Articles by JCS
Let the Chips Fall
The supermarket of care for spinal disorders just got more confusing with the release of an RCT by WC Peul et al. Dr. Peul is Director of the Spine Intervention Prognostic Study Group at Leiden University Medical Center. Since 2004, he has been a full time spinal neurosurgeon in The Hague and Chairman of the Spine Center in The Netherlands.
In the lead article of the June edition of The BACK LETTER, “Balancing Costs and Benefits: Is Disc Surgery Cost-Effective?”, Peul and his associates clouded the treatment of sciatica with a study that is filled with dumbfounding comparisons, glaring omissions, and obvious bias. Sadly, this flawed study may be used against conservative treatments despite its obvious shortcomings that only a professional versed in conservative care and manual medicine would notice.
Peul’s study suggests discectomies for sciatica are preferable/cost effective over conservative care in the short term (6 weeks), but admitted not in the long term (6 months). “The advantage was discernible six weeks after surgery but vanished by six months. And there were no significant differences between treatment groups in pain or disability beyond that follow-up point.”
1. Definition of Conservative Care
First of all, there are many concerns about this Peul study, most prominently, the definition of “conservative care.” From the Peul study:
“Treatment methods were straightforward. Those allocated to disc surgery underwent microdiscectomy and removal of loose degenerated disc material from the disc space. General practitioners supervised conservative care. There are no proven nonoperative treatments for sciatica, so the treatment approach was empirical. It included information, reassurance, pain control, and encouragement to return to normal activity. Those who were fearful of movement were referred for physical therapy. Both groups had access to research nurses for advice and encouragement.”
It seems Peul’s definition of conservative care doomed a true comparison before it started in that he failed to offer the most effective treatments such as spinal manipulative therapy, flexion-distraction, non-surgical spinal decompression and active rehab. In essence, they offered cheap advice and pain pills by general practitioners—the typical medical mis-management of back pain. This is ridiculous as well as ineffective, and it is certainly misleading to suggest this represents the best of conservative care.
Considering the avoidance of the best treatments of conservative care that I mention, I did find it ironic that even using inferior conservative treatments still proved comparable in the long run with spine surgery. Apparently the second-string of conservative care proved equal to the best in microdiscectomy in the long run. I can only imagine the results if the best of conservative care were used.
2. No Proven Nonoperative Treatments for Sciatica
I find it peculiar that this author states “There are no proven nonoperative treatments for sciatica.” As a practicing DC who’s personally suffered with sciatica and who’s treated a few thousand sciatica cases over the past 30 years, I find his opinion bizarre, perhaps indicating his professional bias as a neurosurgeon.
This begs the question: is Peul totally unfamiliar with manual medicine or what?
Dr. Peul’s omission is perplexing considering one quick scan of Medline for sciatica/herniated discs/manual medicine would reveal a plethora of studies showing the effectiveness of spinal manipulative therapy, flexion-distraction, and non-surgical spinal decompression for leg pain/herniated discs.
Here is a short sampling of research supporting manual therapy (SMT, Flexion/distraction, non-surgical spinal decompression) for LBP/leg pain:
As I mentioned, this list is just a quick scan, so apparently Peul failed to do his homework when he stated “there are no proven nonoperative treatments for sciatica” and seems to have purposely designed his comparison with rather ineffective methods. Is it any wonder conservative care didn’t score better in his RCT when you consider he avoided using the best of proven conservative treatments? Is this simply a case of oversight or intellectual dishonesty?
The Decade of Bone and Joint Disorders; Evidence-Informed Management of Chronic Low Back Pain Without Surgery gave meager endorsements of Peul’s choices of conservative care. If he were fair in his comparison, why didn’t Peul use the most effective forms of non-invasive conservative care rather than the old medical version of cheap advice and pain pills? Obviously this is a sham comparison of apples to rotten oranges.
3. General Practitioners Incompetence
The fact that Dr. Peul chose general practitioners (GPs) to manage the conservative care group also is strange considering most GPs know very little about musculo-skeletal disorders (MSDs). This is unconscionable considering many studies have shown the incompetence of GPs for diagnosing and treatment of MSDs.
These studies beg the question: if Peul wants an honest portrayal of care using conservative methods, why didn’t he use DCs (or even PTs or DOs) instead of GPs since most health professionals would agree that DCs, if good for anything, are the most prominent managers of conservative care for spinal treatments? Again, perhaps his bias wouldn’t allow using the best conservative care doctors for fear of not reaching his skewed conclusion that “disc surgery is cost-effective. It earns money for society.”
Okay, stop laughing. Certainly it’s true that disc surgery earns money for spine surgeons, surgical device manufacturers, imaging centers, and hospitals, but I seriously question how anyone can suggest spine surgery is a better buy than proper conservative care considering the average total cost of spine surgery and hospitalization (not withstanding disability, rehab, and reoperation) reaches $50,000 to over $100,000 for disc replacements and is shown to be no better in long-term results.
As NM Hadler, MD, wrote in his book, The Last Well Person, when it comes to the medical management of LBP, ''Maybe you're better off not going to a doctor.'' But maybe you’re best off going to a chiropractor, I might add.
Dr. Peul never questions the validity of the suspect disc theory itself as the underlying cause of LBP/leg pain and as the primary focus of treatment, which may explain why the long-term benefits of disc surgery are so poor. Anyone versed in spinal mechanics realizes that the disc is secondary to the motor unit in the spinal area—the functioning of the spinal joints, joint capsules, ligaments, tendons, and muscles.
Basically, the medical examination of a static spine versus the manual medicine dynamic evaluation is, again, comparing apples to oranges. Even NM Hadler questions the point of MRI exams for LBP: “Why is it so important to define the anatomy of the lumbo-sacral spine of patients with regional low back pain?...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.”
Considering the disc abnormalities found on MRIs are often incidental to back pain, other than to rule out the rare red flags like cancer or fracture, imaging tests seem to be most useful as selling points rather than as finding the source of the pain. Until the medical profession recognizes this problem of misdiagnosis, patients will continue to be mistreated and misinformed about the actual cause and best treatment for their back and leg pain.
Many researchers have questioned the disc theory as the prominent cause of spine disorders, referring to these imaging findings a “false-positives” or “incidentalomas”:
“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 disks are frequently incidental findings…Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”
“‘Ruptured discs and ‘bad back’ are terms that deserve to be relegated to the historical archives…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.
“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.”
Regrettably, the “incidentalomas” seen on imaging are effective selling points by unethical surgeons who know better, but profit greatly by misleading patients with “false positives” on images. If that selling point fails to close the sale, too often patients are given the voodoo diagnosis by unethical surgeons when asked if chiropractic care might help: “If you’re dumb enough to go to a chiropractor, don’t come crawling back to me when you’re paralyzed.” Don’t laugh because if I’ve heard this once, I’ve heard it a thousand times.
5. Similar Long Term Results
Ironically, even when using ineffective treatments like cheap advice and pain pills, the outcomes with surgery were comparable later on.
“There were no significant differences between treatment groups beyond six months. Results of the two groups were identical at one-year follow-up in terms of pain, disability, and global outcome. Over the course of the first year, 95% of both groups reported complete recovery.”
The SPORT study published in JAMA also showed that patients with low back and leg pain who underwent spinal surgery fared no better two years later than those who used non-invasive therapy. Again the obvious question remains: why are they doing expensive, risky surgery when the long term results are no better, even when compared to weak conservative treatments as in the Peul study? No one wants to answer that question because it’s good for business as Dr. Peul suggests.
According to The National Academy of Science, implementation of new treatments is slower than one might expect in this era of evidence-based healthcare. Indeed, if the electronic industry were as slow as medicine, we’d still be in the vacuum tube era.
“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...”
Dr. Thomas Errico, past president of the North American Spine Society, told the NY Times that surgery is a last resort, but he also failed to mention manual medicine in his care. “His patients have X-rays or MRI's. They try over-the-counter anti-inflammatory drugs. They are given an exercise program, or get muscle relaxants or painkilling injections. They are told to stretch and to get their weight under control. They might get a steroid injected into the spine to reduce inflammation.
''That's what the vast majority of the 3,700 members of the North American Spine Society do,'' Dr. Errico said. ''The vast majority discourage surgery or don't offer surgery as the first recourse.''
While he contends surgeons don’t encourage surgery as the first recourse, Dr. Errico failed to mention the role of manual medicine in the care of these cases. Similar to Dr. Peul’s skewed version of conservative care consisting of advice and pain pills, most of these spine surgeons consistently fail to refer to DCs for hands-on spinal therapy that has proven successful in these cases. This oversight certainly isn’t “informed decision making” nor is it ethical to exclude the entire world of manual medicine.
I can only imagine the improved outcomes if manual medicine treatments were used instead of the medical model of advice, pain pills, ESIs, MRIs leading to spine surgery. Presently, many international guidelines on back pain recommend manual medicine as a front line treatment, but the status quo medical approach has yet to change.
Here is a list of the most recent guidelines that endorse manual medicine for spinal problems.
No longer can our medical adversaries say there is no research or recommendations by significant groups on the value of manual medicine. Now the biggest obstacle is the medical profession that stands to lose business if their profession actually follows these international guidelines, but I’m not holding my breath. Recall the backlash by the North American Spine Society after the AHCPR guideline was released.
After the release of AHCPR 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. 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.”
According to RD Guyer, MD, TBI founder and current NASS president, in his recent presidential address, he admits the huge money involved in the spine business. “The stakes are great as there is big money in spine…in 2005 dollars, between $100 and $200 billion per year are spent on spine care…US spinal device manufacturers was estimated at $2.5 billion.”
Indeed, most spine studies (BEAM, SPORT, Meade, Norway Spine Study, Swedish Lumbar Spine Study) have come to the same conclusion that there is ample evidence for manual medicine for LBP as noted by the AHCPR guideline on acute low back pain or the new Decade of Bone and Joint Disorders study on chronic back pain. The AHCPR suggested a course of spinal manipulation should be completed before surgical consult is even considered. But have these recommendations increased the referrals to manual medicine practitioners? Of course not! Professional bias supersedes any evidence-based research that might shift money from the pockets of surgeons.
Even Rick Deyo, MD, MPH, renowned spine researcher, admits:
''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. Deyo also admitted, “More people are interested in getting on the gravy train than on stopping the gravy train.”
As Upton Sinclair once said, “It is difficult to get a man to understand something when his salary depends on his not understanding it.” The NASS v. AHCPR debacle perfectly illustrated this conflict of interest in medicine. Sadly, in this era of evidence-informed management of back pain with or without sciatica, the bottom line rests not with the evidence as much as it rests with profitability.
6. Joint Play
Dr. Peul’s focus as a neurosurgeon on disc abnormalities completely ignores the fact that many back pain problems may stem from the loss of joint play and the subsequent inflammatory response that are resolved by manual medicine and anti-inflammatory treatments like aspirin and simple cold packs as the AHCPR guideline recommended. In fact, the disc is a secondary player in the back/leg pain syndrome according to many researchers.
The paradigm shift in spinal care required by the medical profession is to acknowledge there are 137 spinal joints that can be misaligned, buckled, twisted, wrench apart or fixated to cause a variety of movement problems and pain. Indeed, you don’t slip discs as much as you slip joints.
Overloading, compression, bad leverage combined with spinal injuries from childhood, sports, and accidents lead to loss of joint play causing axial pain and may lead to neurological deficits due to inflammation/compression. Trying to explain this complex cascade of events with the disc abnormality as the sole cause is simplistic and misleading, perhaps explaining the poor results from fusion and the short-lived results from microdiscectomy. In effect, the disc does nothing until forced to by the dynamics of spinal mechanics.
Not only can joint dysfunction cause axial pain and disc abnormalities, new research has shown that joint dysfunction may also cause radiculopathy like sciatica, a condition long equated to disc herniation, according to a recent study by H. Tachihara et al. in Spine.
“When inflammation was induced in a facet joint, inflammatory reactions spread to nerve roots, and leg symptoms were induced by chemical factors. These results support the possibility that facet joint inflammation induces radiculopathy.”
JL Shaw, MD, mentioned years ago that joint dysfunction, particularly the sacroiliac joint, may cause herniation:
“Joint dysfunctions are the major cause of LBP as well as the primary factor causing disc space degeneration and ultimate herniation of disc material.”
Other orthopedists agree with Shaw.
“The sacroiliac joint appears to be the single greatest cause of back pain...when the normal joint play is lost, agonizing pain can be precipitated.”
John McMillan Mennell, MD, testified at the Wilk et al. v. AMA et al. antitrust trial of the role of joint function in LBP:
“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.
“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.”
More recently, research conducted at the Texas Back Institute investigated the joint dysfunction in LBP. According to research by John Triano, DC, PhD, et al., the accumulative effect from traumatic injuries during childhood compounded in adulthood by the effects from gravity and obesity increasing spinal compression aggravated by prolonged sitting/standing, improper lifting, accidents, will develop a functional spinal lesion that causes a “segmental buckling effect.”
Regrettably, despite the many studies supporting the use of manual medicine in the treatment of LBP/leg pain, Peul’s study will be used to dash the role of manual medicine in these cases. Peul’s omission of the best conservative care is reminiscent of the flawed study by Tim Carey, MD, MPH, director of the Cecil G. Sheps Center for Health Services Research. In a cost-comparison study comparing SMT by DCs, drugs by GPs, and modality treatments by PTs, Carey excluded back surgery by spine surgeons. The media then announced that chiropractic care was more expensive than medical care for LBP. How can any researcher supposedly compare spine treatments and exclude spine surgery? Carey’s bias is overwhelming and stands as another example of misleading research.
The recent 2007 guidelines for LBP issued by the American Pain Society also mentions grave concerns about back surgery:
“Some studies have shown no benefit of surgery compared with intensive interdisciplinary rehabilitation, with a significant proportion of patients experiencing suboptimal outcomes, including persistent pain or functional deficits after surgery. On the basis of the evidence, Dr. Roger Chou said, they were unable to give strong recommendations for surgery, "but we think there may be some patients for whom surgery, fusion specifically, might be helpful, but it's really important for doctors to discuss the fact that surgery doesn't tend to lead to huge improvements on average," he said. “You're talking about a 10- to 20-point improvement in function on a 100-point scale, so that's pretty small, and a significant proportion of patients still need to take pain medication and don't return to full function."
Dr. Tim Johnson, ABC World News medical spokesman, asks the appropriate question: “So why are so many back surgeries performed in this country? It could be a combination of too many surgeons who are too eager to operate and the impatience of many patients who want results quickly. The truth is that 90 percent of back pain can be resolved without surgery if both doctors and patients are willing to try other treatments that basically help the back to heal itself.”
Perhaps Dr. Jerry Groopman answered Johnson’s question when he admitted: "If I don't do them, they'll go around the corner and the other surgeon will.”
Sadly, Dr. Peul’s skewed comparison and unconvincing conclusion that disc surgery is cost-effective over so-called conservative methods is a disservice to the millions of back/leg pain patients seeking relief. Dr. Scott Haldeman of the BJD research study admits there are over 200 treatments now used for chronic LBP, which makes a formidable choice for consumers, but skewed studies like Peul’s only throws more confusion into this mess.
And the question of relapse has obvious implications in the clinical management of disc herniations, to which even Peul notes. “Physicians guiding patients with sciatica should remember that the long-term prognosis may be less favorable than is suggested by the first impression after successful treatment,” Peul suggests. Finally, he gives some credible advice, but fails to mention the severity of failed back surgery.
Of the 80,000 new cases of failed back surgery syndrome per year in the US, 60% of initial surgeries were deemed successful with a 19% reoperation rate. The success rate drops to 30% after a second surgery, 15% after a third surgery, and 5% after a fourth surgery. This is a good example of “throwing good money in after bad,” but it hasn’t slowed the spine surgeons whatsoever.
I recall a private communication a few years ago with Dr. Scott Boden, Director of Emory Orthopaedics & Spine Center and cohort in the SPORT study. When speaking of the high spine surgery rates in middle Georgia, Dr. Boden said, “I’d just wish they’d come to see me before the first surgery than after the third.”
Finally, an honest surgeon!
Not only is the long term outcome for surgery no better than for conservative care, another factor is omitted to patients—the fact that most will still be living on pain pills, another point conveniently omitted by Peul.
“The definition of success did not consider pain relief or opioid medication use. Even among the patients classified as having a successful result, most were still using narcotic medications at the 2-year follow-up, including 64% of the successful-result patients in the disc replacement group and 84% in the fusion group.”
Peul’s misleading RCT did nothing to improve patient outcomes as much as it perpetuates mistaken beliefs and disparaged the benefits of “real” conservative care. The fact is the drugs/shots/surgery approach to spinal pain has not proven effective as noted by the editors of The BACK LETTER.
"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.”
The problems with Peul’s study is obvious to astute practitioners in this field. For too long practitioners of manual medicine have been ignored, marginalized, and their methods have been deemed “experimental and unproven” despite the good clinical results. Even when recent RCTs and international guidelines recommend manual medicine for spinal disorders, it is given short shrift by those who suffer from a professional prejudice.
Paul Goodley, orthopedic physician, author of Release from Pain, and long-time promoter of manual medicine, coined a term, Fundamental Flaw, concerning the antipathy of mainstream medicine to manual medicine that he contends as led to a pandemic of pain. I might add it has also led to a pandemic of unnecessary drugs, shots, MRIs, spine surgery and skewed research.
“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.”
Even medical critics like NM Hadler, MD, author of The Last Well Person, who willingly debunks the disc theory, MRIs, and spinal surgery, still has trouble admitting the need for manual medicine in his own practice.
“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 for my own next predicament of a regional musculo-skeletal disorder? Should I refer my patients to such practitioners?”
Of course he should, but even Dr. Hadler has difficulty overcoming his own Fundamental Flaw by admitting those nefarious chiropractors and proponents of manual medicine might have been right all along. Indeed, it’s a bitter pill to swallow after a century of bias against those damn chiropractors.
Apparently international medicine has moved past its fascination with spine surgery (although not here in the USA that leads the world in spine surgery per capita) and these costly, ineffective, and crippling surgeries will rank top on the list of once routine but now considered unnecessary surgery like tonsillectomy, hysterectomy, and appendectomy. Sadly, spine surgery has left a wake of disability costs and impairment unlike these outdated surgeries, but flawed studies like Peul’s will only add to the suffering of patients who are not given adequate evidence-based information to make an informed decision.
There are some people within the USA research realm who admit there is a need to think out of the medical box. According to well known spine researcher, Daniel Cherkin, PhD, there is the
“…possibility that our thinking about back pain is fundamentally wrong. We may be missing something important. And that could be why we have not come up with any dramatic advances. And if that is the case, then the implication is that we need new paradigms. And that once we find the best paradigm, we will make more progress.”
George Lundberg, MD, Medscape Editor in Chief and former editor-in-chief of JAMA, once told me in private communication:
“If some influential individual or group in chiropractic would follow your thesis, and would loudly and openly embrace EBM, let the chips fall where they may, …then I and many other physicians could openly and without fear and derision look at what 2005 EBM chiropractors actually do and go forward together.”
I accept Dr. Lundberg’s challenge wholeheartedly to let the chips fall where they may in regards to manual medicine for spinal disorders, principally LBP and leg pain in this case. But will the AMA be as open to do the same and accept this challenge?
Considering back surgery ranks with heart surgery among the most profitable for surgeons and hospitals, the resistance to manual medicine is obvious. Indeed, in American healthcare, the cheaper mousetrap is not usually a welcome to those who profit dearly from the status quo.
“The extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization. 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.”
Sadly, skewed RCTs like Peul’s will only add to the gravy train by discouraging the implementation of effective conservative care into the mainstream. Little will patients know when they’re told about the ineffectiveness of “conservative care” that, in fact, it was the least effective methods used instead of the most effective treatments.
Again, I challenge the spine researchers like Peul, Deyo, Weinstein, Boden and all others to make a direct comparison of the best of manual medicine versus the medical model of drugs, shots, and surgery. Stop using sham treatments like cheap advice and pain pills and calling them “conservative care” that only clouds the issue. Remove the inherent Fundamental Flaw and let’s judge our various treatments for once on a level playing field using the best players possible.
Recently the AMA House of Delegates apologized for racism toward black physicians. I say it’s about time it did the same about its bias toward DCs and manipulative medicine with its professional racism/Fundamental Flaw toward DCs and manual medicine. It may stick in the craw of many mainstream medical researchers and practitioners to admit that manual medicine and chiropractors won’t go away despite their efforts to thwart its growth, soil its reputation, and skew the research findings as we’ve seen over the past century.
It’s time for mainstream medicine to heal itself of this Fundamental Flaw toward manual medicine and give credit where credit has long been due. The patients deserve it and the DCs and manual medical providers also deserve a break to be unshackled from medical prejudice. Let’s give these patients the best of all worlds, including chiropractic care.
Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: Two-year results of a randomized controlled trial, BMJ, 2008.
vol. 23, no. 6, 2008
Haldeman et al.; The Spine Journal, January/Feb 2008,Volume 8, Number 1
JAMA, Need for less imaging, better understanding June 4, 2003 vol. 289 no. 21
Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70.
 JAMA, Need for less imaging, better understanding June 4, 2003 vol. 289 no. 21
 Weinstein et al. Nov. 2006, JAMA
 Crossing the Quality Chasm: A New Health System for the 21st Century, The National Academy of Sciences, 2001. page 13-14.
“With Costs Rising, Treating Back Pain Often Seems Futile” by Gina Kolata, NY Times, February 9, 2004
 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.
 Richard D. Guyer, Presidential address, “The paradox in medicine today—exciting technology and economic challenges, The Spine Journal, Vol. 8, No. 2, March/April 2008, pp. 279-285.
“With Costs Rising, Treating Back Pain Often Seems Futile” by Gina Kolata, NY Times, February 9, 2004.
 Reed Abelson, Financial Ties Are Cited as Issue in Spine Study, NY Times, January 30, 2008
Tachihara H, Kikuchi S, Konno S, Sekiguchi M. Does facet joint inflammation induce radiculopathy?: an investigation using a rat model of lumbar facet joint inflammation. Spine. 2007 Feb 15;32(4):406-12.
 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.
 Bourdillon JF, Day EA (1987) Spinal manipulation, 4th edition, William Heineman medical books, London, 216-217.
 Triano J Biomechanics of spinal manipulation. Spine 2001;1:121-30.
Carey TS, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. NEJM 1995; 333:913-7.
Low Back Pain Guidelines Expanded to Include Interventional Procedures, American Pain Society 27th Annual Scientific Meeting: Symposium 312. Presented May 8, 2008.
Back Surgery Not Always the Cure for Pain; U.S. Leads the World in Procedures That Some Experts Say Could Be Avoided, by Dr. Timothy Johnson , ABC World News, May 23, 2006
 The New Yorker magazine by Dr. Jerry Groopman, "Knife in the Back,” (April 8, 2002)
Ragab A and Deshazo RD, Management of back pain in patients with previous back surgery, The American Journal of Medicine, 2008; 121:272-8.
 Mirza, Sohail K. MD, MPH, Point of View: Commentary on the Research Reports that Led to Food and Drug Administration Approval of an Artificial Disc, Spine: 30(14) 15 July 2005 pp 1561-1564.
 The BackLetter, vol.12, no. 7, pp.79 July, 2004. The BackPage editorial, The BackLetter, pp. 84, vol. 20, No. 7, 2005.
The Back Letter, vol. 23, No. 5, 2008, pp. 55.
 Kuttner, R., Market-Based Failure — A Second Opinion on U.S. Health Care Costs, NEJM, Vol 358:549-551 Feb. 7, 2008, Number 6.