Articles by JCS

Bad Poster Child

Part Two of Alternative Facts

Bad Poster Child

“Medical spine care is the poster child of inefficient care”

Mr. Mark Schoene, editor of The BACKLetter

It took an opioid crisis of unprecedented numbers created by the AMA and Big Pharma causing hundreds of thousands of deaths and millions of addictions over the past 30 years before the media and government took a closer look at the medical mismanagement of the most disabling condition in our nation – the “Quiet Epidemic” of chronic pain.

As Donald Teater, MD, National Safety Council, once said, "Opioids do not kill pain. They kill people."[1]

Washington Awakens

The updated American College of Physicians (ACP) guidelines are not the first critical assessment of medical spine care. During the last few years numerous federal agencies have examined the issues of the growing opioid painkiller problem and the consensus was very clear:

  • too many opioids,
  • too many promiscuous prescribers,
  • general physicians uneducated in chronic pain management, and
  • the need for nondrug alternatives for care.

Here are a few of the major studies:

  • VA/DoD: Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, 2009.[2]
  • Office of the Army Surgeon General: Pain Management Task Force; Final Report, May 2010.[3]
  • Institute of Medicine (IOM): “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, 2011.[4]
  • National Institutes of Health: Report of the Task Force on Research Standards for Chronic Low Back Pain, 2014.[5]
  • National Institute on Drug Abuse: “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” 2014.[6]
  • Health and Human Services: National Pain Strategy: “A Comprehensive Population Health-Level Strategy for Pain,” 2015.[7] 
  • Centers for Disease Control: Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.[8]
  • American College of Physicians: Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians.”[9] 

This crisis would never have grown to this magnitude if the AMA had not waged a medical war of defamation to marginalize the chiropractic profession, the leading nondrug primary care spine care providers, in order to corner the spine care market.

 Now the public and government programs are paying this price of this medical mess, and it’s time to blow the whistle.

Image result for american college of physicians

Shot in the Back

Although the updated ACP guidelines discouraging the use of opioid painkillers are certainly important and a good place to begin this publicity of medical malpractice, there are bigger fish to fry in spine care—ESI and spine fusions.

Every chiropractor has seen this scenario: when self-care and OTC pain pills fail patients with chronic or acute back pain, they go to the “pain management” clinics for opioids, muscle relaxants, and epidural steroid injections without first taking a detour to the chiropractor’s office for complementary and alternative methods (CAM) as most guidelines now recommend.

Patients are totally unaware epidural corticosteroids injections (ESIs) are used “off-label” for back pain and have been shown to be no better than placebo,[10] sometimes dangerous (such as loss of vision, stroke, paralysis and death), and have never been approved by the FDA for back pain as noted in a FDA publication,   “Epidural Corticosteroid Injection: Drug Safety Communication: Risk of Rare But Serious Neurologic Problems.

The FDA warning clearly states: “Corticosteroids are not approved by FDA for injection into the epidural space of the spine.”[11] Yet “needle jockeys” continue to ignore this FDA warning because it’s easy money.

In 2015, another major review by Roger Chou, MD, sponsored by the U.S. Agency for Healthcare Research and Quality (AHRQ) found the evidence in favor of spinal injections to be distinctly “underwhelming.”

Chou also could not find conclusive evidence that spinal injections were effective treatments for spinal stenosis, facet joints, sacroiliac joints, or non-radicular back pain. The only benefit was temporary relief for sciatica in some patients.

A 2013 study by Nancy E. Epstein, “The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature,” was just as disturbing as Dr. Chou’s assessment:

“For many patients with spinal pain alone and no surgical lesions, the ‘success’ of epidural injections may simply reflect the self-limited course of the disease…

Although not approved by the Food and Drug Administration (FDA), injections are being performed with an increased frequency (160%), are typically short-acting and ineffective over the longer-term, while exposing patients to major risks/complications…

Although the benefits for epidural steroid injections may include transient pain relief for those with/without surgical disease, the multitude of risks attributed to these injections outweighs the benefits.”[12]

Undoubtedly the most infamous case of ESI malpractice occurred with the New England Compounding Center meningitis outbreak which began in September 2012 that sickened over 800 individuals and resulted in the death of 64. Federal prosecutors charged 14 former NECC employees, including president Barry Cadden and pharmacist Glenn Chin, with a host of criminal offenses.

It alleged that from 2006 to 2012, NECC knowingly sent out drugs that were mislabeled, unsanitary or contaminated.[13] The incident resulted in numerous lawsuits against NECC. In May 2015, a $200 million settlement plan was approved that set aside funds for victims of the outbreak and their families.

Nonetheless, while the effectiveness of ESI may be underwhelming and the risks far outweigh the benefits, the money generated by PM&R practitioners at pain management clinics is overwhelming.

Between 1994 and 2001, use of epidural injections increased by 271 percent and facet joint injections by 231 percent among Medicare beneficiaries; costs increased from $24 million to over $175 million over this time period. More recent data indicate rapid growth with an increase of 187 percent in use between 2000 and 2008.[14]

Some needle jockeys allegedly do 5000 per year. According to one estimate, patients have about 9 million epidural steroid injections every year for a chemical band-aid that is temporary at best.[15] The reported median salary for needle jockeys who do not practice anesthesiology is $340,506, and those who practice pain medicine with anesthesiology report an average of $502,024 per year.[16] Not bad pay for giving placebo treatments to unsuspecting patients.

Spine Fusion Folly

Not only are opioid painkillers and ESI dangerous, addictive and ineffective, spinal fusions are also a bad bet for patients in this medical trifecta.

A 2015 study by JT Anderson, et al.[17] in the research journal Spine, noted the poor outcomes of disc fusion in two groups—spondylolisthesis 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. 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.”[18]

Additionally, researchers found studies of workers’ compensation (WC) subjects from several states reported 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%.[19]

The call for reform in spine care has been growing for years.

“Epidemiological and clinical studies show that most lumbar disc prolapses resolve naturally with conservative management and the passage of time,” according to JNA Gibson and Gordon Waddell, who suggest surgery is generally reserved for the minority of patients whose recovery is unacceptably slow.[20]

Nor is the press aware of the huge amount of money involved in spine surgery. The global spinal fusion market is anticipated to reach $9 billion by 2023, based on Global Data research. Valued at $7.1 billion in 2016, the market will likely grow at a compound annual growth rate of 3.4 percent through 2023. China and India will be the next fertile fields for spine surgeons.

According to Becker’s Spine Review, between 1998 and 2011, the number of spinal fusion procedures more than doubled, from 204,000 to 457,000. The percentage increase is 113 percent, according to The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Costs, produced by the United States Bone and Joint Initiative in collaboration with a number of organizations.

The median salary for the 75th percentile of orthopedic surgeons is around $555,789. The highest annual salary for spine surgeons is about $710,055 per year, excluding kickbacks from hospitals, MRI centers, Big Pharma, and device manufacturers that can double their total compensation.[21]

Media Investigations

This economic growth (perhaps more aptly described as highway robbery) comes amidst the controversy that spine surgeries are mostly unnecessary, ineffective, and dangerous, an opinion already expressed by many journalists, not just me.

Undoubtedly the most chilling story you may ever read about spine surgeons gone wild is “Dr. Death: Plano surgeon Christopher Duntsch left a trail of bodies. The shocking story of a madman with a scalpel.” The 46-year-old surgeon was arrested in July 2015 on five aggravated-assault charges and recently sentenced to life in prison.[22]

Dr. Duntsch was paid $50,000 a month plus expenses to work exclusively at the Baylor Regional Medical Center at Plano—a base compensation of $600,000 a year for two years. Duntsch also received 40 percent of all revenue he generated beyond $800,000 each year—the typical fee-for-service incentive that leads to excessive services.

Federal suits claim Duntsch should have never been hired, saying that a previous employer had identified him as “an egomaniac, mentally ill, an alcoholic, drug addict, or a combination thereof.”[23]

You can only assume this $50,000 monthly stipend brought in more than enough in revenues for the hospital to hire this knife-happy surgeon. According to physician recruitment firm Merritt Hawkins, a single neurosurgeon produced his or her hospital an average revenue of $2.45 million in 2015.[24]  

Another exposé recently appeared on February 10, 2017, in the Seattle Times, “High volume, big dollars, rising tension” that exposes more examples of surgeons gone wild.[25]

You can add these articles to a growing list of news accounts investigating the controversies within medical spine care—opioids, ESIs and surgery:

  •  “Back Surgery Fails To Live Up To Hype” By Robert Preidt, June 16, 2005, Healthday News
  • “The Spine as Profit Center,” By Reed Abelson, New York Times, December 30, 2006.
  • “Surgeon Kept Quiet About Stake In Company,” Rutchik J Et Al., The Plain Dealer, December 10, 2006
  • “Symptoms Of Conflict: Another Cleveland Clinic Doctor’s Financial Interest Raises Suspicions About His Advocacy Of A Treatment,” The Plain Dealer, December 12, 2006
  • “Back Pain Eludes Perfect Solutions” By Leslie Berger, The New York Times, May 13, 2008
  • “Highest-Paid U.S. Doctors Get Rich With Fusion Surgery Debunked By Studies” By Peter Waldman And David Armstrong, Bloomberg News, Dec. 30, 2010
  • “Surgery May Not Be The Answer To An Aching Back” By Joanne Silberner, NPR, April 6, 2010
  • “Why You Should Never Get Fusion Surgery For Plain Back Pain” By Robert Langreth, Forbes, Jan. 10, 2011
  • “600,000 Americans Have Back Surgery Each Year,” TODAY,  September 11, 2012
  • “Study Says Back Surgery Often Makes Things Worse”, The Daily Hit, Oct 14, 2010
  • “New Study Reveals That Back Surgery Fails 74 Percent Of The Time,”  Spine, 2011 Feb 15;36(4):320–331
  • “Back Surgery May Backfire On Patients In Pain,” By Linda Carroll, MSNBC.Com, Oct. 14, 2010
  • “Should Sciatica Patients With Workers’ Compensation Claims Avoid Disc Surgery?” The Backletter, April 2010
  • “Top Spine Surgeons Reap Royalties, Medicare Bounty,” By John Carreyrou And Tom Mcginty, The Wall Street Journal, Dec. 20, 2010
  • “Spike In Complex Spinal Surgery Sets Off A Wave Of Serious Complications And Exorbitant Costs,”, June 2010
  • “Dismal Results For Spinal Fusion Among Patients With Workers’ Compensation Claims,” The Backletter, November 2010
  • “Medicare Records Reveal Trail Of Troubling Surgeries” By John Carreyrou And Tom Mcginty, The Wall Street Journal, March 29, 2011
  • “Epidural Steroid Shots Debated Amid Meningitis Scare,” USA Today, Oct 6, 2012
  • “Opioid Painkiller Prescriptions Pose Danger Without Oversight,” Barry Meier, The New York Times, April 8, 2012
  • “How Back Pain Turned Deadly” By Elisabeth Rosenthal, The New York Times, November 17, 2012
  • “Fee-For-Service Rewards Volume: Our View”, The Editorial Board, USA Today, July 7, 2013
  • “Back Pain: Doctors Increasingly Ignore Clinical Guidelines,” The Los Angeles Times, July 29, 2013
  • “Patients With Back Pain Often Get The Wrong Treatment,” USA Today, July 29, 2013
  • “Worrisome Trends In Back Pain Management,” Medscape Medical News, July 30, 2013
  • “New Solutions For Long-Lingering Back Pain - CBS News,  “CBS This Morning,” July 31, 2013
  • “Outpatient Back Pain Treatments: Not What The Doctor Should Order,” By Jaime Toro, MD, The New England Journal Of Medicine, August 20, 2013
  • “The Back Pain Most Surgeons Won't Find,” By Dr. Nick Shamie, CNN.Com, September 18, 2013
  • “Spinal Fusions Serve As Case Study For Debate Over When Certain Surgeries Are Necessary,” By Peter Whoriskey And Dan Keating, The Washington Post, October 27, 2013
  • “The Price Of Relief,” By Massimo Clabresi, Time Magazine, June 15, 2015
  • “High Volume, Big Dollars, Rising Tension” By Mike Baker And Justin Mayo, Seattle Times Staff Reporters, February 10, 2017.[26]
  • “Doctors Finally Admit Drugs Can’t Fix Most Cases Of Back Pain: The American College Of Physicians Now Recommends Heat Therapy And Yoga Ahead Of Pain Meds For Low Back Pain” By Julia Belluz, VOX, Feb 14, 2017.
  •  “No Drugs For Back Pain, New Guidelines Say: The American College Of Physicians Says To Use Natural And Alternative Therapies First,” By Sumathi Reddy, The Wall Street Journal, Feb. 13, 2017.[27]
  •  “Doctors Have Been Treating Lower Back Pain All Wrong: New Guidelines Champion Alternative Treatments Over Drugs” By Sarah Digiulio, The Huffington Post, Feb. 17, 2017. [28]

Bad Discs Debunked

Certainly many spine surgeries are essential—the “red flags” of cancer, fracture, infections, cauda equina or those non-responsive to lengthy conservative care—which amount to 10-15% of all cases that can be given a pathoanatomical diagnosis.[29]

However, reporters and the public do not understand the reason why disc fusion surgery often fails. Since the “bad disc” diagnosis is the basis of most fusions and remains an urban lore the public has bought, why most fusions fail is an important issue to emphasize.

This revelation alone should reveal to the NPC audience why most spine fusions are medically unnecessary—the disc may not be the cause of the problem. Technically, this is the pathoanatomic vs. pathophysiologic argument—bad anatomy versus bad function in the spine—an issue over the top of most reporters, but not for informed spine researchers such as spine researcher Chien-Jen Hsu, MD, who admitted in the Journal of Neurosurgery:

"By far the number one reason back surgeries are not effective and some patients experience continued pain after surgery is because the disc lesion that was operated on is not, in fact, the cause of the patient's pain."[30]

Hopefully the future will show disc fusions are the biggest scam in modern medicine but, in the meantime, the present problem remains with millions of people who are misdiagnosed and mistreated daily by “pain management” physicians and spine surgeons.

The MRI research debunking “bad discs” began in 1990 with Scott Boden, MD, and Sam W. Wiesel, MD, chair and professor, Department of Orthopaedic Surgery at Georgetown University.[31]

Dr. Boden summarized their findings:

“It should be emphasized that back pain is not necessarily correlated or associated with morphologic or biomechanical changes in the disc. The vast majority of people with back pain aren't candidates for disc surgery.”[32]

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.”[33]

More 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:[34]

“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.”

The issue of low back pain patients misdiagnosed with bad discs and overtreated with disc fusions remains a huge financial burden. Its treatment ranks among the highest of all conditions at nearly $100 billion annually for medical treatment and $300 billion for total costs (lost wages/production, disability compensation).[35]

Steven Brill, author of America’s Bitter Pill, noted the relative cost of spine care compared to our nation’s police forces:

“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.”[36]

Professional Cooperation

In 2003, Dr. Scott Boden, director of the Emory Spine Center, recommended: “The best thing is to have an organized, integrated approach that uses state-of-the-art and cost-effective care,” and at the top of this list stands chiropractic care.[37]

His assessment is not new, just ignored, as have other important studies and guidelines.

As far back as 1987, a study in Spine by NM Hadler, MD, et al. found those who were hurting for two to four weeks experienced a 50 percent reduction in score more rapidly with spinal manipulation. They concluded “the ability to abrogate an episode of backache, even by a few days, has major ramifications.”[38]

In 1994 the U.S. Public Health Service’s Agency for Health Care Policy & Research (AHCPR) Quick Reference Guide for Clinicians guideline specifically mentioned, “Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulation.”[39] 

In 2010 the North American Spine Society (NASS) also suggested spine fusion should be a last resort and recommended spinal manipulation—5 to 10 sessions over 2 to 4 weeks—should be considered before surgery.[40]

In 2012 the NASS also found “patients with lumbar radiculopathy due to lumbar disc herniation, 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.”[41]

Hopefully the 2017 ACP guidelines on nondrug treatments for back pain will not also be added to this list of forgotten guidelines. This message must be made at the NPC meeting.

Say Yes to Chiropractic

This National Press Conference offers an excellent opportunity to reveal the paradigm shift in spine care—the downside of medical spine care as well as showcase the upside of chiropractic profession as the leading nondrug profession that deals specifically with the chronic pain pandemic and spine-related musculoskeletal disorders.

The research tide has finally turned. The National Pain Strategy along with the AHCPR, CDC, and American College of Physicians guidelines as well as the Joint Commission’s policy revision to include chiropractic care may be the chiropractic profession’s foot in the door opened by the same medical establishment that kept it closed for decades.

While this would have been viewed as hyperbole in yesteryear before the research began in the early 1990s, today we are on safe ground; in fact, we are on high ground.

The goal of the presenters at the NPC should be to challenge the press corps about the imperative to bring this paradigm shift to the public—our long awaited tipping point. For the sake of “public safety,” this turn-around is fair play after decades of medical “fake news” suggesting chiropractic is dangerous and an unscientific cult.

Now this shoe is on the other foot, finally.

It’s past time to put the medical profession on its heels as Dr. Gordon Waddell DSc, MD, FRCS, author of The Back Pain Revolution, wrote over 28 years ago in 1989:

“Low back pain has been a 20th century health care disaster. Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem...It [back surgery] has been accused of leaving more tragic human wreckage in its wake than any other operation in history. [42]

Now the research is clear why medical spine care—opioid painkillers, ESI, MRIs and spine fusion—were aptly deemed a “national disaster” that has now led to this medical travesty.

If the chiropractic professionals speaking at the NPC session can impress this information upon the national media, this will be a huge event in the tipping point we’ve long waited for. The supportive research is clear, the ACP guidelines serendipitously occurred, and the nation is in a terrible need for our nondrug services.

Perhaps for the first time, the stars are aligned to help us achieve our goal to become America’s primary spine care providers.



[1] Da Hee Han, PharmD, “Survey Finds Most Doctors Prescribe Opioids for Longer Than CDC Advises,” MPR Daily Dose, March 28, 2016

[9] http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice

[10] 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; 119:907-31

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

[12] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3642757/

[13] Eichenwald, Kurt (16 April 2015). "Killer Pharmacy: Inside a Medical Mass Murder Case". Newsweek. Retrieved 21 September 2015.

[14] Major Review Finds Scant Evidence to Support Spinal Injections as Treatments for Back and Leg Pain, BackLetter: June 2015 - Volume 30 - Issue 6 - p 64–65

[15] Private communication with Mark Schoene, 5/20/2015.

[16] Pain Medicine Physician Salary, http://mdsalaries.com/2012/09/17/pain-medicine-physician-salary/

[17] 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

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

[19] 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.

[20] Gibson JNA and Waddell G, Surgical interventions for lumbar disc prolapse, Cochrane Library,

John Wiley & Sons, Ltd., 2007;(1):CD001350. Gibson JNA et al., Surgery

[21] 8 Statistics on Spine, Orthopedic Surgeon Salary, www.beckersspine.com/spine/item/20121-8-statistics-on-spine-orthopedic-surgeon-salary

[22] http://www.dmagazine.com/frontburner/2017/02/ex-neurosurgeon-christopher-duntsch-sentenced-to-life/

[23] http://healthcare.dmagazine.com/2014/02/13/lawsuit-baylor-plano-allowed-mentally-ill-alcoholic-doctor-to-operate/

[24] https://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/2016%20Merritt%20Hawkins%20-%20Inpatient-Outpatient%20Revenue-%20Press%20Release.pdf

[25] https://projects.seattletimes.com/2017/quantity-of-care/hospital/

[26] https://projects.seattletimes.com/2017/quantity-of-care/hospital/

[27] https://www.wsj.com/articles/no-drugs-for-back-pain-new-guidelines-say-1487024168

[28] http://www.huffingtonpost.com/entry/lower-back-pain-treatment_us_58a5e282e4b037d17d25b4ab

[29] RA Deyo, Conservative Therapy for Low Back Pain: Distinguishing Useful From Useless Therapy,” Journal of American Medical Association 250 (1983):1057-62.

[30] Hsu CJ, et al. Clinical follow up after instrumentation-augmented lumbar spinal surgery in patients with unsatisfactory outcomes. J Neurosurg: Spine, October 2006;5(4):281-286.

[31] 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.

[32] Boden, S et al. (2003) Emerging techniques for treatment of degenerative lumbar disc disease, Spine 28:524-525.

[33]  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.

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

[35] Luo X, Pietrobon R, Sun SX, et al. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine 2004; 29:79–86

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

[37] Boden, S et al. (2003) Emerging techniques for treatment of degenerative lumbar disc disease, Spine 28:524-525.

[38] NM Hadler, P Curtis, DB Gillings, S Stinnet, “A Benefit of Spinal Manipulation as Adjunctive Therapy for Acute Low-Back Pain: A Stratified Controlled Trial,” Spine  12/ 7 (1987): 705.

[39] The U.S. Department of Health and Human Services, AHCPR Clinical Practice Guideline, Number 14, Acute Low Back Problems in Adults, http://d4c2.com/d4c2-000038.htm

[40] MD Freeman and JM Mayer “NASS Contemporary Concepts in Spine Care: Spinal Manipulation Therapy For Acute Low Back Pain,” The Spine Journal 10/10 (October 2010):918-940

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

[42] G Waddell and OB Allan, “A Historical Perspective On Low Back Pain And Disability, “Acta Orthop Scand 60 (suppl 234), (1989) 

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