Articles by JCS

Fundamental Flaws

Fundamental Flaws

By

JCS

“False Positive” Imaging           

Undoubtedly the foremost reason why there’s too many surgeries is due to the failed disc theory that still abounds in the minds of most MDs. As you will learn, spine experts from around the world have shown the fallacy of the “slipped disc” concept that most spine surgeons literally bank on to convince patients to the need for surgery. But just as the germ theory proved to be wrong for degenerative diseases, now researchers believe the disc theory is also dead as an explanation for most, not all, back pain.

There’s been a tendency to let imaging trump clinical presentation in acute LBP cases. EBM now questions whether or not scans are necessary in light of the cost and ubiquitous nature of disc abnormalities.  “It should be emphasized that back pain is not necessarily correlated or associated with morphologic or biomechanical changes in the disc,” according to Dr. Scott Boden. “The vast majority of people with back pain aren't candidates for disc surgery.”[1]

Agreeing with Dr. Boden is another leading spine researcher, Richard Deyo, MD, MPH, published an article in the Scientific American titled “Low-Back Pain,”[2] in which he continues to criticize “Old concepts supported only by weak evidence,” and the reliance on MRI exams to infer disc abnormalities as the cause of back pain is now regarded as clearly misguided advice.

In The New England Journal of Medicine, he again debunks the disc theory that often leads to a “false positive” misdiagnosis:

“Early or frequent use of these tests [CT and MRI] is discouraged, however, because disc and other abnormalities are common among asymptomatic adults. Degenerated, bulging, and herniated disks are frequently incidental findings, even among patients with low back pain, and may be misleading. Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”[3]

Dr. Deyo concludes that 97% of back pain is “mechanical” in nature, and disc abnormalities account for only 1% of back problems.

These are the fundamental alaws in this war on back pain and the medical profession is unwilling to admit, for the most part that their paradigm has been wrong and those damn chiropractors may have been right all along. There’s just too much money and pride at stake to let the evidence cloud their actions.

“Again, the problem of back pain offers good examples. Experts have concluded that perhaps 85% of patients with back pain can’t be given a definitive diagnosis, despite the best medical evaluation. In part, this is because so many structures in the spine can give rise to pain, including muscles, ligaments, bones, nerve roots, and parts of the discs between vertebrae [where’s mention of the joints?]. X-rays and MRI scans often can’t distinguish which of these is the true source of an individual’s pain.

“And we know that bulging, degenerated, and even herniated discs in the spine are common among healthy people with no symptoms. When doctors find such discs in people with back pain, the discs may be irrelevant, but they are likely to lead to more tests, patient anxiety, and perhaps even unnecessary surgery. In fact, back surgery rates are highest where MRI are the highest. In a randomized trial, we found that doing an MRI instead of a plain x-ray led to more back surgery, but didn’t improve the overall results of treatment.

“Because we see more things on these scans, certain medical problems seem to be becoming more common year after year. This is not because abnormalities re getting more common; it’s only that we’re more likely to discover them. But finding things makes doctors and patients more enthusiastic about doing the tests and seems to justify them many of these abnormalities are trivial, harmless, and irrelevant, so they’ve been dubbed ‘incidentalomas.’”

“Nonetheless, these incidentalomas get treated. It’s easy to be fooled into thinking that if the patient does fine, it’s because we found an abnormality and treated it. But with an incidentalomas, the patient was destined to get better anyway because the condition was a nondisease to begin with. However, patients are grateful for a good outcome and often attribute their success to finding the abnormality early on.”[4]

Sadly, most field MDs will use this false positive to convince patients of the need for surgery and fail to admit that the guidelines call for conservative care first. It certainly doesn’t imply that you require surgery as the surgeon’s sales pitch suggests: “Look right here at this abnormal disc that plainly means you need surgery.”

The paradox of herniated discs finally has been admitted by some spine surgeons, but certainly not all.

“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,” says Raj Rao, M.D., director of spine surgery in the Department of Orthopaedic Surgery at the Medical College of Wisconsin.[5]

  • According to WH Kirkaldy-Willis, MD and David Cassidy, DC, discs are involved in fewer than 10% of back pain cases.[6]
  • According to Nikolai Bogduk, MD, PhD, discs are involved in fewer than 5% of these cases.[7]
  • According to V. Mooney, MD, discs problems account for less than 1% of these cases.[8]
  • According to Dr. Scott Boden, orthopedist/researcher, “the disc might not be the cause of pain. And if so, fixing it is a waste.” [9]

Text Box: MRI of L5 herniation This points out the single-most prevalent cause of misdiagnosis in low back pain problems—that is, the use of costly MRI images to show disc abnormalities to convince patients that some sort of disc problem is the cause of their pain and surgery is the only solution when, in fact, as Dr. Deyo and other researchers have repeatedly shown, disc abnormalities are not the cause of most back pain, often appear in perfectly pain-free patients, and continue as the largest segment of “false positives” in the diagnosis of most back pain problems.

Concerning herniated intervertebral discs, Dr. Deyo believes,

“In the absence of the cauda equina syndrome or progressive neurologic deficit, patients with suspected disc herniation should be treated non-surgically for at least a month.”[10]

Sage advice that is mostly ignored nowadays by surgeons and other stakeholders involved in the escalating costs of back pain.

Not only does Deyo bash many medical concepts and treatments for back pain, he also mentions chiropractic as a possible 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.” [11]

Gordon Waddell also suggests chiropractic care is a solution:

“There is now considerable evidence that manipulation can be an effective method of providing symptomatic relief for some patients with acute LBP.”[12]

Dr. NM Hadler, MD, author of “The Last Well Person” and professor at the University of North Carolina School of Medicine, believes that “‘Ruptured discs’ and ‘bad back’ are terms that deserve to be relegated to the historical archives.”

Rather strong words especially considering coming from a renowned orthopedist, author, and professor at a medical school.

Unfortunately, the outdated disc theory remains very much alive. The problem with failed back surgery begins with the assumption that any disc abnormality alone is the cause of back pain and requires surgery. While some disc protrusions may be the cause of leg pain, it is not the main cause of back pain, nor does it mean you need surgery.

Dr. NM Hadler, MD, is also very critical of the use of MRI and the disc theory as the sole reason for spine surgery for LBP.

“Whatever we see on the MRI is likely to have been present when the person heals. The discal hypothesis—the idea promulgated seventy years ago that the ‘ruptured disc’ is the culprit—has not withstood scientific scrutiny well. It is largely untenable for axial pain, and marginal for radicular pain.”

Not only are MRI and x-ray scans expensive, unnecessary, and looking for the wrong causes of back pain, accurately diagnoses disc prolapse and annular tears in less than 40% of cases according to researchers.

“Histological features (e.g., tears, rim lesions, prolapse of nucleus material) were poorly recognized by MRI, which had a sensitivity for disc material prolapse and annulus tears of less than 40%. Our study showed that discs from patients over 50 years are histologically severely degenerated; however, these changes may not be detected by conventional radiography and MRI.”[13]

It’s relatively well known that disc abnormalities found on MRIs are incidental to LBP, and now another study found no evidence of a relationship between facet joint degeneration and low back symptoms which fuels the epidural steroid injections so commonly used by anesthetists who want to get into the back pain business.

Despite overwhelming scientific evidence to the contrary, it has been a fairly common practice for some MDs to blame radiographic findings (x-ray, MRI, CT scans) of multilevel degenerative changes in the spine (spinal joint arthritis) as the cause of low back pain.

In a 2008 study published in Spine, no relationship between degenerative changes in the spinal joints and low back pain was found in 3529 participants. “In the present study, we failed to find an association between facet joint arthritis (OA), identified by multi-detector CT, at any spinal level and low back pain in a community-based study population,” said Leonard Kalichman, PhD, and colleagues.

Blaming radiographic facet joint arthritis as a cause of low back pain has been a fairly common clinical practice off-and-on since the early 20th century. However, no form of imaging has proved to be capable of identifying painful facets. And it remains a matter of bitter controversy whether other diagnostic methods, particularly facet joint blocks, can identify painful syndromes related to these lumbar joints.[14]

New research now shows that even diagnostic tests for herniated discs lead to future problems.[15] Results of a 10-year study suggest that discography can result in accelerated disc degeneration and herniation.

Discs that had been exposed to discography demonstrated signs of greater degeneration and a greater loss of disc height 10 years later than discs that were not exposed to the procedure, said Eugene A. Carragee, MD, of Stanford University.

Discography is currently used to determine whether the disk is the source of pain in patients with predominantly axial back or neck pain.

During discography, contrast medium is injected into the disk and the patient's response to the injection is noted; provocation of pain that is similar to the patient's existing back or neck pain suggests that the disk might the source of the pain. Computed tomography (CT) is usually performed after discography to assess anatomical changes in the disk and to demonstrate intradiscal clefts and radial tears.

Other known complications associated with discography include spinal headache, meningitis, discitis, intrathecal hemorrhage, arachnoiditis, severe reaction to accidental intradural injection, damage to the disk, urticaria, retroperitoneal hemorrhage, nausea (2%), seizures (4%), headache (10%), and increased pain (81%). In rare cases, discography has been found to result in disk herniations. New-onset or a persistent exacerbation of radicular symptoms following provocative discography merits further investigation.[16]

“Disc puncture, even with modern discographic techniques, causes definitive structural injury to IV discs,” he said.

The findings confirm the results of earlier animal and organ culture studies, Carragee noted. As such, orthopedic spine surgeons need to carefully consider the risk and benefit of disc puncture for diagnostic or therapeutic interventions.

I seriously doubt spine surgeons will stop doing discographies or surgery since back surgery is very lucrative with the average cost approaching $50,000, there are nearly 500,000 back surgery cases as rates increase almost linearly with the per capita supply of orthopedic and neurosurgeons in the country, with increased risk of complications, higher medical costs and no difference in quality of life at 2 years after surgery.[17]

Admitting the erroneous nature of the disc theory and the failure of drugs, MRIs, discography, shots, and surgery, Dr. Hadler concluded, “Maybe you're better off not going to a doctor.'' Again, very strong words from a medical professor, but not unfounded by today’s science.

Obviously, instead of relying upon your family doctor, you definitely should find a good chiropractor who is better trained, more skilled, and treating the primary cause of back pain—spinal joint dysfunction—and chiropractic care is much quicker, safer, more effective, and less costly.

Perhaps conflicted between his bias against chiropractors and the research that debunks the disc theory and the poor rates of surgery, Dr. Hadler asks the perplexing question that many MDs must ultimately face:

“I am a rheumatologist, a mainstream physician with an MD, schooled in and committed to the care of patients with musculo-skeletal disorders.

“Do I have to learn manual medicine?

“Should I seek such a salve [chiropractic care] for my own next predicament of a regional musculo-skeletal disorder?

“Should I refer my patients to such practitioners?”

Of course, my answers to his questions are “No,” “Yes” and “Yes.”

The Fundamental Flaws

However, it’s tough for any treatment to emerge in the supermarket of treatments available today due to tradition and bias. For medical treatments that ultimately proved to be valuable, there is a time lag of 17 years between discovery and scientific validation. Scientists refer to the time lag as the “valley of death,” according to an article in Newsweek.[18]

I might add, for chiropractic spinal care, the valley of death and lag time has been over 110 years! Indeed, it’s a sordid story that affects the vast majority of Americans who suffer with the silent epidemic of back pain. If the electronic industry were like the medical profession, it’d still be in the vacuum tube era.

Imagine the impact of this information upon the impending healthcare reform effort if the legislators knew that chiropractic care could eliminate upwards of 90-95% of all back surgeries. The financial savings, the decrease in disability costs and human suffering would do wonders to improve the epidemic of back pain, productivity of the work force, and the general health of our entire society.

Compounding this dilemma, these acute pain patients seek help from some MDs who I doubt give an honest appraisal of non-operative care, particularly toward chiropractic care. Indeed, if these relatively lower-educated patients were scared by surgeons, it’s understandable that more of them would choose surgery over those highly educated patients who possible knew the real risks of surgery versus non-operative care.

Indeed, in most cases patients have been misled about the cause of their back pain, had unnecessary MRIs to detect incidentalomas, treated with unproven or ineffective treatments, misled about the likelihood of success from surgery and reoperations, and the most glaring omission concerns one alternative treatment in particular—chiropractic spinal manipulation.

Why? Foremost is the institutionalized medical bias—the Fundamental Flaw toward anything to do with chiropractors is the biggest reason why spinal manipulative therapy (SMT) has been ignored despite the abundance of evidence showing the clinical and cost-effectiveness of SMT. Again, it’s simply a matter of ideology over science; prejudice over data.

This medical bias is deeply rooted in most physicians and nurses, a medical catechism taught from day one in medical school. Sadly, this prejudice has not only hurt chiropractors but the millions of patients who suffer from back/neck pain and other musculo-skeletal disorders (MSDs) such as extremity joint problems, temporomandibular joint pain (TMJ) and carpal-tunnel syndrome (CTS)—many of which can be helped by simple manipulation.

Despite the growing realization that the medical approach to back pain treatments—drugs, shots, and surgery—have not withstood the scrutiny of international researchers, the public remains confused by the persistent inability of the medical profession to admit its limitations in this area or admit to its historical prejudice against chiropractors, the most appropriate practitioners for 97% of these cases.

Indeed, the seeds of this dispute were sown decades ago on mistrust and deceit. Instead of admitting back surgeries aren’t necessary in most cases and those pesky chiropractors may be right all along, many MDs continue to lie to their own patients and ridicule them when they ask about chiropractic care.

The call for reform now is not only for scientific evidence, but for professional integrity. Spine doctors cannot ignore the many research findings that call for an end to the tsunami of spine surgeries, nor can they ignore the call for reform. But both have happened due to the lack of integrity to do the right thing. Instead, many spine surgeons still use demagoguery to misinform and scare the public into unnecessary spine surgery.

“If you’re stupid enough go to a chiropractor, don’t come crawling back to me after you’re paralyzed,” is the voodoo diagnosis I’ve heard often enough to realize the deceitfulness and intellectual dishonesty of misguided MDs and surgeons. Years ago I had a new patient who worked as an RN in the local hospital operating room assisting spine surgeons. She came to me with her low back pain and was scared to death initially since she’d heard the same voodoo from her doctors.

Her case was easy—a simple sacroiliac problems that cleared up quickly. After she attended my Health Class to learn the madness behind my method, she became an ardent patient who referred patients often to my office.

One day I asked her about the voodoo diagnosis—why doctors scare people about being hurt by chiropractic care. Her response was classic when she responded, “We’re told to tell that to anyone who asks about chiropractors,” she said rather ashamedly. “I don’t know why patients believe me since I’ve never known anyone who’s been hurt by a chiropractor, but I know plenty of people who’ve been hurt by surgery.”

 Whether patients are subjected to unnecessary drugs, shots or surgeries, or lied to about chiropractic care by unscrupulous MDs, the present situation on spine care in America is not only ineffective, expensive, and risky, it’s blatantly appalling.

Text Box: Paul Goodley, MD Paul Goodley, MD and author of Release from Pain and a leading orthopedic physician and champion of manual medicine/spinal manipulation among the medical profession, has also experienced the bias that has deterred the integration of manual medicine into the mainstream, an attitude he’s termed the Fundamental Flaw—the bias of medicine toward manipulative therapy and specifically, those despised chiropractors:

“Eventually, while the schism's origin was lost like dark legend, the prejudice against manipulation self-perpetuated, and evidence was always available to justify this attitude. There have always been [chiropractic] charlatans. So, instead of the manipulative fundamental dynamically developing as a cohesive, trustworthy guide within traditional medicine, it was discredited as the synonymous derelict symbol of its most despised competitor - chiropractic.

 

Admittedly, Dr. Goodley is right in that there has always been a small percentage of unethical chiropractors who can be viewed as charlatans—those DCs who overstep the research with outrageous claims of cure, those who commit fraud and those who are very unprofessional in their practices. I’ll be the first to admit the chiropractic profession has had its share of shady characters, but they are dwindling in numbers as the licensing boards become stronger and the chiropractic colleges matriculate better students. Indeed, sometimes the chiropractors have shot themselves in the foot by their own desperate actions, only adding fuel to the fire of medical bias begun decades ago by Morris Fishbein.

Dr. Goodley laments of the damage this medical bias has done to suffering patients. Many spine experts like Dr. Richard Deyo admit the inability of MDs to accurately diagnose and treat the cause of back pain, but they fail to admit their own medical bias against manipulative therapy is also a big reason for their dismal results.

“Up to 85% of patients cannot be given a definitive diagnosis because of weak associations among symptoms, pathological changes, and imaging results. We assume that many of these cases are related to musculo-ligamentous injury or degenerative changes.” [19]

Dr. Goodley answers Dr. Deyo’s admission with his belief that the Fundamental Flaw against manipulative therapy is a large reason for this pandemic of pain.

“I accuse that a big slice of the 85% ignorance is accountable to the                  rejection of the thinking involved in manipulative approaches. The conflict remains so near unimaginable that future historians may well describe the past century as a time of unnecessarily perpetuated pain.”

 

He recalled an incident that illustrated the wrath of the Fundamental Flaw back during the height of the medical holocaust against chiropractors:

“In 1972, I was visiting Rancho Los Amigos Hospital when Verne Nickels was chief of ortho and antagonistic to anything not. He had a glorious time revisiting the Symes amputation to prove its value after a century of being neglected. When I asked him why he wasn't expressing the same curiosity to rethink manipulation, he flared, ‘Because those who know the back cold say it doesn't work, SO IT DOESN'T!!!!!!!!!!!!!!!!  I gave him a few seconds to recover from his apoplexy and asked him who knew the back that cold? If looks could kill.”

I admire Dr. Goodley’s strong backbone to admit his orthopedic profession has turned a blind eye toward manipulative therapy as an answer to this back pain epidemic. The boycott of chiropractic care, for whatever reason, has led to denying one of the best methods to control this pandemic of pain to the suffering.

Consider the enormity of this pandemic of pain caused by the medical boycott of chiropractors and spinal manipulative therapy. Let me reiterate the  report by the BJD experts that the daily prevalence of LBP in the general adult population is estimated at 37%, the 1-year prevalence is 76%, and the lifetime prevalence is 85%; approximately 20% of sufferers describe their pain as severe or disabling.[20]

I daresay 90% of these cases could be helped to some degree by chiropractors, but the medical society and its Fundamental Flaw that discriminates against manipulative therapy would prefer patients suffer with drugs, shots and surgeries knowing full well those methods are ineffective, risky, and expensive.

The Fundamental Flaw of MDs toward chiropractors stems not only from prejudice and economic rivalry, but from academic ignorance. While the medical model focuses on discs, the chiropractic model and justification for manipulation focuses on joints. Most people fail to know that there are 206 bones in the body, nor do they know the spine alone has 313 joints that can misalign, buckle, twist, wrench or become stiff thus causing pain as well.

What even the most astute physician doesn’t know is the number and role of joints in the spine. This is essential to the paradigm shift from the medical model of “pulled muscles” and “slipped discs” that has proven to be so terribly ineffective. Once these joints are jammed or wrenched, the nerves inside the joint capsule will cause localized pain and muscle spasm. If the disc also swells, only then will it pinch the nerve root that goes down your leg. But this sequence starts with the joints, not the disc that is secondary. A disc does nothing until forced to by the spinal mechanics.

Chiropractors aim to restore normal joint function with alignment and motion, similar to setting any joint that’s buckled, twisted, compressed or slightly dislocated; in chiropractic parlance, what we call a vertebral subluxation.

Until the joints are functioning properly, the healing process will not begin, tissues will not deflame, and the pain will not be alleviated, which explains why manipulation should be the first form of spinal treatment, long before any drugs, shots or surgery is contemplated.

Joints by Region[21]

 

Synovial

Symphysis

Syndesmosis

Total

Cervical Spine

17

6

39

62

Thoracic Spine

68

12

116

196

Lumbar Spine

10

5

29

44

Sacrum & Pelvis

2

3

6

11

Total

97

26

190

313

 

Joint dysfunction is the major source of back pain and chiropractors diagnose these joint problems and skillfully adjust them to improve joint play/motion. In fact, some MDs believe that disc problems are secondary to joint problems, which suggests adjusting misaligned joints can circumvent the need for disc surgery.

According to orthopedist JL Shaw, MD and noted lecturer:

“Joint dysfunctions are the major cause of LBP as well as the primary factor causing disc space degeneration and ultimate herniation of disc material.” [22]

Text Box: Dr. Shaw suggests that before lumbar discs herniate, the ignored sacroiliac joints become dysfunctional because there are no discs in these two joints. The SI joint is a butting, not interlocking, type of joint that does not have the discs seen in the lumbar spine, but when these SI joints twist out of alignment, patients experience severe pain in their buttocks. This initial misalignment may cause the entire pelvis to twist out of balance and lead to disc problems elsewhere. But the main cause of the disc problems stems from the SI problem according to Shaw.

Dr. Shaw noted in his research 98% of 1000 patients had a mechanical dysfunction of the SI joints as the cause of their LBP. Treatment by restoration of full SI joint motion led to relief of symptoms in almost all cases. Most remarkable was the absence of need for surgery—only 2 patients needed surgery for protruded discs.

Despite the worldwide research, the sad fact remains chiropractors are still on the fringe of the back pain professions for no other reason than the Fundamental Flaw among biased MDs and surgeons who continue to push their drugs, shots and surgery despite the evidence to the contrary. “Don’t confuse us with the facts” remains their motto.

Secondly, and perhaps the main Fundamental Flaw is the money for spinal treatment is astronomical—$36 billion for treatments and nearly $100 billion annually for total costs—the lion’s share of the cost of back pain comes from expenses related to work loss, disability claims, early retirement, and lost productivity. [23]

Spine surgery is the second largest money maker behind heart surgeries, so there is little interest by hospitals to change tracks despite what the evidence and ethics might indicate. Again, profit and ideology triumph over evidence-based research and cost-effectiveness.

Thirdly, the outdated medical diagnosis of back pain, based primarily on disc abnormalities as the main focus, has been contraindicated by recent research, yet many medical professionals have turned a blind eye upon this latest research because it would take a lot of money out of their pockets.

Fourthly, numerous analyses of medical training for musculo-skeletal conditions have shown consistently low scores in Basic Competency Exams by medical students, recent medical graduates, non-orthopedic staff physicians, osteopathic students, and physical therapy students. Chiropractic clinicians with postgraduate training have showed considerably better results than chiropractic interns.[24] Despite these failings, primary care physicians hold themselves out to be competent diagnosticians to patients for spinal disorders when, in fact, a dentist would be just as competent, albeit just as uninformed.

Fifthly, as Dr. Deyo laments:

“I think many people have unrealistic expectations of medical care,” said Deyo. “We live in a culture that wants quick, easy fixes. Many people seem to think that they should never have pain if they’re getting good medical care.”

“These expectations didn’t rise in a vacuum,” Deyo pointed out. “The marketing of new products to patients and physicians may help create those expectations. We in the medical profession are also probably guilty of creating unrealistic expectations,” he added. [25]

These are the fundamental flaws in this war on back pain and the medical profession is unwilling to admit, for the most part that their paradigm has been wrong and those medical villains—chiropractors—may have been right all along. There’s just too much money and pride at stake to let the evidence cloud their actions.

The experts couldn’t be clearer on the overuse of back surgery, an ethos that escapes unethical MDs who are biased against chiropractors. Do you need more evidence that back surgeries are out and conservative care like chiropractic is in?

Jens Ivar Brox, MD, department of orthopaedics at National Hospital in Oslo, Norway, believes that spinal fusion should be an uncommon option for patients with chronic disabling low back pain. He admitted some of the orthopaedic surgeons in his department have recurrent back pain and disc degeneration, but these surgeons refuse to have fusion surgery or recommend fusion surgery for their family members.

Dr. Brox asks, “So the question is: why should we recommend these procedures for our patients?”[26]

That Pain in the Neck

Another recent seven-year, international study by The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders published in the journal Spine finds that some alternative therapies such as acupuncture, neck manipulation and massage are better choices for managing most common neck pain than many current practices.[27] The study also found that corticosteroid injections and surgery should only be considered if there is associated pain, weakness or numbness in the arm, fracture or serious disease.

Text Box: Cervical fusion “Neck pain is not a trivial condition for many people,” says Task Force president Dr. Scott Haldeman, clinical professor, department of neurology at the University of California, Irvine; and adjunct professor, department of epidemiology at UCLA.  “It can be associated with headaches, arm and upper back pain and depression.  Whether it arises from sports injuries, car collisions, workplace issues or stress, it can be incapacitating.  Understanding the best way to diagnose and manage this problem is of high importance for those who are suffering and for those who manage and pay for its care.”

“One thing that became very clear to us is that the classic model we use in clinical practice doesn’t work. We tend as clinicians to see a person with neck pain, try to diagnose the cause of the problem, prescribe treatment, and hope the patient has no more pain. What we found is that this model just doesn’t fit the evidence,” said Dr. Haldeman. Given the existing evidence, management models based on the effective diagnosis and treatment of neck pain are simply “doomed to failure,” Haldeman suggested. [28]

“This is an important body of research that will help to improve the quality of patient care by incorporating the best evidence into practice and patient education,” says Dr. Linda Carroll.  “Neck pain can be a stubborn problem - we hope this comprehensive analysis of the evidence will help both sufferers and health care providers better manage this widespread complaint.” [29]

The Task Force admitted that surgery has a role to play in the treatment of neck problems, but there are huge gaps in the evidence on surgery. There is some evidence that surgery can lead to substantial relief of pain and disability over the short-term in the treatment of cervical radiculopathy. But there is no compelling evidence from high-quality clinical trials that surgery is superior to nonsurgical care or that any form of surgery is clearly superior to others in the treatment of radiculopathy. And there is currently very little compelling evidence that surgery is an effective treatment for axial neck pain in the absence of radicular (arm) symptoms. [30]

Another study published in Neurosurgery found surgery did not greatly relieve two-thirds of patients with neck pain and myelopathy, which is the gradual loss of nerve function caused by disorders of the spine.[31]

 Most interesting, this study alluded to a chiropractic explanation instead when it stated that abnormal movement and malalignment were associated with cervical spondylotic myelopathy (CSM):

“Abnormal or excessive motion of the cervical spine is strongly associated with the clinical progression of CSM. Delayed progressive cervical myelopathy may result from underlying structural kyphosis and abnormal or excessive cervical motion. Hypermobility and frank instability are probably uncommon in CSM, but kyphosis is common.  The presence of spinal cord compression in association with abnormal motion or kyphosis strongly predicts clinical progression of CSM.”

The authors also concluded that “Surgical decompression resulting in expansion of the spinal canal and relief of compressive pressures does not consistently alter the natural history of cervical spine myelopathy. It is cited that follow-up of 7 years post surgery shows only 1/3 of the patients were improved.”

Back Pain Supermarket

Despite these studies, the rates of spine surgery in the US have only increased, which shows that evidence-based spine care is ignored when it conflicts with their profit motive. Not only is this evidence ignored, many surgeons continue to ridicule the researchers, just as we saw when the North American Spine Society attacked the researchers of the AHCPR guideline on acute low back pain.

Considering 90% of adults will suffer an acute low back episode that often leads to a chronic problem, the various treatments available only compound their misery. To make matters worse, often surgeons have a conflict of interest, many doctors ignore evidence-based guidelines, some physicians practice outdated methods, and many still hold a bias against what’s proven to be effective—spinal manipulative therapy.

In a recent article in The Spine Journal, acclaimed multi-dimensional spine spokesman, Scott Haldeman, DC, MD, PhD, mentions this quandary for patients and practitioners in regards to treatment for chronic LBP.

“Patients with chronic low back pain (CLBP) are finding it increasingly difficult to make sense of the growing list of treatment approaches promoted as solutions to this widespread problem...The current approach to the management of CLBP makes this goal virtually unobtainable.

“When a new treatment approach is being considered in fields as cardiology, infectious diseases, acute trauma, or neurology, there is a general expectation that adequate research will support its effectiveness, safety, and cost effectiveness before it is endorsed as a viable treatment option. With CLBP, however, treatment options appear virtually endless and increasing every year, have strong and vocal advocates, and often limited scientific evidence… Conversely, approaches that have demonstrated only minimal benefit in clinical trials continue to be recommended by proponents who allege that such studies were flawed and do not accurately represent current clinical practice.”

According to Dr. Haldeman,

Decades spent listening to presentations at scientific meetings, reading textbooks, discussing the problem with clinicians and patients, listening to advertisements on the television or radio, and browsing the internet, could lead one to conclude that the classical method of making healthcare decisions based on scientific evidence and expert consensus appears to have been replaced with a commercial and competitive model akin to shopping at a supermarket.”[32]

 

He might also have included what is most profitable to the practitioner’s franchise.

“This simplified, partial inventory of treatment options available to a person with CLBP includes over 200 different medications, therapies, injections, products, or procedures. It is a challenge for anyone involved in the management of CLBP to memorize this list, let alone understand the relative benefits and harms of each intervention at a level that is sufficient to provide advice to their patients. Although true informed consent requires a discussion of available alternatives, it would be impossible—or at least unfeasible—for a clinician to do so fully and accurately when it comes to CLBP.”

When one of the most astute spine authorities in the world admits confusion about back pain treatments, you know we have a big problem. But one thing is for certain, in the for-profit American healthcare system, everyone agrees there is too much spine surgery. Despite the media image of surgeons as saviors to patients, in fact, many spine surgeons may be ripping off the majority of their patients as the recent research indicates.

A 15-member Spine Care Advisory Committee was formed in 2005 to investigate this growing problem. Margaret E. O'Kane, National Committee for Quality Assurance president, also agrees with Haldeman and Deyo:

“In many cases, back pain is treated with unnecessary surgery that still leaves the patient in pain. This program will steer people to doctors who not only know how to diagnose back problems, but who also explain the pros and cons of treatment options, help them manage their condition and get well again.”[33]

 

Despite the admonitions from experts, their message is not getting to the public in the popular press. Consequently, the dilemma for consumers remains—conflicting diagnosis, divergent treatment paradigms, huge surgical costs, insurance non-coverage for alternative treatments, serious side-effects, lack of informed consent, and common medical treatments unsupported by current research.

Compounding these problems is a biased medical profession still averse to referring patients to chiropractors despite the overwhelming research supporting “hands-on therapy” in the form of active rehab, including spinal manipulative therapy, for mechanical low back pain. 26, 27

A recent poll by Consumers Reports magazine of 14,000 people showed that “hands-on therapies were among the top-rated. Fifty-eight percent of those who tried chiropractic manipulation said it helped a lot, and 59 percent were "completely" or "very" satisfied with their chiropractor. Massage and physical therapy were close runners-up.” Most notable were both medical care (specialized) was rated at 44% while standard medical care (pills) was rated the lowest at 34%. [34]

Despite the public’s opinion that “hands-on” therapies were best, the huge money involved with spine surgery has tainted the ethics of surgeons, made accomplices of  hospital administrators and perverse insurance companies who prefer expensive surgery over cheaper conservative care like SMT because there’s more money for everyone!

Where else can American doctors, hospitals and insurance companies profit so easily off the backs of unassuming patients who mistakenly think their best interests are at the heart of this epidemic of back surgery? Only in America does this medical scam persist due to the perverse for-profit system despite the lack of evidence to support the massive amounts of spine surgeries.

"If we stopped paying for everything that had no evidence of benefit, we would be a very unpopular organization," said Dr. Steve Phurrough, director of Medicare's coverage and analysis group. "Back pain is an increasing problem in our country and people . . . want something done."[35]

It appears managed care organizations are willing to pay for expensive procedures that lack evidence, but refrain from non-medical methods like SMT that have proven effective because in the perverse for-profit system, the more they pay, the more they profit.

Although the perverse motivation remains strong in managed care organizations, hospitals are now under pressure from large private insurers, state governments and Medicare not to charge when they make medical mistakes, also called "never events" because they shouldn't happen, such as patients who had surgery on the wrong body part or were disabled from the wrong medication. This is major revolution in the hospital world.

"Asking hospitals to commit to normal customer-service principles should not be radical, but it is," said Rachel Weissburg of The Leapfrog Group, a nonprofit organization that pushed for the move. "We have a very strange system in the U.S., where you don't pay for quality, you pay for service."[36]

Perhaps unnecessary and ineffective spine surgeries should be added to this list of “never events,” especially if conservative care is not done beforehand as many of the international guidelines recommend. Considering the high percentage of ineffective spine surgeries and the fact that 20% of spine surgeries have reoperations, how can hospitals and surgeons charge for these failed surgeries?

Only in medicine are services charged despite poor results, known as the proverbial “operation that was a success, but the patient died.” Imagine if hospitals were required to offer guarantees or warranties to patients, just as other product manufacturers are required to do, many would go broke.

Aside from the perverse motivation by surgeons, hospitals, and insurance executives, other stakeholders in the back pain business also exhibit perverse motivations. Certainly some DCs can be accused of over-treating some patients, but these costs are miniscule compared to the costs of unnecessary spine surgery considering researchers state disc abnormalities are not the primary problem in LBP.

As a 30-year practitioner working near the largest single-sight employer in the state of Georgia, Robins Air Force Base, I can count on one hand the number of workers’ comp. cases I’ve gotten. Sadly, physicians on base are instructed to refer all back pain cases to the surgeons, which certainly add to the costs and explains why Macon is supposedly the capital of back surgeries per capita in the state and ranks fourth on the list nationally. Knowing the ease to having spine surgery, many employees opt for surgery in order to become disabled and be awarded compensation. Is this not perverse or what? Other patients opt to have surgery simply because their health insurance covers surgery and not chiropractic care.

 

 



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

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

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

[4] Richard Deyo, MD, PHY and Donald Patrick, PhD, MSPH, Hope or Hype, The obsession with medical advances and the high costs of false promises. 2005 AMACOM books.

[5] Perry Garfinkel, The Back Story, AARP: the magazine, July & August 2009

[6] Kirkaldy-Willis WH and D. Cassidy, Can. Fam. Phys. 31 (1985): 535-40.

[7] Bogduk N. Clinical anatomy of the lumbar spine, pp. 170.

[8] Mooney V, Spine 12(6):754-59 (1987).

[9] S.D. Boden et al., “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects,” J. Bone Joint Surgery (AM) 72(3):403-8 (1990).

[10] Richard A. Deyo, James N. Weinstein, Primary Care: Low Back Pain The New England Journal of Medicine, Feb. 1, 2001, vol. 344, no. 5

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

[12]Waddell G. and OB Allan, “A historical perspective on low back pain and disability, “Acta Orthop Scand 60 (suppl 234), 1989.

[13] Christe, A; Laubli, R; Guzman, R; Berlemann, U; Moore, RJ; Schroth, G; Vock, P; Lovblad, KO: Degeneration of the cervical disc: histology compared with radiography and magnetic resonance imaging. Neuroradiology 47 (10). Oct 2005. P.721-729 Springer, New York.

[14]Kalichman L et al., Facet joint, osteoarthritis and low back pain in the community-based population,

Spine, 2008; 33:2560–5.

[15] Carragee E, Don A, Hurwitz E, et al. Does discography cause accelerated progression of degeneration changes in the lumbar disc: A ten-year cohort-controlled study. Paper # 57. Presented at the 36th Annual Meeting of the International Society of the Study of the Lumbar Spine. May 4-8, 2009. Miami

[16] Barna, Steven A, Discography: Medical Director of MGH Pain Clinic, Harvard Medical School, Massachusetts General Hospital, http://emedicine.medscape.com/article/1145703-overview

[17] Mohit Bhandari, Brad Petrisor, Jason W. Busse and Brian Drew Division of Orthopaedic Surgery, Department of Surgery; McMaster University;  Spine Unit, Hamilton Health Sciences–General Hospital, Hamilton, Ont., CMAJ • August 16, 2005; 173 (4). doi:10.1503/cmaj.050884.

[18] Begley, Sharon, Where are the cures? November 10, 2008, pp. 56, Newsweek.

[19] Conservative Therapy for Low Back Pain: Distinguishing useful from useless therapy. JAMA 1983: 250;1057 - 62.

[20] Scott Haldeman DC, MD, PhD, FRCP(C) and Simon Dagenais DC, PhD. A supermarket approach to the evidence-informed management of chronic low back pain. The Spine Journal, vol. 8, Issue 1, January-February 2008, Pages 1-7.

[21] Cramer, G. Dean of Research, National University of Health Sciences, private communication, May, 2009

[22] Shaw JL, “The role of the sacroiliac joints as a cause of low back pain and dysfunction,” speech before the World Congress on Low Back Pain, University of California, San Diego, Nov. 5-6, 1992 .

[23] See AHRQ, MEPS, Total expenditures for conditions by site of service, United States, 2005;

[24] B. Kim Humphreys, DC, PhD, Andrew Sulkowski, DC, Kevin McIntyre, DC, Mark Kasiban, DC and A. Neil Patrick, DC; an examination of musculoskeletal cognitive competency in  chiropractic interns; Journal of Manipulative and Physiological Therapeutics, Volume 30, Number 1.

[25] The BackLetter® 33 Volume 23, Number 3, 2008.

[26] Brox JI, Sørensen R, Friis A, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913–1921.

[27] Scott Haldeman, DC, MD, PhD; Linda Carroll, PhD; J David Cassidy, DC, PhD, DrMedSc; Jon Schubert, CMA; Åke Nygren, DDS, MD, DrMedSc., The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: Executive Summary. February 15, 2008, Volume 33, Issue 4S Neck Pain Task Force Supplement.

[28] The Bone and Joint Decade Task Force Questions Common Assumptions About Neck Pain; THE BACKLetter; Published by Lippincott Williams & Wilkins Vol. 23, No. 2, February 2008

[29] The Bone and Joint Decade Task Force Questions Common Assumptions About Neck Pain; THE BACKLetter; Published by Lippincott Williams & Wilkins Vol. 23, No. 2, February 2008

[30] Carragee EJ et al., Treatment of neck pain: Injections and surgical interventions, Spine, 2008; 33(4S):S153–S169.

[31] Henderson FC, et al: Stretch associated injury in cervical spondylotic  myelopathy: new concept and review. Neurosurgery 56 No 5, May 2005

 

[32]Scott Haldeman DC, MD, PhD, FRCP(C) and Simon Dagenais DC, PhD. A supermarket approach to the evidence-informed management of chronic low back pain. The Spine Journal, vol. 8, Issue 1, January-February 2008, Pages 1-7.

[33]  “National Spine Care Advisory Committee Formed,” Dynamic Chiropractic September 14, 2005, Volume 23, Issue 19.

[34] Relief for aching backs, Hands-on therapies were top-rated by 14,000 consumers, Consumer Reports May 2009

[35] Dembner, Alice Spine tuning, Innovative surgeries raise hope, concern, Boston Globe Staff ,  September 3, 2007.

[36]Fulmer, Melinda, Hospitals won't get to bill for errors, MSN website, March 8, 2008.

Website Builder