people confirming early suspicions that herniated, bulging, or degenerated discs were coincidental and not the holy grail of back pain causation that require fusion. [2],[3]

A few years later in 1994, the US Public Health Service (AHCPR) federal guideline on acute low back pain in adults also echoed Dr. Boden’s finding:

Degenerative discs, bulging disc and even herniated discs are part of the aging process for the spine and may be irrelevant findings: they are seen on imaging tests of the lumbar spine in a significant percentage of subjects with no history of low back problems. Therefore, abnormal imaging findings seen in a patient with acute low back problems may or may not be related to that individual’s symptoms.”[4]

Most recently in November, 2014, the Mayo Clinic published a systematic review of 33 studies from around the world that agree “bad disks” are commonplace among pain-free people. According to this Mayo Clinic Review[5]:

“Our study suggests that imaging findings of degenerative changes such as disk degeneration, disk signal loss, disk height loss, disk protrusion, and facet arthropathy are generally part of the normal aging process rather than pathologic processes requiring intervention.”

Usually when the Mayo Clinic speaks, people listen, but despite the far-reaching importance of this study, the media and spine surgeons have kept a lid on this scientific revelation. Obviously the huge fees for surgeons, hospitals, device manufacturers, drug companies and for-profit insurance companies that all profit from these expensive surgeries are a huge incentive to continue this surgical scam upon the public.

For a moment, just take a look at this chart from the Mayo Clinic Review that should make your patients’ heads spin:


 

 

 

 

 

 

 

 

 




As you can see, for 20-year old patients with no pain, 37% still have disk degeneration. For 80-year old people, 96% were found to have “bad disks,” but none had any back pain. Yet if any of these pain-free people were to visit their primary MD or a surgeon, they would be convinced with the common “red herring” sales pitch: “I can prove you have a degenerative disk that requires fusion — look right here on this MRI.”

If these patients did have low back pain, never would they be told their LBP is due to joint dysfunction, not bad disks.

The same surgeon also will never tell the patient what Dr. Richard Deyo, MD, MPH, professor at Oregon Health and Science University, stated years ago, “Many of these abnormalities are trivial, harmless, and irrelevant, so they have been recently dubbed ‘incidentalomas’,” because it may be incidental to your pain.[6]

Dr. Deyo, a noted researcher, published in 1998 an article in the Scientific American titled “Low-Back Pain,”[7] criticizing “Old concepts supported only by weak evidence,” and the reliance on MRI exams to infer disc abnormalities as the cause of back pain. His sentiments still hold true today: “Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.” [8]

To illustrate the ubiquitous nature of “bad disks” in pain-free people, at the 2000 Sydney Olympic Games researchers found these elite athletes had a greater prevalence and greater degree of lumbar disk degeneration than the normal population, yet they were among the best athletes in the world![9]

 Not only based on a debunked bad disk premise, most disk fusions are ineffective. A study by JT Anderson, et al.[10] in the research journal Spine, noted the poor outcomes of disc fusion in two groups—spondylolisthesis (slippage of one vertebrae upon another) and degenerative disc disease (DDD).  

This study had an incredibly low bar for success that most patients still could not reach. A case was considered “successful” in this study if a patient could return to work within a two-year limit and work at least six months, although many were still taking opioids for nearly a year postoperatively.

 This study revealed rather pitiful success rates – only 36 percent for spondylolisthesis and 24 percent for DDD cases were able to return to work after two years of recovery. Conversely, this means nearly 2/3rds of the spondylolisthesis and 3/4ths of the DDD patients did not return to work by two years.

The Anderson study concluded:

“Our study is support of the conclusion that DDD is a questionable indication for spinal fusion. Given the generally poor outcomes of this study, future studies should determine if lumbar fusion surgery is an effective treatment modality in similar patients.”[11]

Additionally these researchers found workers’ compensation studies from several states reporting return to work rates ranging from only 26% to 36%, re-operation rates from 22% to 27%, and high rates of chronic opioid use after fusion. The prevalence of opioid use among the entire WC population is approximately 32%.[12]

Certainly the research is clear: fusion for “bad disks” is a bad idea that leads to a high rate of opioid use, addictions, disability and deaths.

Truth about Back Pain

What’s most important is not how the spine looks on an x-ray or MRI image, but how it functions. The traditional medical model continues to view the cause of back pain as primarily an anatomical incidentalomas with surgery as the logical solution when, in reality, most spine pain is now believed to be a mechanical (pathophysiologic) problem, primarily as vertebral joint complex dysfunction.

Until the public and press understands that you don’t slip disks, but you can slip joints, the “bad disk” premise will remain the underlying concept in the public’s mind as the cause of back pain.

Counting all the vertebral joints, sacroiliac joints, rib heads, and the pubic symphysis, new research now suggest the total number of joints in the spine is 361, a fact lost to most physicians and certainly the public. This total includes all synovial, symphysis and syndesmosis joints according to Gregory D. Cramer, DC, PhD, Dean of Research at National University of Health Sciences.[13]

Dr. Deyo also acknowledged that 97 percent of back pain is “mechanical” in nature, meaning the loss of normal joint play between spinal vertebras combined with over-loading will cause the spinal joints to “buckle.”[14] As simply cartilaginous shock absorbers between vertebrae, disks are secondary to the mechanics of the spine and the pain process.

Aside from the typical causes of a back attack such as traumatic accidents, childhood falls, sports injuries and improper lifting, even prolong sitting/standing can develop a functional spinal problem described as a “segmental buckling effect” according to Jay Triano, DC, PhD, et al. while at the Texas Back Institute, an interdisciplinary clinic offering comprehensive spinal care.

The buckling effect is a function of mechanical overloading of the vertebral motor unit rather than solely a problem with the disk:

Several characteristics of buckling behavior are known. An obvious causative factor is a single overload event that exceeds critical load for the conditions. For less severe tasks, the process is more complex. Normal creep deformity occurs with prolonged static posture. Creep alters the constitutive properties of the tissue and the relative critical load. Under the right conditions, even a small additional load will cause the joint to buckle. Rapidly applied loads also are associated with buckling and vibration reduces the threshold necessary to achieve it. Finally tissues that are damaged, as in discopathy, may buckle sooner and reach maximum displacement (deformation) under lower peak loads than do healthy tissues.[15]

John McMillan Mennell, MD, testified at the Wilk v. AMA antitrust trial as a distinguished orthopedist, professor, and expert on manipulative therapy who also had taught at eight medical schools. In a letter dated October 28, 1968, to the HEW panel on Medicare coverage for chiropractic in which he participated, he mentioned the value of SMT, the backbone of chiropractic care:

Manipulative therapy relieves symptoms of pain arising from mechanical joint dysfunction and restores lost joint function. No other modality or physical treatment can do this as effectively…I would suspect that nearly 20 million Americans today could be spared suffering and be returned to normal pain-free life were manipulation therapy as readily available to them as empirical nonspecific drug treatment is.” [16]

Sadly, the medical war against chiropractors has led to a terrible crisis of low back pain today in America with opioid painkiller addictions/deaths, ineffective epidural steroid injections unapproved by the FDA[17], and spine fusions based on a debunked “bad disk” premise.

Let me show you in my equation of this medical mismanagement of back pain:

The epidemic of disk fusions = bad training + outdated practices + disproven theories + chirophobia + greed.

Inept MDs

Dr. Deyo admits “Calling a physician a back-pain expert, therefore, is perhaps faint praise—medicine has at best a limited understanding of the condition. In fact, medicines’ reliance on outdated ideas may have actually contributed to the problem.”[18]

Certainly the local MDs will never admit to their lack of training in musculoskeletal disorders, but Dr. Boden also noted most MDs are inept on MSDs. “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”[19]

The recent National Pain Strategy also mentioned MDs are ill-prepared to manage this opioid crisis:

Physicians are not adequately prepared and require greater knowledge and skills to contribute to the cultural transformation in the perception and treatment of people with pain.”[20]

Other studies have shown MDs are not trained in this pandemic of back pain:

  • MDs are “inept” in their training on musculoskeletal disorders,[21] 
  • more likely to ignore recent guidelines,[22]
  • most likely to be “promiscuous prescribers”[23] and
  • more likely to suggest spine surgery than surgeons themselves.[24]

Mr. Mark Schoene, editor of The BACKLetter, an international spine journal, also noted the paradox of using MDs as POE for MSDs:

“Primary care physicians and pain specialists are primarily responsible for the opioid overtreatment crisis. Are the two professions that helped create the worst pain management crisis in history of modern medicine capable of leading the way forward? That remains to be seen.”[25]

And they are more likely not to refer these patients to chiropractors due to their ingrained bias, “chirophobia,” from years of the illegal medical boycott. Consequently, patients are still misdiagnosed (“bad disks”), misinformed (“don’t go to a chiropractor”) and mistreated (opioids, ESIs, and fusions).

Disproven Disk Theory

Many spine surgeons agree there are too many fusions:

  • HL Rosomoff, MD: “Low back pain in the population at large is not usually a surgical problem and the chances of there being significant pathology requiring surgical or other forms of intervention may be less than 1% of those affected…”[26]
  • Zoher Ghogawala, Yale neurosurgeon: “I see too many patients who are recommended for fusion that absolutely do not need it.”[27]
  • Lynn Johnson, MD, director of the Center for Pain Medicine of North Carolina: “Just about any approach is better than having surgery because all the studies have shown that, if you take a surgical population and non-surgical population, they all seem to do the same in five years.”[28]
  • Chien-Jen Hsu, MD: “By far the number one reason back surgeries are not effective and some patients experience continued pain after surgery is because the [disk] lesion that was operated on is not, in fact, the cause of the patient’s pain.”[29]
  • Raj Rao, M.D., director of spine surgery in the Department of Orthopaedic Surgery at the Medical College of Wisconsin:  “You can look at the MRIs of two people, both showing degenerative discs, but in one case there is little to no pain, while in the other, extreme pain. On the other hand, you can see a healthy spine but the patient has severe pain.”[30]
  • Scott Boden, MD, of the Emory Spine Center said: “The vast majority of people with back pain aren’t candidates for disk surgery.”[31]
  • Eugene J. Carragee, MD, from Stanford University, admitted the “fundamental failing” with unnecessary spine surgery:

“The proliferation of risky and expensive practice beyond reasonable supporting evidence is commonly mentioned as a fundamental failing of medical practice in the United States.”[32]

“New and more complex technologies are being used for patients with little specific indication for the approaches and for whom there is good evidence that simpler methods are highly effective.”[33]

In agreement with Dr. Carragee, Dr. Deyo mentions chiropractic as a “simpler” solution: “Chiropractic is the most common choice, and evidence accumulates that spinal manipulation may indeed be an effective short-term pain remedy for patients with recent back problems.” [34]

Perhaps the most surprising endorsement of chiropractic care came from the North American Spine Society. This medical society of spine surgeons developed its Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy[35] that admits spinal manipulation was found to be comparable to successful surgery:

Of patients with lumbar radiculopathy due to lumbar disc herniation, 60%  who  failed  three  months  of  medical  management  obtained  comparable  relief  to  those  patients  that  underwent successful surgery.  The authors concluded that of patients with sciatica that fail three months of medical management, 60% will benefit  from  spinal  manipulation  to  the  same  degree  as  if  they  undergo surgical intervention. For the 40% that are unsatisfied, surgery provides  an  excellent  outcome.    Although  this  study  is  a randomized controlled trial, it provides case series (Level IV) therapeutic  evidence  that  spinal  manipulation  is  beneficial  in  treating patients with lumbar disc herniation with radiculopathy.

When the NASS guideline touts SMT as effective as surgery, obviously there is a new day in spine care, but these recommendations have not stopped the tsunami of expensive and ineffective spine surgeries because the medical media such as Dr. Sanjay Gupta, a neurosurgeon and chief medical correspondent at CNN, has never told his viewing audience.


Greed Factor

As the bible teaches, the love of money is the root of all evil, and this is certainly evident in the “bad disk” spinal fusion scam.

Dr. Jerry Groopman, professor of Medicine at Harvard Medical School, perhaps said it best in The New Yorker magazine when he asked his orthopedist about doing controversial disc fusions, "If I don't do them, they'll go around the corner and the other surgeon will.”[36]

Despite the growing evidence against spine fusions, the median salary of an orthopedic spine surgeon is the highest of all medical specialties at $736,710, which excludes kickbacks from Big Pharma, hospitals, MRI centers, and device manufacturers that often doubles their income.[37]

Here are just a few articles revealing the profit in spine surgery:

Steven Brill, author of America’s Bitter Pill, noted: “We spend $85.9 billion trying to treat back pain, which is as much as we spend on all the country’s state, city, county, and town police forces. And experts say that as much as half of that is unnecessary.”[38]

Of course, the biggest waste in spine care is spinal fusions and the biggest motivation for spine surgeons is money, in fact, a lot of money. The annual number of fusion operations (all indications and spinal levels) has increased from about 61,000 in 1993 to over 450,000 in 2011, more than a 600 percent increase.[39]

As Richard Deyo, MD, MPH, suggested, “It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just six years,” and a strong motivation was “financial incentives involving both surgeons and hospitals.”[40]

The global market for spinal surgery is projected to reach $9.3 billion by the year 2017.[41] A report on the spine surgery market forecasts the global spine surgery devices market will be worth $14.8 billion by 2017.[42] Hospitalization for spinal fusion surgeries alone creates the largest expenditure of any hospital-based surgery at over $40 billion annually.[43]

Not only are surgeons and hospitals cashing in on this rampage of fusions, so has Big Pharma. Prescription opioid painkillers for back pain brought in $17.8 billion, and OxyContin alone made $3 billion in 2010.[44]

Pain management physicians, aka, spine interventionists, at “pill mills” milk the back pain pandemic while rendering what are now considered placebo treatments, such as muscle relaxants, opioid painkillers and epidural steroid injections.[45],[46],[47],[48],[49]

Never to turn down easy money, the “needle jockeys” operating pain management clinics saw their reimbursements skyrocket among Medicare beneficiaries from $24 million to over $175 million between 2000 and 2008.[50] Doling out OxyContin like Halloween candy and giving corticosteroid injections at $600 is a quick buck despite the fact both opioids and ESIs have been found to be placebo at best.

Obviously there is too much money and too few ethics in medical spine care to think this area of medicine has any intention to reform itself by following the guidelines that call for conservative care first.

Overcoming Chirophobia

Editor Mark Schoene was also very candid in his assessment of medical spine care:

Medical spine care is the poster child of inefficient care…such an important area of medicine has fallen to this level of dysfunction should be a national scandal. In fact, this situation is bringing the United States disrespect internationally.[51]

“Over the past two decades, US physicians have delivered some of the worst back care in the history of modern medicine — as exemplified by the opioid overtreatment and addiction crisis, which has killed more than 500,000 people since the mid-1990s. Back care in primary care medical settings in the US appears to be ineffective and way off line with the scientific evidence.”[52]

Dr. Tim Johnson, former ABC World News medical spokesman, spoke of this medical mess:   

“It could be a combination of too many surgeons who are too eager to operate and the impatience of many patients who want results quickly. The truth is that 90 percent of back pain can be resolved without surgery if both doctors and patients are willing to try other treatments that basically help the back to heal itself.”[53] 

This is a slippery slope for the medical profession that cannot justify its boycott of chiropractic care in light of the growing evidence supporting the paradigm shift in spine care. Just as the public and media have pushed back against other forms of prejudice, the next major push back will be against the medical discrimination against chiropractors, aka, chirophobia.

Indeed, in the pursuit of better health, chiropractic has made a huge and important impact upon healthcare in this country, yet this revelation has remained off the radar in the public media since chiropractors cannot buy ink by the barrel to tell their story.

Dr. JC Smith is the author of the Medical War Against Chiropractors and his newest book, To Kill a Chiropractor: The Media War Against Chiropractors. He also hosts a blog at chiropractorsforfairjournalism.com.



[1] Peter Eisler, Six common surgeries often done unnecessarily, USA TODAY June 19, 2013

[2] SD Boden, DO Davis, TS Dina, NJ Patronas, SW Wiesel, “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects: A Prospective Investigation,” J Bone Joint Surg Am. 72 (1990):403–408.

[3] MC Jensen, MN Brant-Zawadzki, N Obuchowski, MT Modic, D Malkasian, and JS Ross, “Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain,” NEJM, 331/2 (July 14, 1994):69-73

[4] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[5] Brinjikji W, et al., Systematic literature review of imaging features of spinal degeneration in asymptomatic populations, American Journal of Neuroradiology, 2014

[6] Richard A. Deyo, MD, MPH and Donald L. Patrick, PhD, MSPH, Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises, AMACOM books, (2005): 36-37

[7] Deyo, RA. Low -back pain., Scientific American, pp. 49-53, August 1998.

[8] Deyo, RA. Low -back pain., Scientific American, pp. 49-53, August 1998.

[9] A Ong, J Anderson, J Roche, A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games, Br J Sports Med 2003;37:263-266 doi:10.1136/bjsm.37.3.263

[10] Anderson, Joshua T. BS; Haas, Arnold R. BS, BA; Percy, Rick PhD; Woods, Stephen T. MD; Ahn, Uri M. MD; Ahn, Nicholas U. MD, Single-Level Lumbar Fusion for Degenerative Disc Disease Is Associated With Worse Outcomes Compared With Fusion for Spondylolisthesis in a Workers' Compensation Setting, Spine: 01 March 2015 - Volume 40 - Issue 5 - p 323–331

[11] http://journals.lww.com/spinejournal/Abstract/2015/03010/SingleLevelLumbarFusionforDegenerativeDisc.15.aspx

[12] Joshua T. Anderson, BS; Arnold R. Haas, BS, BA; Rick Percy, PhD; Stephen T. Woods, MD; Uri M. Ahn, MD; Nicholas U. Ahn, MD, Chronic Opioid Therapy After Lumbar Fusion Surgery for Degenerative Disc Disease in a Workers' Compensation Setting, Spine. 2015;40(22):1775-1784.

[13] Cramer, G.; Darby, S. 2014 Clinical anatomy of the spine, spinal cord, and ANS. 3rd Edition, Elsevier/Mosby, St. Louis, 559 illustrations, 672pp. Appendix I, pp. 638-642.

[14] Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70.

[15] JJ Triano, et al.Biomechanics of Spinal Manipulation,” Spine 1 (2001):121-30

[16] G Null, PhD, “Medical Genocide, Part Four:  Painful Treatment,” Penthouse (November 1985).

[17] http://www.fda.gov/Drugs/DrugSafety/ucm394280.htm

[18] Deyo, RA. Low -back pain, Scientific American, pp. 49-53, August 1998.

[19] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28 (2003):524-525.

[20] http://iom.nationalacademies.org/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx, pp.5.

[21] EA Joy, S Van Hala, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/11 (November 2004).

[22] PB Bishop et al., “The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A Randomized Controlled Trial On The Effectiveness Of Clinical Practice Guidelines In The Medical And Chiropractic Management Of Patients With Acute Mechanical Low Back Pain,” presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine,

[23] Jonathan Chen, Overprescribing of opioids is not limited to a few bad apples, Stanford Medicine News Center, Dec 14 2015

[24] SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, And Surgeons For Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115,

[25] Why Should the National Pain Strategy Be MD-Centric? BackLetter: February 2016 - Volume 31 - Issue 2 - p 16

[26]   HL Rosomoff, RS Rosomoff, “Low Back Pain. Evaluation And Management In The Primary Care Setting,” Medical Clinics of  North American,  83/3 (May 1999):643-62.

[27] RA Deyo and DL Patrick, Hope or Hype:  The Obsession with Medical Advances and the High Cost of False Promises (2002):191.

[28] M Widen, “Back Specialists Are Discouraging The Use Of Surgery,” American Academy of Pain Medicine, 17th annual meeting, Miami Beach, Fl. (Feb. 14-18, 2001)

[29] CJ Hsu, et al. “Clinical Follow Up After Instrumentation-Augmented Lumbar Spinal Surgery in Patients with Unsatisfactory Outcomes. In Journal of Neurosurgery,” Spine 5/4 (October 2006):281-286.

[30] P Garfinkel, “The Back Story,” AARP: the magazine, (July & August 2009)

[31] SD Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28(2003):524-525.

[32] “Spike in Complex Spinal Surgery Sets Off a Wave of Serious Complications and Exorbitant Costs,” The BACKLETTER, 25/6 (June 2010):61,67

[33] EJ Carragee, “The Increasing Morbidity of Elective Spinal Stenosis Surgery: Is It Necessary?” JAMA 303 (2010):1309-10

[34] Deyo, RA. Low -back pain., Scientific American, pp. 49-53, August 1998.

[35] https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf

[36] The New Yorker magazine, Dr. Jerry Groopman, "Knife in the Back,“ (April 8, 2002) 

[37] http://www.mgma.com/store/surveys-and-benchmarking/online/mgma-datadive-provider-compensation-2015

[38] Steven Brill, America’s Bitter Pill; Money, politics, backroom deals, and the fight to fix our broken healthcare system, Random House, NY, 2015

[39] R.A. Deyo / The Spine Journal 15 (2015) 272–274 273

[40] “New Study Demonstrates A Three-Fold Increase in Life-Threatening Complications With Complex Surgery,” The BACKLETTER, 2010 June; 25(6):66

[41] http://www.prweb.com/releases/spinal_surgery_devices/spinal_fusion_fixation/prweb8977144.htm

[42] http://www.marketsandmarkets.com/PressReleases/spine-surgery-devices.asp

[43] HCUPnet. Agency for Healthcare Research and Quality. Available at: http://hcupnet.ahrq.gov/HCUPnet.jsp. Accessed October 30, 2014.

[44] Rafia S. Rasu, BPharm, MPharm, MBA, PhD; Kiengkham Vouthy, PharmD; Ashley N. Crowl, PharmD; Anne E. Stegeman, PharmD; Bithia Fikru, PharmD, MPA; Walter Agbor Bawa, MS, PharmD; and Maureen E. Knell, PharmD, BCACP, “Cost of Pain Medication to Treat Adult Patients with Nonmalignant Chronic Pain in the United States,” Vol. 20, No. 9 September 2014 JMCP Journal of Managed Care & Specialty Pharmacy

[45] Bernstein, E, Carey TS, Garrett JM (2004) The use of muscle relaxant medications in acute low back pain. Spine 2004:29(12):1346-51.  

[46] Centers for Disease Control and Prevention Press Release, CDC Vital Signs: Overdose of Prescription Opioid Pain Relievers—United States, 1999-2008; 2011: www.cdc.gov/media/releases/2011/t1101_presecription_pain_relievers.html.

[47] Luis Enrique Chaparro, MD, Andrea D. Furlan, MD, PhD, Amol Deshpande, MD, Angela Mailis-Gagnon, MD, MSc, FRCPC, Steven Atlas, MD, Dennis C. Turk, PhD, Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain, An Update of the Cochrane Review, Spine. 2014;39(7):556-563

[48] Bicket MC et al, Epidural injections for spinal pain:  A systematic review and meta-analysis evaluating the “control’ injections in randomized control trials, Anesthesiology, 2013;

[49]Epidural Corticosteroid Injection: Drug Safety Communication - Risk of Rare But Serious Neurologic Problems,” FDA, April 23, 2014

[50]  Pain Management Injection Therapies for Low back Pain – Project ID ESIB0813

9/19/14, Pacific Northwest Evidence-based Practice Center, Agency for Healthcare Research and Quality Task Order Officer: Kim Wittenberg Partner: Centers for Medicare and Medicaid Services

[51] U.S. Spine Care System in a State of Continuing Decline?, the BackLetter, vol. 28, No. 10, 2012, pp.1

[52] Could Physician Assistants and Nurse Practitioners Do Any Better Than Physicians in Managing Low Back Pain? The BackLetter Volume 31, Number 10, 2016

[53] Back Surgery Not Always the Cure for Pain; U.S. Leads the World in Procedures That Some Experts Say Could Be Avoided, by Dr. Timothy Johnson , ABC World News, May 23, 2006.

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