Articles by JCS

Disc Debate

                                                                                                         

                                                             Disc Debate

While the rash of unnecessary disc fusions continues, seemingly unabated whatever the guidelines, research, or experts have to say, the buzz on the street grows louder despite the media silence. Whenever I consult with new patients, invariably they mention coming to my office because many of their friends or family members have suffered from failed back surgery; in many cases, more than one failure because they are told, “the first one didn’t take.”

Considering back pain is widespread, the leading cause of disability, and spine disc fusions are huge in both cost and quantity while riddled by poor outcomes, one might assume in this era of healthcare reform the press would be interested in stories about lowering costs and improving outcomes, especially with back surgery, the largest expenditure in healthcare today.[1]

Since no one in the mainstream media spoke of the Mayo Clinic review debunking the ‘bad disc’ theory, I wrote an op-ed piece to bring to light this important research via my local newspaper, the Macon Telegraph.

Too much unnecessary back treatments due to ‘bad discs’

Special to The Telegraph, February 13, 2015  

Golfing great Tiger Woods withdrew from another tournament still suffering with his bad back despite having spine surgery last year. Hundreds of thousands have back surgery for ‘bad discs’ and like Tiger, many are never the same, which poses the question: if ‘bad discs’ are the cause of pain, why do many still hurt after disc surgery?

 Conversely, research at the Mayo Clinic recently found there are people with ‘bad discs’ who have no pain at all, a concept that began 25 years ago with MRI research by Scott Boden, MD, Director of the Spine Center at Emory University.[2] He found ‘bad discs’ in pain-free people confirming early suspicions that herniated, bulging, or degenerated discs were “coincidental” and not the holy grail of back pain causation.[3]

 Since nearly $100 billion is spent annually on treatments for bad backs, healthcare reformists are looking closely at this huge expense to reduce costs and improve outcomes. For example, spinal fusion begins around $75,000 and can range closer to $100,000 with the extra costs of the operating room time, anesthesia bill, specialist fees, and especially if there is instrumentation involved that may cost half as much as the surgery itself.[4]

 At the Mayo Clinic Waleed Brinjikji, MD, and his colleagues performed a systematic review of all studies that reported on the prevalence of lumbar degenerative findings on MRI scans among individuals with no history of low back pain. The researchers found 33 studies of 3110 individuals published through April of 2014 and found the vast prevalence of ‘bad discs’ in pain-free people and no more significant than “gray hair or crow's feet around their eyes.”[5]

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

 Obviously debunking the ‘bad disc’ diagnosis is huge, but a revelation that remains unknown to the public. For example, medical reporter Dr. Sanjay Gupta at CNN is also a neurosurgeon at Emory alongside Dr. Boden who has never told his viewers that the ‘bad disc’ diagnosis is dead, perhaps illustrating his conflict of interest as a reporter who will never blow the whistle on his fellow spine surgeons who continue to sell ‘bad discs’ fusions to unsuspecting patients.

 The best advice for anyone diagnosed with a ‘bad disc’ is to follow the evidence-based guidelines that call for conservative (non-drug, non-surgical) chiropractic spinal manipulation first. This includes nearly 90% of cases where spinal mechanics, principally joint dysfunction, is the main cause of back pain.

 According to the guidelines, the only people who need spine surgery are those who suffer from cancer, fractures, serious infection like TB or staph, cauda equina, or the one in 100 disc case that doesn’t respond to chiropractic care.[6]

 So, the next time you hear someone way, “I have a slipped disc and need surgery,” tell them the truth that ‘you don’t slip discs, but you can slip joints,’ and encourage them to seek chiropractic care before drugs, shots, or surgery as the guidelines recommend.

 JC Smith, MA, DC, is a Warner Robins chiropractor.

Medical Push-Back

Throughout the years I have had many op-ed pieces in the Macon newspaper, short articles in magazines, television infomercials, and letters to organizations, but rarely does anyone respond. ‘Don’t confuse us with the facts,’ seems to be the attitude of the medical industrial complex, completely content with their questionable treatments making billions of dollars while leaving a wake of disability behind.

Realistically, I understand that the medical giants couldn’t care less about anything a lone-wolf chiropractor from the peach and pecan country of middle Georgia has to say. Certainly there is no wish on the part of spine surgeons and pill mill doctors to change the present drugs-shots-surgery based spine care system.

Indeed, how many doctors will give up their huge salaries because research doesn’t support what they do and the public will never know otherwise? As one observer put it: “This is a field where there is too much money and too few ethics.”[7]

However, my op-ed piece apparently riled a local Macon orthopedist, Wayne Kelley, Jr, who responded with an essay that clearly revealed his typical medical chauvinism and avoidance of the research.

Leave back problems to the most trained professionals

Special to The Telegraph, March 1, 2015  

The recent article by J.C. Smith, (Too much unnecessary back treatment due to “bad discs”) on Feb. 13 seems more like an advertisement than public awareness article on spinal conditions. The article starts out stating, erroneously, that “Tiger Woods withdrew from the recent tournament suffering from his bad back despite having spine surgery.” Woods actually stated his back surgery was not the reason he withdrew from the tournament and that his back is feeling better every day.

Patients rely on good, honest advice from health care providers. The medical community relies on evidence-based medicine versus anecdotal treatments to provide the best treatment options for patients. Be careful about treatments recommended only through patient testimonials. This means we need good research data supporting our decisions on the best treatment options for our patients.

The highest quality of evidence-based medicine is generated by randomized, prospective multicenter trials. The sports trial that analyzed lumbar radiculopathy, lumbar spinal stenosis and degenerative spondylolisthesis is one of these trials that was conducted over two years with grant money totaling $15 million. The study includes patients who have been followed for eight years now with published results on the findings.

It has been demonstrated that patients with lumbar radiculopathy, lumbar spinal stenosis and degenerative spondylolisthesis have superior outcomes compared to non-operative treatments, and these results are maintained currently up to eight years. It also found that patients returned to work quicker after lumbar microdisectomy compared with non-operative treatments. Evidence also supports most of these conditions improve without treatment within six weeks.

The choice of a particular treatment should be based on evidence in the medical literature that supports its safety and efficacy.

As a medical doctor that specializes in orthopaedic spine care, I feel we have the most knowledge on how to take care of all spinal conditions, both operative and non-operative. Many of my patients with these spinal conditions never see the operating room and are treated non-operatively with great results. Taking care of spinal conditions takes a multi-modal approach with many different techniques to provide individualized care for each patients diagnosis. Not all conditions can be treated with one approach.

While spinal manipulation is one modality used to treat spinal conditions, there are no such guidelines as stated by J.C. Smith “that only patients with cancer, fractures, serious infections, cauda equina, or the one of 100 disc cases that don’t respond to chiropractic care should seek the care of a spine surgeon.”

Orthopaedic spine surgeons have more knowledge of spinal anatomy, physiology and biomechanics than any other health care specialist.

So whether you are experiencing back pain, lumbar radiculopathy, spinal stenosis or any other spinal condition, start with the physician that has the most knowledge for these conditions first.

Five key questions to ask your physician prior to treatment:

• What is my diagnosis?

• What else can this be?

• What will happen if I don’t do anything?

• What are my treatment options?

• What evidence is there in the medical literature that this treatment is safe and effective for my condition?

Dr. Wayne Kelley Jr. is an orthopaedic spine surgeon practicing in Macon.

My Response

I was struck by Dr. Kelley’s snarky reply mainly due to his chauvinistic attitude:

  • “As a medical doctor that specializes in orthopaedic spine care, I feel we have the most knowledge on how to take care of all spinal conditions, both operative and non-operative,” and
  • “Orthopaedic spine surgeons have more knowledge of spinal anatomy, physiology and biomechanics than any other health care specialist.”

While his self-aggrandizement is certainly annoying but not unexpected, he totally ignored the new Mayo Clinic review critical of the ‘bad disc’ theory and the unnecessary need for spine fusions. He also ignored the plethora of research showing the poor outcomes of fusion surgery. His apples vs. oranges argument instead touted his “superior outcomes” with degenerative spondylolisthesis and stenosis during his infomercial that, in fact, are misleading according to the latest research.

Of course, I couldn’t let his remarks go without comment, so I wrote a response to him that has not been published to date in the newspaper. My response is limited to approximately 500 words, which is hard for someone as long-winded as I am to ‘write short’, so I had to omit a few comments that were appropriate, such as an Associated Press article on March 14, 2015, “Woods won’t play at Bay Hill” due to on-going “tightness in his lower back,” that contradicts Dr. Kelley’s claim, “Woods actually stated his back surgery was not the reason he withdrew from the tournament and that his back is feeling better every day.” Any sports fan knows that is untrue and just one of many half-truths in his response.

Response to Dr. Wayne Kelley

Let me respond to Wayne Kelley’s essay, “Leave back problems to the most trained professionals,” in response to my initial article, “Too much unnecessary back treatments due to ‘bad discs’.”

Dr. Kelley missed the point that I highlighted concerning the systematic review of 33 studies of 3,110 individuals by Dr.  Brinijikji from the Mayo Clinic[8] that reported ‘bad discs’ in pain-free people were part of the normal aging process, no more significant than gray hair, and certainly not an indication for disc fusion surgery.

Instead, Dr. Kelley speaks of conditions such as stenosis and spondylolisthesis not addressed in the Mayo Clinic’s study or my letter. He also omits new research that does not support his optimistic position concerning surgery for spondylolisthesis or stenosis.

A recent study in Spine confirmed poor outcomes for disc fusion surgery: only 36.4% of the spondylolisthesis group and a mere 24.4% of degenerative disc disease group returned to work within two years, many still taking opioid painkillers.[9]

Dr. Kelley suggests surgery for stenosis had superior results, however, the latest SPORT study did not support his assumption in its conclusion that “Patients with symptomatic spinal stenosis show diminishing benefits of surgery…between 4 and 8 years…”[10] For most people stenosis seems to be a condition that demands good coping skills, but rarely a ‘treat and cure’ condition.

I agree with Dr. Kelley, “This means we need good research data supporting our decisions on the best treatment options for our patients.”

Inexplicably Dr. Kelley ignores a study concerning non-surgical management of lumbar spinal stenosis that found distraction manipulation and neural mobilization done by chiropractors was extremely beneficial with patient-rated percentage improvement in pain at 75.6% and the clinically meaningful improvement in disability for 73.2% of patients.[11]

Dr. Kelley recommends patients to see an orthopedist first. “I feel we have the most knowledge on how to take care of all spinal conditions, both operative and non-operative.”

The guidelines agree on the need for ‘best practices’, but not with his conclusion to use orthopedists first.

For example, a 2012 analysis of 1.4 million back pain patients determined, “When a patient consults a chiropractor first, spine care is characterized by low rates of imaging, Rx, injections, and surgery…more favorable solutions at more reasonable costs. [12]

A Washington State workers’ comp study found injured workers who first saw a surgeon, 42.7% had surgery; in contrast, only 1.5% of those who saw a chiropractor eventually had surgery.[13]

Another study found back surgery rates increase with the number of surgeons. A study found back surgery per capita in the United States was more than five-times that in England and Scotland.[14]

I certainly agree with Dr. Kelley when he recommends patients should ask, “What are my treatment options?”

Unfortunately, evidence suggests patients are not provided with alternatives considering only 2% of MDs refer to chiropractors.[15] Indeed, the medical boycott is still very pervasive despite the research recommending chiropractic care, which may explain why back pain is the leading disability and most costly healthcare expenditure in our country.

JC Smith, MA, DC

Warner Robins, GA

 

Clearly Dr. Kelley completely ignored the thrust of my article about the Mayo Clinic review debunking the ‘bad disc’ concept; he never referred to it once. Certainly it’s easier to criticize a chiropractor than the Mayo Clinic.

More importantly, he forgot to mention the latest research on spine fusions showing the pitiful success rates when only 36% and 24% for spondylolisthesis and DDD cases returned to work after two years.[16]  

Instead, he speaks from atop his medical pedestal assuming all will believe his sanctimonious sales pitch by denigrating me, ignoring the Mayo review altogether, and telling people to “start with the physician that has the most knowledge for these conditions first.”

I would suggest patients should start with the most effective conservative care (non-drug, non-surgical) treatments as the guidelines suggest, not what the most braggadocio doctor pitching surgeries has to say.

 



[1] Thomas M. Kosloff, DC, David Elton, DC, Stephanie A. Shulman, DVM, MPH, Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Amanda Solis, MS, Conservative Spine Care: Opportunities to Improve the Quality and Value of Care, Popul Health Manag. Dec 1, 2013; 16(6): 390–396.

[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] The Cost of Spinal Fusion Surgery, 02 December 2010, http://www.spinalfusioninfo.com/the-cost-of-spinal-fusion-surgery/

[5] Brinjikji W, et al., Systematic literature review of imaging features of spinal degeneration in asymptomatic populations, American Journal of Neuroradiology, 2014, prepub ahead of print; www.ajnr.org/content/early/2014/11/27/ajnr.A4173.long.

[6] 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.

[7] Unsavory Publicity for U.S. Spine Surgeons, The BACKLetter, Volume 22, Number 2, 2007

[8] Brinjikji W, et al., Systematic literature review of imaging features of spinal degeneration in asymptomatic populations, American Journal of Neuroradiology, 2014, prepub ahead of print; www.ajnr.org/content/early/2014/11/27/ajnr.A4173.long

[9] 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

[10] Jon D. Lurie, MD, MS, Tor D. Tosteson, ScD, Anna Tosteson, ScD, William A. Abdu, MD, MS, Wenyan Zhao, PhD, Tamara S. Morgan, MA, James N. Weinstein, DO, MS, Long-term Outcomes of Lumbar Spinal Stenosis, Eight-Year Results of the Spine Patient Outcomes Research Trial (SPORT), Spine. 2015; 40(2):63-76.

[11] Murphy DR, Hurwitz EL, Gregory AA, Clary R. A non-surgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study, BMC Musculoskelet Disord. 2006 Feb 23;7:16.

[12] Thomas M. Kosloff, DC, David Elton, DC, Stephanie A. Shulman, DVM, MPH, Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Amanda Solis, MS, Conservative Spine Care: Opportunities to Improve the Quality and Value of Care, Popul Health Manag. Dec 1, 2013; 16(6): 390–396.

[13] Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM.,

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State.,Spine (Phila Pa 1976). 2012 Dec 12. 

[14] DC Cherkin, RA Deyo, et al. An International Comparison Of Back Surgery Rates,” Spine, 19/11 (June 1994):1201-1206.

[15] Matzkin E, Smith MD, Freccero DC, Richardson AB, Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am 2005, 87-A:310-314

[16] 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



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