Articles by JCS

Just Say No

Just Say No

Nearly twenty years ago international researchers agreed that spine surgery should not be considered until there had been initially a trial of conservative care but, for the most part, this advice has been ignored.[1],[2],[3],[4]

Ironically, the original two spine surgeons who promulgated the abnormal disc theory, WJ Mixter, MD, and JS Barr, MD, from the Massachusetts General Hospital, also recommended conservative care before surgery.[5]

Say No to Discs

The paradigm shift away from the abnormal disc theory in spine diagnosis began in 1990 when research by Scott Boden, MD, found no clear correlation between disc abnormalities and back pain.[6] 

            Richard Deyo, MD, MPH, noted this misleading disc theory has led to “false positive” misdiagnosis, suggesting that “many of these abnormalities are trivial, harmless, and irrelevant, so they have been recently dubbed incidentalomas,”  and “they are likely to lead to more tests, patient anxiety, and perhaps even unnecessary surgery.” [7]

Both the North American Spine Society and American Society of Spine Radiology now admit the term ‘bulging disc’ should only be used as a descriptive term, not a diagnostic term.[8] In 2011, North Carolina Blue Cross/Blue Shield announced it will no longer pay for spine fusion if the sole criterion is an abnormal disc.[9]

 

Say No to MRIs

Evidence-based medicine now questions whether or not scans are necessary in light of the ubiquitous nature of disc abnormalities. Deyo cites the huge 307% increase of CT and MRI scans and estimates “one-third to two-thirds…may be inappropriate.”[10]

A 2009 Stanford University study confirmed that patients in areas with more MRI scanners are more likely to undergo spine surgery.[11] Indisputably, MRI scans are used essentially as selling points to gullible patients and have greatly increased the number of unnecessary disc surgeries.

Say No to Surgery

According to Trang Nguyen, MD, fusion surgeries are “associated with significant increase in disability, opiate use, prolonged work loss, and poor return to work status.” [12]

The rise of drugs, shots, and surgery is shocking. From 1994 to 2007, spinal fusion surgery increased 204%, spinal injections increased 629%, and opiate use increased 423%. The most complex type of back surgery had increased 15-fold.[13]

Deyo openly admits that too many people are getting risky and expensive back surgery when more minimal approaches would work.[14] He mentioned one strong motivation included “financial incentives involving both surgeons and hospitals.”[15] Deyo pulled no punches when he said, “More people are interested in getting on the gravy train than on stopping the gravy train.”[16]

Say No to Pain Clinics

Robert J. Barth  believes “pain management does not accomplish anything but getting the patient addicted.” Nonetheless, it is among the fastest growing segments in medicine today considering that one injection costs $1,000.[17]

Pain clinics have also added to the “hillbilly heroin” epidemic. In 2010, American pharmacists dispensed over 101 tons of opioids like pure oxycodone and hydrocodone—equivalent to 40 5-mg Percocets and 24 5-mg Vicodins for every US resident that caused 14,800 deaths and untold addictions, including to the unborn.[18]

The number of babies born dependent on prescription painkillers like Oxycotin tripled in the last decade along with higher costs to treat their withdrawal symptoms.[19]

The long term impact is now emerging that morphine can cause regional neuroplastic changes in the human brain after only one month of daily administration. There is also no evidence yet that these changes reverse, creating difficulty in full recovery after cessation.[20]

Say No to PCPs

Primary care physicians are typically inept in their training on musculoskeletal disorders,[21] prone to ignore recent guidelines[22], and more likely to suggest spine surgery than surgeons themselves.[23]

According to Boden, “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”[24]

Biased physicians also suffer from “professional amnesia”[25] when they fail to inform patients that chiropractic care is a recommended option to medical methods.

Paradigm Shift from Discs to Joints

While the medical model of back pain remains focused on static pathoanatomical disc and arthritic issues, the chiropractic model and justification for manipulation focuses on dynamic pathophysiological issues. In other words, chiropractors believe it is more important how the spine functions than how it looks on an image.

Unbeknownst to most MDs, the total vertebral and pelvic joints number 313, which include all synovial, symphysis, and syndesmosis joints according to Gregory D. Cramer, DC, PhD.[26] Foremost from this “joints” perspective, back pain constitutes a “joint complex dysfunction” according to David R. Seaman, MS, DC, and James F. Winterstein, DC.[27],[28] As well, Jay Triano, DC, PhD, suggests a “segmental buckling effect.”[29] In this light, certainly the adjustment of spinal joints is the logical initial treatment.

In Conclusion:

The evidence for chiropractic care is mounting. A 1998 editorial in the Annals of Internal Medicine noted that “spinal manipulation is the treatment of choice.”[30] In 2007 a Joint Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain also recommended spinal manipulation for acute, sub-acute, or chronic low back pain. [31] Surprisingly, the North American Spine Society also recommends spinal manipulation before surgery.[32]

            So, how should we consider those “inept” MDs who refuse to refer to DCs, but still prescribe addictive narcotics, epidural steroid injections that are no more effective than placebo[33], and do hundreds of thousands of expensive MRIs and spine surgeries based on the disproved disc theory?

Quacks or criminals?

This is the real dilemma in evidence-based spine care today.

Deyo commented on this dilemma: “…we’ve witnessed disturbing practices that seem designed to maximize someone’s income, regardless of whether there was benefit or harm to patients.”[34]

Now we can understand why Gordon Waddell, MD, once said:

“Low back pain has been a 20th century health care disaster. Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem...It [back surgery] has been accused of leaving more tragic human wreckage in its wake than any other operation in history.”[35]

Certainly any investigation must conclude medical spine care is economic-based, not evidence-based nor ethics-based.

 

 



[1] H Weber, “The Natural History Of Disc Herniation And The Influence Of Intervention,” Spine 19 (1994):2234-2238.

[2] J Saal, “Natural History And Nonoperative Treatment Of Lumbar Disc Herniation,” Spine 21(1996):2S-9S.

[3] F Postacchini, “Results of Surgery Compared With Conservative Management For Lumbar Disc Herniations,” Spine 21(1996):1383-1387.

[4] Bigos 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)

[5] Joseph S. Barr M.D. And William Jason Mixter M.D. “Posterior Protrusion Of The Lumbar Intervertebral Discs,” Journal of Bone and Joint Surgery, 23 (1941): 444-456. Orthopaedic and Neurosurgical Services of the Massachusetts General Hospital, Boston.

[6] 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.

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

[8] http://www.americanspinal.com/bulging-disc.html

[9] www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/lumbar_spine_fusion_surgery.pdf

[10] Richard A. Deyo, MD, MPH; Sohail K. Mirza, MD, MPH; Judith A. Turner, PhD; Brook I. Martin, MPH, “Overtreating Chronic Back Pain: Time to Back Off?” J Am Board Fam Med.  22/1 (2009):62-68

[11] Michelle Brandt, Stanford University Medical Center, “MRI Abundance May Lead To Excess In Back Surgery,” Oct. 14, 2009

[12] Nguyen TH, Randolph, DC, et al. Long-term outcomes of lumbar fusion among workers' compensation subjects: an historical cohort study. Spine, Feb. 15, 2011;36(4):320-331.

[13] J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR (April 6, 2010)

[14] Joanne Silberner, “Surgery May Not Be The Answer To An Aching Back,” All Things Considered, National Public Radio, Melissa Block, host. April 6, 2010

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

[16] Reed Abelson, “Financial Ties Are Cited as Issue in Spine Study,” NY Times, January 30, 2008

[17] Robert J. Barth, “Saying No!—Unjustified Surgeries, Pain Management and Tests,” For the Defense 48/3, (March 2006):33-39. Washington & Lee Law School Current Law Journal Content

[18] Popular painkillers exploding in U.S. by Chris Hawley, The Associated Press, 4/06/2012

[19] Nicole Ostrow,  Infants Born Addicted to Painkillers Tripled in Last Decade, May 1, 2012 Bloomberg News

[20]Jarred W. Younger, Prescription opioid analgesics rapidly change the human brain, PAIN_ 152 (2011) 1803–1810

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

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

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

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

[25] Anthony Rosner, PhD, “Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient,” Dynamic Chiropractic,  20/25  (November 30, 2002)

[26] Greg Cramer, PhD, Dean of Research, National University of Health Sciences, personal communication, April 29, 2009

[27] DR Seaman, JF Winterstein. “Dysafferentiation, a Novel Term To Describe The Neuropathophysiological Effects Of Joint Complex Dysfunction: A Look At Likely Mechanisms Of Symptom Generation,” J. Manipulative Physiol Ther 21 (1998): 267-80.

[28] David Seaman, “Joint Complex Dysfunction, A Novel Term To Replace Subluxation/Subluxation Complex. Etiological And Treatment Considerations,” J. Manip Physiol Ther 20 (1997):634-44.

[29] John J. Triano, et al. “Biomechanics of Spinal Manipulation,” Spine 1 (2001):121-30

[30] Marc S., Micozz, MD, PhD, “Complementary Care: When Is It Appropriate? Who Will Provide It?” Annals of Internal Medicine 129/1  ( July 1998): 65-66

[31]  R. Chou, et al. , “Diagnosis and Treatment of Low Back Pain:  A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society,” Low Back Pain Guidelines Panel, Annals of Internal Medicine 2 147/ 7,  (October 2007): 478-491

[32] Michael D. Freeman PhD, MPH, DC and John M. Mayer DC, PhD, “NASS Contemporary Concepts in Spine Care: Spinal Manipulation Therapy For Acute Low Back Pain,” The Spine Journal, 10/10 (October 2010): 918-940

[33] Ann Rheum Dis. 2003;62:639-643

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

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

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