Articles by JCS
Golden Opportunity Missed
The 2007 Presidential Address by RD Guyer, MD, “The paradox in medicine today—exciting technology and economic challenges,” reprinted in The Spine Journal, failed to answer his proposition as to what is absurd or contradictory in medicine today. Instead, he spoke of the diversity in spine surgery and the financial problems all physicians face with managed care organizations.
As a non-surgical spine specialist and doctor of chiropractic, I expected this address to mention the actual absurdities in spine care today, but I found instead that Dr. Guyer failed to address what the current literature is now validating—the fact that most spine surgeries are now deemed unnecessary, ineffective, costly, and based on a suspect disc theory. I would have expected Dr. Guyer’s position of leadership to take the lead in bringing these issues to the forefront in light of the plethora of international research.
After all, The Spine Journal purports to be “A Multidisciplinary Journal of Spine Disorders,” but upon reading his address that omits any mention of multidisciplinary methods, one must conclude knowledge of non-surgical methods is not actually welcomed by most spine surgeons. Until he addresses these issues, indeed, spine care will remain paradoxical to most surgeons and ineffective for many patients.
According to an article in Fortune magazine, “The battle over your aching back: New alternatives to surgery are gaining favor,”  Dr. Guyer’s involvement as co-founder of the Texas Back Institute (TBI) was applauded:
“Launched in 1978, the Texas Back Institute represents the establishment approach to treating back pain, one that has evolved to encompass a host of disciplines. In its early days TBI had just three surgeons and nine employees, but today its 204 staffers include physiatrists, psychologists, pain specialists, chiropractors, and physical therapists. Every year TBI handles more than 55,000 patient visits, and its 11 surgeons perform about 2,000 surgeries. (That may sound like a lot, but only 11% of TBI's patients actually go under the knife.)”
With his extensive background in multidisciplinary spinal care, I was shocked to see the complete omission of conservative care like spinal manipulative therapy (SMT) and chiropractic care in his address. The Fortune article disclosed, “Orthopedic surgeons and chiropractors make up the standard approach - although chiropractors themselves were not long ago regarded as charlatans by the medical establishment and even now, many MDs do no more than tolerate them.”
I know little about the politics of the NASS organization, but his address would have been a golden opportunity to suggest to his colleagues that if they wanted to solve the paradox to the epidemic of spine ailments, a great starting point would have been to mention the multidisciplinary work he’s done at TBI.
Evidently the standard approach hasn’t been very successful according to the Fortune article:
“Saying that back surgery can be a roll of the dice is not far from the truth. Last year there were 1,175,000 inpatient spinal surgeries in the U.S. alone, according to market research firm Spinemarket and newsletter Orthopedic Network News.
“The best surgeons claim that 80% of their cases are successful, but ‘success’ is a pretty nebulous concept. Most surgery patients still have some pain postoperatively. Failure is so common, meanwhile, that a term, ‘failed-back-surgery syndrome,’ has been coined to account for it.”
The 800 Pound Gorilla
Admittedly, there is a certain myopia that permeates spine care in America, a country that does more spine surgery than any other nation in the world. According to Deyo and Cherkin, the annual number of spinal fusion operations rose by 77% between 1996 and 2001 and continues to rise astronomically despite the evidence, guidelines, and critical comments of spine experts from around the world.
“Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country.” The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland. This fact illustrates that the reason why we have too many spine surgeries is due to too many surgeons making too much money.
This opinion is shared by the editors of The BACKLETTER:
"The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate…Despite a steady stream of technological innovations over the past 15 years—from pedical screws to fusion cages to artificial discs—there is little evidence that patient outcomes have improved.”
On the other hand, as the Decade of Bone and Joint Disorders (BJD) wanes, a cascade of evidence has emerged showing the clinical and cost-effectiveness of spinal manipulative therapy for the epidemic of neck and low back pain, which only thickens the paradox that shows the huge costs and disability attributed to those disciplines who prefer marginally effective drugs, shots and surgery over conservative care.
Remarkably, The Spine Journal (Volume 8, Issue 1, pp. 1-278, January-February 2008) also spoke of these newest research findings which hopefully will be recognized as the best evidence we have to date and perhaps this is the beginning of a paradigm shift in spine practices. Tony Rosner, PhD, in his testimony before The Institute of Medicine: Committee on Use of CAM by the American Public: “Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”
Scott Haldeman, DC, MD, PhD, lead researcher for the task force of the Decade of Bone and Joint Disorders (BJD), announced recently at the Chiropractic Research Agenda Conference that the recent findings of the BJD for chronic LBP came to the same conclusions as the 1994 AHCPR guidelines on acute LBP—that SMT and active rehab are best for both acute and chronic LBP. It’s an issue that Dr. Guyer cannot continue to ignore despite the medical antipathy toward chiropractors.
Obviously we cannot naively ignore the economic impact of spine and musculo-skeletal care as a factor in this myopia. Dr. Guyer’s address mentions the huge monies involved: $100-$200 billion per year are spent on spine care. LBP is an ailment that affects 76% of people annually and 85% of people in their lifetime and has total costs of $84 to $624 billion worldwide according to Dr. Haldeman. According to the Fortune article, “A Duke University study found that treating back pain costs Americans more than $26 billion a year, or 2.5% of our nation's total health-care bill. Much of that spending is devoted to the 10% or so of back patients who suffer from chronic, debilitating pain.”
In Dr. Guyer’s address he states:
“Certainly with these staggering figures in mind, there is a potential to determine the best cost-effective treatment. There will no doubt even further dollar shifting in the spine care arena with the advent of new or motion preservation technology, including disc replacements, nucleus replacements, and dynamic posterior stabilization devices.”
Again, he missed a golden opportunity to talk about non-surgical care and the already proven cost-effectiveness of low risk manipulation for LBP. I am curious as to how someone with his extensive background failed to incorporate all the elements of tomorrow’s shift in spine care to non-surgical, conservative care.
The Fundamental Flaw
Indeed, if Dr. Guyer suggests “there is a potential to determine the best cost-effective treatment,” he has to consider the plethora of research supporting conservative care. To do anything less is unconscionable considering the recent findings and only contributes to the paradox he bemoans.
Evidently as he seemingly applauds the increase of new technology in spine surgery and The Spine Journal is replete with ads from device manufacturers, other spine experts decry this trend in spine care, such as Richard Deyo, MD, MPH:
''People say, 'I'm not going to put up with it,’ and we in the medical profession have turned to ever more aggressive medication, narcotic medication, surgery, more invasive surgery.'' 
Dr. Guyer’s omission of dollars possibly shifting toward conservative spinal care is interesting and possibly evidence of the Fundamental Flaw that Paul Goodley, MD, orthopedic physician and author, coined in his revealing book, Release from Pain, that admits the blind eye mainstream medicine has exhibited toward SMT.
“Eventually, 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.”
As evidence of the Fundamental Flaw within spine medicine, Dr. Vert Mooney, formerly Professor of Orthopedic Surgery at the University of California, San Diego confessed:
“I have been an orthopaedic surgeon for 35 years, and despite its responsibilities I have sadly seen my specialty become more and more surgically oriented. There were 502 presentations at the 1998 Annual Meeting of the American Association of Orthopaedic Surgeons. Not one of them discussed a non-surgical orthopaedic subject.”
The Big Assumption
Researchers now question the underlying premise of spine surgery based on an outdated disc premise, another paradox omitted in Dr. Guiyer’s presidential address. Considering the disc premise is the basis of most back surgeries, this omission is significant since the primary selling point by most spine surgeons remains focused on abnormal discs because it’s easy to show a patient a degenerative disc on x-ray or a herniated disc on an MRI. But, in fact, some researchers now mockingly refer to these abnormalities as “incidentalomas.”
Richard Deyo and many others have written about the fallacy of the disc theory:
“Early or frequent use of these tests [CT and MRI] is discouraged because disc and other abnormalities are common among asymptomatic adults…Degenerated, bulging, and herniated discs are frequently incidental findings…Detecting a herniated disc on an imaging test therefore proves only one thing conclusively: the patient has a herniated disc.”
He concludes that 97% of back pain is “mechanical” in nature, and disc abnormalities account for only 1% of back 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.”
NM Hadler, MD, professor at UNC Medical School and author of “The Last Well Person” also criticized the disc theory:
“Magnetic resonance imaging cannot be used to predict back pain. Magnetic resonance imaging is not even sensitive to anatomical changes that might correlate with new symptoms. Why is it so important to define the anatomy of the lumbo-sacral spine of patients with regional low back pain?”
“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.”
The editors of www.spine-health.com also question the validity of the disc theory as a sole causative factor in back pain:
“You may have a bulging disc that shows up on an MRI scan, but that may not be the cause of your leg pain. You can have disc degeneration or other anatomical lesions that show up on the scan, but are not causing pain. Studies have shown that many people with no pain or other symptoms often have some sort of disc problem show up on an MRI scan.”
Dr. JI Brox of the Norway Spine Study says that he and his colleagues no longer perform spinal fusion specifically for degenerative disc disease because they do not regard it as a clearly diagnosable entity.
“Although pain receptors in degenerated discs may produce severe pain, we have gradually recognized that abnormal findings and positive discography are common even in asymptomatic individuals…The concept of highly selected patients is not evidence-based.
“These surgeons refuse to have fusion surgery or recommend fusion surgery for their family members. So the question is: why should we recommend these procedures for our patients?”
The Forgotten Cause
Indeed, considering the anatomy of the spinal column with 137 joints interconnecting 24 highly movable vertebrae sitting on top of 3 pelvic bones, inexplicably the concept of joint dysfunction as the major cause of pain (and the reason why SMT works so well) remains obscure to most surgeons and physicians. Most acute LBP may not be caused primarily by a slipped disc as much as by slipped joints that have finally buckled.
Research from Dr. Guyer’s own Texas Back Institute suggests many cases of LBP are the result of a “segmental buckling effect,” according to research by John Triano, DC, PhD, et al. Someone of Dr. Guyer’s stature addressing the NASS and talking about the paradox of spine treatment would have been a giant step to understand the dynamics of LBP.
According to John McMillan Mennell, MD in his testimony at the Wilk v. AMA antitrust trial:
“When you are dealing with manipulative therapy in the spine…your objective is to try to restore the proper motion joint play, which is prerequisite to the normal function in the spine…If you don’t manipulate to relieve the symptoms from this condition of joint dysfunction, then you are depriving the patient of the one thing that is likely to relieve them of their suffering.
“The science of mechanics demands that joint play movement is prerequisite to normal pain-free functioning of movement …in the spine there are about 137 synovial joints between the lamina facets, the occipital condyles, the bottom of the skull as it rests on the atlas, the sacroiliac joints, the sacrococcygeal joints, the z-joints, even the joints of the fundusca in the neck.
“Eight out of 10 patients that come out of any doctor’s office complain of a musculoskeletal system problem regardless of from what system the pain is coming…
“I will say 100% of those complaints, which are, in fact, due to joint dysfunction in the musculoskeletal.”
Not only is joint dysfunction a major cause of LBP, according to JL Shaw, orthopedist, they may also be the cause of disc problems. In his speech before the World Congress on Low Back Pain, in 1992, “The role of the sacroiliac joints as a cause of low back pain and dysfunction,” he mentioned: “Joint dysfunctions are the major cause of LBP as well as the primary factor causing disc space degeneration and ultimate herniation of disc material.”
Alf L. Nachemson, MD, regarded as the godfather of the evidence-based spine care movement, suggested that many in the medical community and spine surgeons in particular have been slow to embrace the results of rigorous scientific research. As a result, many patients with back pain don’t receive optimal spine care. Many continue to undergo unproven and counter-productive treatments.
“Fusion surgery is typically not a cure and should not be presented as such,” Nachemson noted. “Few patients experience complete relief of back pain following surgery. Only one in five patients in these studies became pain-free,” he observed.
“Examine and inform your patients, recommend activity, and advise against bed rest. Don’t perform x-ray or MRI unless there is a red flag. Offer pain medicine or manual therapy if the patient prefers it.
The Ethical Challenge
Aside from technological and economical challenges, there also exists the ethical challenge that Dr. Guyer failed to mention. Principally, the paradox of spine care must include this paradigm shift away from drugs, shots and surgery toward the conservative management of back pain.
Coincidentally, in the Dec/Jan 2008 Bone and Joint Decade newsletter, the current president, J. Edward Puzas, PhD, discusses the Privilege and Responsibility: Two Cornerstones of Research. In his column he mentions:
“Biomedical research has many layers of responsibility. One of these that the general public, probably doesn’t think much about is scientific integrity, the integrity to hold one’s work up to detailed scrutiny. It doesn’t take long for a young scientist to figure out that it is possible and actually quite easy to step off the path of scientific integrity.
“Probably in few other professions can dishonesty be hidden for as long as it can in research. There are plenty of examples of careers being made, grants being funded and papers being published from scientists with a deceitful approach.
“Eventually, with time these untrustworthy individuals are identified but in the interim much harm can be done. And so, the responsibility of being unconditionally honest must be at the top of a scientist’s nature.
“Privilege and responsibility, in many ways, define the traits that make for good research. As in any profession where the stakes are large, only those researchers that are guided by the highest of standards will truly make a contribution to the needs of us all. And these traits are critical to engaging the public and patients in supporting the need for more research t reduce, and eventually eliminate, the burden of disease.”
While Dr. Puzas mentions, “Probably in few other professions can dishonesty be hidden for as long as it can in research,” the remnants of this dishonesty prevail when MCOs headed by MDs still limit or contain conservative care and physicians still refuse to refer to DCs despite the overwhelming evidence that SMT is the first avenue of treatment as the landmark 1994 US Public Health Service’s Agency for Health Care Practice and Research guidelines clearly stated years ago.
The reaction by medicine was a prime example of this professional contempt toward evidence-based research after this extensive two-year study on acute low back pain that recommended spinal manipulation as a “proven method.”
The most shocking conclusion in this federal guideline by the US Public Health Services panel found back surgeries were generally ineffective and over-used.
“Even having a lot of back pain does not by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.” 
The AHCPR guideline also mentions the low success rate of back surgery and fusion in particular.
“Moreover, surgery increases the chance of future procedures with higher complication rates…There appears to be no good evidence from controlled trails that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fracture or dislocations…Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level.”
The AHCPR panel also recommended spinal manipulation as a “Proven Treatment” and the preferred initial professional treatment for acute low back pain. This guideline states:
“This treatment (using the hands to apply force to the back to ‘adjust’ the spine) can be helpful for some people in the first month of low back symptoms. It should only be done by a professional with experience in manipulation.”
The Great Escape
Despite the evidence of this extensive study, after its release in December, 1994, the North American Spine Society successfully lobbied Congress to revoke the ability of the Agency on Health Care Policy and Research to do its job mandated by Congress to investigate medical procedures and to recommend treatment guidelines with the goal to lower costs and improve outcomes. Its ire stemmed from the criticism levied at spinal fusions, especially those involving pedicle screws due to the findings that fusions had few scientifically validated indications and was associated with higher costs and complications rates than other types of back surgery.
NASS also formed a so-called grassroots movement dubbed “Center for Patient Advocacy” to make it appear its objections were from consumers, not special interests. A manufacturer of pedicle screws, Sofamor Danek, unsuccessfully sought a court injunction to prevent publication of the AHCPR guideline on acute low back pain. Not only were they successful in gutting the AHCPR, these angry orthopedists even sued the researchers involved to discourage any other attempts to change the medical status quo.
As a member of the AHCPR panel, Dr. Richard Deyo subsequently co-authored in The New England Journal of Medicine an article in response to this intimidation, "The Messenger Under Attack--Intimidation of Researchers by Special Interest Groups." He alluded that the for-profit mindset of some surgeons supersedes the value of research:
"The huge financial implications of many research studies invite vigorous attack... Intimidation of investigators and funding agencies by powerful constituencies may inhibit important research on health risks and rational approaches to cost-effective health care."
Dr. Deyo, in his book, “Hope or Hype: The obsessions with medical advances and the high cost of false promises,” mentions the sentiments of ethical spine surgeons:
“Some surgeons, like Dr. Edward Benzel at the Cleveland Clinic Spine Institute, believe that too much spine fusion surgery is being performed. Benzel estimated to the New York Times that less than half the spinal fusions being performed were appropriate. ‘The reality of it is, we all cave in to market and economic forces,’ he was quoted as saying, adding that the current system of paying doctors is ‘totally perverted.’ Dr. Zoher Ghogawala, a Yale neurosurgeon, agreed that too much fusion surgery is done, saying, ‘I see too many patients who are recommended for fusion that absolutely do not need it.’”
Profits vs. Needs
This resistance to new guidelines in for-profit systems comes as no surprise to many researchers. According to a recent article, “Market-Based Failure,” in the NEJM by Robert Kuttner, “Comprehensive, government-organized, universal health insurance systems are far better equipped to realize these efficiencies because everyone is covered and there are no incentives to pursue the most profitable treatments rather than those dictated by medical need.” Certainly in the for-profit healthcare system in the US, back surgeons have little interest in following EB guidelines and referring to DCs when huge fees are involved and insurance companies readily pay for them.
“The extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization,” according to Dr. Kuttner. “The dominance of for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players raise costs and distort resource allocation. Profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent, but the more serious and less appreciated syndrome is the set of perverse incentives produced by commercial dominance of the system.”
To illustrate the vast difference between for-profit and non-profit healthcare systems, Medicare now covers about 40 million seniors, gets high marks for customer satisfaction and whips the private sector on efficiency by allocating approximately 5% toward administrative costs. Private insurers spend six times as much on administration, proportionally—mostly to weed out costly customers or fight payment, according to Richard Coniff.
The perverse motivation in healthcare is not new, whether it’s due to perverse economic motivations or the Fundamental Flaw. In 2001 the National Academy of Sciences report admitted that applying evidence-based research to health care delivery is a huge gap that must be crossed.
“In the current health care system, scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. An average of about 17 years is required for new knowledge generated by randomized controlled trials to be incorporated into practice, and even then application is highly uneven…and that there are insufficient tools and incentives to promote rapid adoption of best practices.”
It’s already been 14 years since the AHCPR findings, and will it take another 17 years for the BJD recommendations on LBP to be implemented in the mainstream medical profession? If Dr. Puzas is keen on eliminating the burden of disease in this Decade of Bone and Joint Disorders, I daresay someday he and Dr. Guyer will have to confront the Fundamental Flaw in medicine—its blind eye toward manipulative therapies. When knowledgeable people like them admit the effectiveness of SMT, the peer pressure to ignore it goes unsaid, but the ethical and professional duty to discuss this fact is simply leadership in action.
“Show Me the Data”
All the research noted by Dr. Haldeman and his colleagues may go for naught just as we saw with the AHCPR guidelines until someone holds the gatekeepers responsible for denying the proven and effective treatment methods like SMT.
In his address, Dr. Guyer wrote concerning Solutions: “What can and must we do to address this paradox for the benefit of our patients, physicians, and society?” May I suggest that your NASS simply follow the guidelines of AHCPR and the BJD that recommend SMT first and surgery last, just as you’ve done for years at TBI?
Dr. Guyer also wrote, “To paraphrase Jerry Mcguire: ‘Show me the data.’” Indeed, the data suggest that there is too much spine surgery in the USA, but this data was absent from his address and the silence will never advance the truth.
The January/February edition of The Spine Journal is also testament to the various methods in the supermarket of 200 spine treatments. You can review the findings of the BJD studies in The Spine Journal.
The BACKPage editors summarized the present dilemma and admitted its failure:
“The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate…Despite a steady stream of technological innovations over the past 15 years—from pedical screws to fusion cages to artificial discs—there is little evidence that patient outcomes have improved.”
Ignored Data & Lack of Informed Consent
According to Pran Manga, PhD, medical economist, “There is an overwhelming body of evidence indicating that chiropractic management of LBP is more cost-effective than medical management.”  There is now broad agreement internationally that surgery should not generally be considered until there has been a trial of conservative non-surgical care.,,
For the most part, however, this evidence has been ignored due to Fundamental Flaws in for-profit medicine in America. Rather than evidence as the guiding light, the medical attitude in regards to back pain appears to be “Don’t confuse us with the facts.” Indeed, there is simply too much money and too much pride involved to change the present medical system in the USA.
After the World Health Organization (WHO) report released in June 2000 ranked the US 37th in the world in overall health system performance and 72nd on population health, we would have expected an overhaul of the American healthcare system. Combined with the fact that 47 million Americans are without healthcare insurance and the recent international critique of surgical spine care, again we might have expected a reformation in healthcare. Instead, we see the blind eye by organized medicine and managed healthcare organizations to keep the profitable status quo.
Although all spine physicians—surgical and non-surgical alike—have little control over the for-profit healthcare in the USA, we still see the sordid plot of the past to starve DCs of patients and to deny patients true informed consent with the failure to mention SMT as a proven treatment. Just when will the plot change for the better to serve patients by adhering to the recommended guidelines of AHCPR and the BJD to include SMT as a first avenue of treatment? The facts are clear: for the majority of LBP, SMT is proven best, the disc theory is over-played, and spine surgeries are mostly ineffective and costly. So when will there be a happy ending to this century old story of bias and exploitation?
Or will the research findings from this Decade of Bone and Joint Disorders find the same circular filing bin as the old AHCPR guidelines? Time will tell, but until the powers to be insist on SMT before drugs, shots and surgery, in our capitalistic medical society, I fear that money shall prevail, not science or ethics. Indeed, while Dr. Puzas complains of dishonesty in research, will he or Dr. Guyer do the same and discuss the dishonesty in spine treatments? That is the biggest hurdle we face in the USA today—surgeons and hospitals who continue to perpetuate the epidemic of unnecessary spine surgery.
Indeed, if there’s dishonesty in research as Dr. Puzas admits, there’s an equal amount of intellectual dishonesty among American spine surgeons who continue to perform unnecessary spine surgeries despite the international research that basically does not support it for the majority of back cases.
Admittedly the sub-set of the population that has been carefully screened may benefit from spine surgery if they were given informed consent concerning alternative treatments beforehand. Indeed, then that would constitute the ideal evidence-based practice.
Dr. James Weinstein, orthopedist and lead author of the SPORT study, said the rapid growth in surgical procedures, coupled with the lack of hard evidence, points to the need to spell out all the risks and benefits for patients and let them choose—in other words, to end the medical stranglehold on the back pain business.
“As in most of medicine, there isn't as much evidence as we would like," said Weinstein, director of the Dartmouth Institute for Health Policy and Clinical Practice. “We need to be clear that there is a choice of treatments,” he said, and "that one isn't necessarily better than the other." Quite an admission from an orthopedist undoubtedly tormented that the standard medical methods cannot be substantiated for their high usage rates in this era of EBM.
This missing element—intellectual honesty—remains a huge part of the paradox in medicine today, Dr. Guyer. The research is clear that most spine surgeries are unnecessary, American surgeons do more per capita than any other country in the world, the disc theory is over-rated, yet the numbers of spine surgeries steadily increase.
Dr. Guyer could play a pivotal role in encouraging NASS to announce its commitment to follow the AHCPR and BJD recommendations to use SMT before drugs, shots, and surgery in appropriate cases. This would engender the trust of patients who will feel that their best interests are truly being served rather than the financial interests of surgeons.
As the research clearly notes, the paradox of spine care is not just technology, economics or dishonesty in research, but rather a failure of informed decision-making to acknowledge the inclusion of conservative care into the mainstream medical management of back and neck pain.
 Guyer, RD, 2007 Presidential Address, The Spine Journal 8 (2008) pp. 279-285.
 Boyle, Matthew, The battle over your aching back: New alternatives to surgery are gaining favor. Here's a look at the best treatment options. Fortune. August 25 2006.
 An international comparison of back surgery rates. Cherkin DC, Deyo RA, et al. Spine. 2004 Jun 1;19(11):1201-6.
 The BackLetter, vol.12, no. 7, pp.79 July, 2004. The BackPage editorial, The BackLetter, pp. 84, vol. 20, No. 7, 2005.
 Guyer, RD, 2007 Presidential Address, The Spine Journal 8 (2008) pp. 279-285.
 Haldeman, S. Evidenced-informed management of chronic low back pain without surgery, ACC-RAC 2008, March 13-15, Washington DC.
 Boyle, Matthew, ibid.
 “With Costs Rising, Treating Back Pain Often Seems Futile” by Gina Kolata, NY Times, February 9, 2004
 Goodly, PH, Release from Pain, Don’t be a victim of the pain pandemic, 2005. www.Dr.Goodley.com
 Deyo, RA, ibid.
 Richard A. Deyo, James N. Weinstein, Primary Care: Low Back Pain The New England Journal of Medicine, Feb. 1, 2001, vol. 344, no. 5
JAMA, Need for less imaging, better understanding June 4, 2003 vol. 289 no. 21.
 Hadler, NH. The Last Well Person, McGill-Queen's University Press, 2004. ISBN 0-7735-2795-8.
 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.
 Triano J Biomechanics of spinal manipulation. Spine 2001;1:121-30.
 Wilk et al v AMA et al. US District Court Northern District of Illinois, No. 76C3777, Getzendanner J, Judgment dated August 27, 1987.
 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.
 Spinal-Fusion Surgery — The Case for Restraint, Richard A. Deyo, M.D., M.P.H., Alf Nachemson, M.D., Ph.D., and Sohail K. Mirza, M.D. Volume 350:722-726 February 12, 2004 Number 7
 Puzas, JE. Privilege and Responsibility: Two Cornerstones of Research, Bone and Joint Decade, vol. 9, issue 3, Dec 2007/Jan 2008.
 Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, December 1994.
 Bigos et al.
 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.
 Bigos S. et al. US Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline, Number 14:
Acute Low Back Problems in Adults AHCPR Publication No. 95-0642, December 1994.
 Turner JA, Ersek M, Herron L, Haselkorn J, Kent D, Ciol MA, Deyo R. Patient outcomes after lumbar spinal fusions. JAMA 1992; 268: 907-911.
 Deyo RA, Psaty BM, et al. The Messenger under Attack--Intimidation of Researchers by Special-Interest Groups, NEJM, vol. 336, No. 16, pp. 1176-79, April 17, 1997.
 Deyo RA, Patrick DL, Hope or Hype: The obsession with medical advances and the high cost of false promises, AMACOM publication, 2002, pp. 191.
Kuttner, R., Market-Based Failure — A Second Opinion on U.S. Health Care Costs, NEJM, Vol 358:549-551 Feb. 7, 2008, Number 6.
 Kuttner, R., Market-Based Failure — A Second Opinion on U.S. Health Care Costs, NEJM, Vol 358:549-551 Feb. 7, 2008, Number 6.
Conniff, Richard; How to fix: Health care; MSN Money Feb. 19, 2008.
 Crossing the Quality Chasm: A New Health System for the 21st Century, The National Academy of Sciences, 2001. page 13-14.
 The BackPage editorial, The BackLetter, pp. 84, vol. 20, No. 7, 2005
 Manga et al.
 Weber H (1994) The natural history of disc herniation and the influence of intervention, Spine 19:2234-2238.
 Saal J (1996) Natural history and nonoperative treatment of lumbar disc herniation, Spine 21:2S-9S.
 Postacchini F (1996) Results of surgery compared with conservative management for lumbar disc herniations, Spine 21:1383-1387.
 World Health Organization, The World Health Report 2000: Health Systems—Improving Performance (Geneva: WHOP, 2000).
Weinstein JN et al., Surgical vs. nonoperative treatment for lumbar disc herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort, JAMA, 2006; 296:2451–9
 Dembner, Alice Spine tuning, Innovative surgeries raise hope, concern, Boston Globe Staff , September 3, 2007.