Articles by JCS

Moratorium on Surgery

Moratorium on Back Surgeries

 

There’s a new and unlikely champion in spine care. Similar to the underdog boxer Rocky fighting the overpowering champ, Apollo Creed, not only does Rocky go the distance, but eventually he came out on top.

Now it’s time for the entire chiropractic profession to take a victory lap in its upset of the toughest of all opponents – the medical industrial complex including primary care providers, surgeons, pain management, pharmacists, imaging centers, hospitals, all who have profited dearly but have badly mismanaged the pandemic of back pain.

How hard would you fight if the purse were $177 billion, the cost of medical spine care annually? Indeed, pride, prejudice and profit are strong motivators.

Just as we witnessed in the Rocky movie, this medical fight has been a blood bath not only for chiropractors who were jailed, ridiculed and boycotted, but it has been a bloody mess for patients who have suffered from opioid abuse and addiction, unnecessary and ineffective back surgeries, and the wake of disability and hopelessness that follows this medical spine care fiasco.

But in the last round of this fight, after the dust settled and the facts were evaluated, the chiropractic profession was crowned a new champion in this fight.

After the ringside judges evaluated the new research and guidelines, it’s time for chiropractors to take center ring, raise our fists in victory and explain why our methods work so well without drugs, shots, or surgery – the untold story of chiropractic.

In the medical fight, we were not dominating, but we did prevail. Just like Rocky, if chiropractors weren’t able to hang onto the ropes at times during this one-sided fight, the art of SMT would have been KO’d. Thankfully our predecessors were courageous men and women who sacrifices were finally rewarded.

Just as Apollo Creed terrified Rocky, so too the AMA represented the most ominous foe ever for principled chiropractors who were saved by the bell along with their healing art of spinal manipulation even though bruised by dirty punches, hit with low blows and defamed by character assassinations. Although battered, our predecessors repeatedly got off the mat by the 8 count to keep up the good fight.

It’s past time to crown a new champion in spine care – chiropractors. Today every DC must stand tall with their fists in the air after surviving this brutal fight being declared victorious, finally.

New Guidelines: Chiropractors Were Right!

With the tragic opioid crisis and a growing litany of studies discouraging the use of spine surgery, people are taking another look at the management of spine-related disorders in midst of this Quiet Epidemic of chronic pain that affects millions of people annually.

With new guidelines endorsing “hands-on” care, headlines such as “Spinal Manipulation Therapy for Low Back Pain Linked to Improved Pain and Function” would never have appeared just a few years ago; indeed, the research now speaks clearly in favor of chiropractors and can no longer be denied by any medical troll.

On February 14, 2017, spinal manipulative therapy (SMT), the mainstay of chiropractic care, was recommended as a front-line treatment by the updated American College of Physicians (ACP) guidelines.

Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation.  If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants. (Grade: strong recommendation)

Recommendation 2:

For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation. (Grade: strong recommendation)

As you may notice, the new guidelines did not recommend medical spine care for initial care including all OTC drugs and especially opioid painkillers, epidural shots or surgery.

Numerous studies also confirm most primary care physicians are inept in their training on musculoskeletal disorders,[1] more likely to ignore recent guidelines[2], more likely to suggest spine surgery than surgeons themselves[3], and most likely to prescribe opioid painkillers.[4]

The belief primary care physicians are inept in MSDs was stated by Dr. Marc Siegel on his FOX News report when he admitted MDs have only 9 hours on “back” as well as stating, “We’re getting a growing awareness of two things: the abuse of back surgery and the abuse of opioids.”

Dr. Marc Siegel on FOX News.

Click on arrow to begin video.

This plethora of critical studies has been a huge blow to the medical spine establishment that should not have come as a surprise considering the first knockout punch in 1994 was thrown when the AHCPR guideline #14 on acute low back pain in adults, a remarkable study ditched by political medicine, recommended SMT as a “proven treatment.”[5]

The Joint Commission’s policy revision in 2014 to include chiropractic care and the National Pain Strategy study in 2016 on opioid abuse certainly helped to open the same door that the medical establishment kept closed to DCs for decades.

Ironically, the Joint Commission was the thug behind the AMA’s boycott of chiropractic by enforcing the illegal medical ethics of the Committee on Quackery with the loss of licensure if a hospital or MD worked with chiropractors.

After the ACP recommendations, on April 11, 2017, another supportive study was released in JAMA: “Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis,” that also recommends spinal manipulation as a first-line treatment for LBP.

According to this systematic review and meta-analysis[6]:

“Spinal manipulative therapy (SMT) is associated with moderate improvements in pain and function in patients with acute low back pain (LBP).”

Despite our paper victory, lest we not forget strewn along the path of medical iatrogenesis are the victims of opioid addiction and failed back surgery. In the wake of failed medical spine care are the millions left addicted to opioid painkillers of which nearly 30% are taken alone for LBP[7], the leading cause of disability in the nation, workplace, military and VA. Imagine if we could get our hands on this 30% before MDs give them opioids.

Moratorium on Medical Spine Care

Empowered by numerous research studies and evidence-based guidelines, chiropractors immediately should call for a moratorium on medical spine care due to the devastation of opioid painkillers, the unapproved and “underwhelming” epidural steroid injections, and, of course, ineffective, expensive, disabling spine fusions.

Indeed, the evidence has never been clearer that medical spine care is a “national scandal” as editor Mark Schoene admitted. Many mainstream media have already set the stage for a declaration to reevaluate the madness in spine medicine:

This article is a must-read and includes the frank conclusion:

"But at a broader level, the rapid rise of spinal fusions in the United States, especially for diagnoses that generally don’t require the procedure, has raised questions from experts about whether, amid medical uncertainty, the financial rewards are spurring the boom.
"

Aside from the guidelines and media reports debunking medical spine care, this call for a moratorium is not a new issue since a few ethical surgeons have also commented on this wave of unnecessary surgery.

Here are five instances where MDs call for a moratorium:

  1. In 1993, Alf Nachemson, MD, PhD, (1931-2006) spoke of issues plaguing spine care in America. Keep in mind Dr. Nachemson was an “exceptional pioneer in spine care” as the primary thought-leader, researcher, and for 20 years he was co-editor of SPINE, the bible of spine surgeons.

In other words, his opinion is huge as the godfather of spine surgeons.

His editorial, “Low-back pain: Are orthopedic surgeons missing the boat?” makes an argument for a moratorium on spine surgeries:

 “During the last decade we have seen an enormous increase in imaging and surgical technology. CT, MRI, etc. demonstrate anatomic changes which often have no importance at all for the patient’s pain. New surgical methods are constantly being introduced and presented in uncontrolled case series. Orthopedists, trained for surgical solutions, are too quick to use the new screws, hooks, pins and needles, promoted by the inventors and the instrument companies despite mediocre results and many complications.[8]

After 60 years of surgical experimentation we seem to have reached an impasse. Given the potential risks of our interventions with various ingenious contraptions for the lumbar spine, and the lack of clinically proven success, there should, perhaps with a few exceptions be a moratorium on unproven invasive methods for the treatment of chronic low-back pain.”

Clearly orthopedists are missing the boat, but few seem to care since they’re the wealthiest of all physicians and most people remain convince surgery is the best solution.

  1. Another thought-leader was Hubert L. Rosomoff, MD, (1927-2008) medical director of the Comprehensive Pain and Rehabilitation Center at the University of Miami School of Medicine.

Back in the 1970s he admittedly did a lot of back surgery, but found out there wasn’t the need when he started patients on an intensive pre-surgical rehabilitation program. He realized after two weeks of rehab, patients no longer had indications for surgery.

Dr. Rosomoff called a moratorium in 2001 on back surgeries by telling patients they had to go through rehab before he’d operate. "Nobody got operated on in the first six months" with a resulting 99 percent drop in surgeries. “In fact, the incidence of surgery if one really looks at this appropriately is one in 500."[9]  

Rosomoff bases his therapy on the premise that many operations for back pain are “addressing the wrong problem.” He believes the source of most agony is not the injury to a vertebra or disc but to the muscles surrounding it. These muscles are sending the urgent messages to the brain that result in pain—and it is the proper realignment of the body after an accident or other trauma that will make the pain go away.[10] We can only wonder if he had a DC on staff using manual adjustments to realign the spine.

  1. Another critical review of unnecessary and ineffective spine surgeries appeared recently by Dr. Kamshad Raiszadeh, MD, author of the 2016 book, Take Back Control: A Surgeon’s Guide to Healing Your Spine Without Medications or Surgery, who admitted, “Surgery is risky, it has a long recovery period, and often it just doesn’t work for chronic low back pain.”

It might even make the problem worse. My advice: exhaust every possible option first. The good news is there are better options,” he adds. “The system is slowly shifting toward prevention and natural healing methods for spine conditions, and for good reason. Not only are these options a fraction of the cost of surgery, for many patients these methods simply work better.”

Bad MRI findings are NOT a valid reason to have surgery. “It is very common for adults to have abnormal MRI readings—even those who don’t have low back pain or sciatica,” he says. “It does not usually justify a surgery that will require weeks of recuperation and time out of work and could be ineffective at curing the pain in the first place. Very often, surgery won’t cure back pain anyway.

Without an evident reason for pain, like instability, nerve compression or a fracture, surgery has an inconsistent record of success and shouldn’t be rushed. Most back pain will resolve itself when you take a “wait and see” approach.

Although Dr. Raiszadeh’s comments were insightful, his treatise was written before the ACP and JAMA recommendations were published. It is also evident he has not worked directly with DCs to understand a “wait and see” approach would be facilitated by first addressing joint dysfunction.

In each of these cases, it is obvious even these progressive surgeons who are willing to admit medical spine care is a bust still have a blind spot about chiropractic care.

Waiting Period Down Under

We now hear the call for restraint from Down Under.

  1. Spinal Fusion Surgeries Questioned,” an article published by the Medical Journal of Australia in its InSight newsletter on April 26, 2016, spoke of the urgent need to stop the tsunami of back surgeries:

“Spinal fusion surgeries for chronic low back pain are on the rise, despite the lack of research to back their efficacy, and experts are now calling for tighter guidelines, including a waiting period.”

The dire results of surgery for low back pain became evident in a 2012 study Down Under illustrating workers' compensation in New South Wales found only 3 per cent had returned to pre-injury work duties two years after surgery. About 70 per cent were still taking strong opioids such as OxyContin in an attempt to manage their pain.

         


POLL of Readers of MJA article

Is spinal fusion surgery being done too often?

  • Yes, there isn't the evidence to support it (71%, 148 Votes)
  • Maybe, the jury's out (17%, 35 Votes)
  • No, in my experience it is effective (12%, 24 Votes)

Dr. Richard Williams, orthopaedic surgeon and spokesperson for the Royal Australasian College of Surgeons, told MJA InSight that a key regulation called for a waiting period of 12 months before a spinal fusion surgery was performed, noting "Most patients will recover after these 12 months” without any surgery.

Professor Jeffrey Rosenfeld, senior neurosurgeon at the Alfred Hospital and director  of the Monash Institute of Medical Engineering,  also mentioned for patients who do not have clear indicators for spinal fusion surgery (the “red flags” of cancer, fracture, infections), a non-invasive multidisciplinary approach is preferable, which includes chiropractors

 “This will often give people better long-term pain outcomes than having multiple spinal surgeries.”[11]

  1. In February, 2016, spine surgery was again deemed “the ultimate placebo” by Australian spine surgeon Ian Harris in his book, Surgery, the Ultimate PlaceboA Surgeon Cuts through the Evidence.[12] 

According to Dr. Harris, spine fusion is not only ineffective but often leads to complications and even when it appears to work it's usually because of the placebo effect:  

“Millions of people have had spine fusions for back pain and I am not at all convinced that the benefits of this surgery outweigh the considerable harmsthere is very little evidence that spine fusion surgery for back pain is effective. It is very expensive (the implants alone are often tens of thousands of dollars per case), often leads to complications, often requires further surgery, is associated with increased mortality, and often does not even result in the spine being fused.”[13]

Dr. Harris understands the incentive of big money motivates these spine surgeons:

“At an average cost of $100,000 each, I am certainly not convinced that it is worth $50 billion a year. Somebody is winning here and it isn't the patients.”

Professor Harris said some surgeons also continued to perform spinal fusion surgery to treat low back pain despite studies showing no benefit over non-surgical alternatives. Why does that not come as a surprise? Obviously spine surgeons will not give up their cash cow as long as patients seek them and payers pay them.

Not Slipped Discs, but Slipped Joints

I believe the public needs to know why 75% of patients with spine fusions fail to improve. The public will remain easy to fool as long as they have the mistaken belief a back attack is mainly due to a “slipped” or “bad disc”  that necessitates back surgery. Unfortunately, this notion has been disproven by science but promoted by unethical surgeons upon gullible patients eager for a “quick fix.”

Chien-Jen Hsu, MD, commented on this dilemma: “By far the number one reason back surgeries are not effective and some patients experience continued pain after surgery is because the [disc] lesion that was operated on is not, in fact, the cause of the patient’s pain.”[14]

In fact, this “bad disc” notion has been debunked by numerous studies over the past three decades but remains an urban legend believed by most people and kept alive by surgeons.

The research undermining “bad discs” began with Scott Boden, MD, now director of the Emory Spine Center, and Sam W. Wiesel, MD, chair of Orthopaedic Surgery at Georgetown University, who conducted the first MRI analysis in 1990 that found “bad discs” in pain-free people.[15]

In 2014 the Mayo Clinic conducted a systematic review of 33 worldwide studies since Boden’s first studyd that confirmed “bad discs” were prevalent in almost every adult, including many who were pain-free.[16]

CONCLUSIONS: Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient's clinical condition.

Patients are rarely told these bad discs are ubiquitous—appearing in 80% of 50-year old people who are pain-free – and  surgeons have no qualms convincing unaware patients these “incidentalomas” are the source of pain and need fusion. “I can prove it to you. Just look right here at this bad disc,” the surgeon tells the unsuspecting patient, suggesting it is reason enough to have a fusion.

Unfortunately, this important Mayo Clinic review never went viral in the media to warn the public of this common “bad disc” misdiagnosis used to railroad patients into unnecessary spine surgeries. And it may never as long as MDs control health news on television.

For example, Dr. Sanjay Gupta @ CNN who works alongside Dr. Boden at Emory has never revealed Boden’s study or the Mayo review to his viewers that certainly would have helped millions of people avoid fusion surgery if they only knew the truth.

Plus, I have to say the chiropractic profession has also been negligent to inform the public of this major research debunking the basis for most spine fusions. Imagine the billions of dollars saved and the millions of people whose lives would improve if they knew the “bad disc” diagnosis is invalid.

Indeed, this would be sweet revenge for the century of defamation our profession has endured if we were to successfully bring these research facts and new guidelines recommending our wonderful healing art to the suffering public around the world.

Today research confirms the role of joints in back pain and the value of manipulation. Two studies led by Donald Murphy DC, DACAN, found joint dysfunction was the cause of neck pain in 69 percent of cases and the cause of low back pain (lumbar and sacroiliac) in 50 percent of patients.[17],[18]

A 2006 study on lumbar spinal stenosis, also led by Dr. Murphy and Eric L. Hurwitz, DC, found patients treated with manipulative therapy had an astounding self-rated improvement of 75 percent overall.[19] Dr. Murphy is now involved with the Primary Spine Provider Network to train DCs and PTs to be primary spine providers inasmuch as medical primary providers are woefully ill-trained in MSDs.[20]

Not only did Dr. Murphy’s study support the use of spinal manipulative therapy for spinal stenosis, it also proves another point in the argument of physiology versus anatomy.

Although he showed a 75 percent success rate for pain control, these patients afterwards still had the pathoanatomy of spinal stenosis, just as patients with degenerative disc disease who improved with chiropractic care still have bad discs afterwards. What improved was the functioning of spinal mechanics while the pathoanatomy remained the same.

Dr. Murphy addressed this paradox:

Clearly the pathoanatomy did not change. We have this discussion frequently in the neurosurgery department when I make the point that the spine is capable of handling pathoanatomy as long as the physiology is right (and psychology, of course).

Pathoanatomy only creates the potential for pain. Physiology is what determines whether pain actually occurs or not, and psychology determines how much suffering results from that pain.”[21]

The question whether or not SMT is the best type of conservative care for the pandemic of low back pain was also explained by John McMillan Mennell, MD, who enlightened the court as to the value of spinal manipulation during his testimony at the Wilk trial:

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.”[22]

Until this information reaches the public, people will continue to be railroaded by corrupt MDs down the path of opioids, ESI, and spine surgery that has led to the current scandal in spine care.

“Chiropractors Were Right All Along”

If we seek transformational action, isn’t it time now with the new guidelines and research to use disruptive journalism and advertisements to inform the public that “Chiropractors were right all along”? That statement will stir the pot of controversy and get more media attention than all the WOC stories ever done.



[1] EA Joy, S Van Hala, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/11 (November 2004).

[2] 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.

[3] 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.

[4] Jonathan Chen, Overprescribing of opioids is not limited to a few bad apples, Stanford Medicine News Center, Dec 14 2015

[5] Bigos et al. U.S. 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)

[6] Paige NM, Miake-Lye IM, Booth MS, et al. Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain systematic review and meta-analysis. JAMA. 2017; 317(14):1451-1460. doi:10.1001/jama.2017.3086

[7] Denise Boudreau, PhD, Michael Von Korff, ScD, Carolyn M. Rutter, PhD, Kathleen Saunders, G. Thomas Ray, Mark D. Sullivan, MD, PhD, Cynthia Campbell, PhD, Joseph O. Merrill, MD, MPH, Michael J. Silverberg, PhD, MPH, Caleb Banta-Green, and Constance Weisner, DrPH, MSW. “Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain,” Pharmacoepidemiol Drug Saf. 2009 December; 18(12): 1166–1175. doi:10.1002/pds.1833.

[8] Alf Nachemson (1993) Low-back pain: Are orthopedic surgeons missing the boat?, Acta Orthopaedica Scandinavica, 64:1, 1-2, DOI: 10.3109/17453679308994515

[9] Lisette Hilton, Failed Back Syndrome: The Disturbing Statistics, Special To DG News, February 20, 2001

[10] http://people.com/archive/hubert-rosomoff-only-hurts-the-back-pain-patients-he-loves-vol-27-no-20/

[11] Charlotte Mitchell, Spinal fusion surgeries questioned, MJA InSight, 26 April, 2016

[13] “Back pain? Try some placebo surgery,” Ian Harris, THE AGE, February 26, 2016

[14] CJ Hsu, et al. “Clinical Follow Up After Instrumentation-Augmented Lumbar Spinal Surgery in Patients with Unsatisfactory Outcomes. In Journal of Neurosurgery,” Spine 5/4 (October 2006):281-286.

[15] 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.

[16]  Painless Aging, BackLetter: February 2015 - Volume 30 - Issue 2 - p 13–22

[17] Donald R Murphy and Eric L Hurwitz, Application of a diagnosis-based clinical decision guide in patients with neck pain, Chiropractic & Manual Therapies 2011, 19:19

[18] Donald R Murphy and Eric L Hurwitz, “Application of a diagnosis-based clinical decision guide in patients with low back pain,” Chiropractic & Manual Therapies 2011, 19:26

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

[20] KB Freedman, J Bernstein, “The Adequacy Of Medical School Education In Musculoskeletal Medicine,” J Bone Joint Surg Am. 80/10 (1998):1421-7

[21] Donald Murphy in private communication with JC Smith, July 20, 2012 

[22] Transcript of testimony of John McMillan Mennell, M.D., Wilk v AMA transcript pp. 2090-2093.


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