Articles by JCS
Fusions Strike Out
JC Smith, MA, DC
The era of evidence-based health care has reached a critical juncture in the spine care industry in America. Actually, it was more of a collision course that was inevitable considering the high costs, poor outcomes, and unsustainable escalation of drugs, shots, and back surgeries. As one of the most expensive types of care, it was a gravy train that was bound to be derailed. Indeed, the medical overuse of unnecessary and expensive back treatments and surgery has finally been revealed to the public unlike ever before.
Although chiropractors and spine researchers have long said many back surgeries were unnecessary, this call was ignored by the mainstream press and certainly by the mainstream medical profession. Now the latest call for restraint of spine fusions stems from medical editors, journalists in the public media, and, most importantly, from the insurance payers. Finally in this era of “budgetary belt-tightening”, they have jumped on the bandwagon extolling the preponderance of evidence to denounce the epidemic of back surgery and other ineffectual medical treatments for back pain.
This momentum has quickly become the Achilles heel for spine surgeons who have become the highest paid and most powerful segment in medicine. For decades the orthopedists and neurosurgeons staved off their chiropractic critics, attempting with their usual prejudice to invalidate the belief that most spine surgeries were unnecessary, ineffective, and based on a failed disc theory. The media also ignored the emerging studies showing chiropractic care to be more cost and clinically effective than anything the medical world had to offer, including the standard pain pills, muscle relaxers, opioids, epidural steroid injections, physical therapy, and spine surgery.
The proof began emerging in the 1990s from international studies such as Manga (Canada), AHCPR (US), Meade (UK BEAM), to name a few comparative studies that shocked but were ignored by the medical-industrial complex. The renaissance in spine diagnosis—the disc theory—began in 1990 when research by Scott Boden et al. followed in 1994 by a supportive study by Maureen Jensen et al. found no clear correlation between disc abnormalities and back pain. These studies showed that degenerative and herniated discs are often found in asymptomatic patients, questioning the validity of the disc theory itself, the basis of most back surgery.
Now other important players are jumping on the bandwagon. The media and the insurance payers are now voicing their critical opinions due to the huge costs, possible fraud, and incriminating failure rates associated with the medical management of back pain. The figures involved with spine care are staggering and escalating. A 2006 study by James N. Weinstein et al., “Trends and Regional Variations in Lumbar Spine Surgery in the United States,” indicated the shocking cost increases of 500 percent between 1992 and 2002 from $75 million to $482 million. 
Just how long the media would ignore this medical abuse and how long insurance payers would continue to pay for these questionable surgeries was the question, and for many Americans subjected to these risky and ineffective procedures, this bandwagon has come too late.
According to Rick B. Delamarter, MD, from Cedars-Sinai Medical Center, “Estimates vary and are probably understated, but health care expenditures for back pain top $91 billion a year, not including indirect and societal costs such as time lost from work and worker’s compensation.” The number of fusions at U.S. hospitals doubled to 413,000 between 2002 and 2008 and the number of the surgeries will rise this year to 453,300, according to Millennium Research Group of Toronto. Unnecessary surgeries cost at least $150 billion a year, and unnecessary spine surgeries are at the top of this list.
Increasingly, more in the mass media have taken a critical look at these expensive and unnecessary spine surgeries. Here are some of the recent headlines that you would never have seen just a few years ago:
These hard-hitting articles in major newspapers, including The Wall Street Journal (aside from the numerous spin off articles), national public radio, and the Internet appeared in just a five-month period. These articles shined light on the greed of surgeons, royalties and commissions earned from spine device manufacturers, the devastating human toll from unsuccessful multiple surgeries leaving patients still in pain and addicted to narcotics, as well as the lack of scientific evidence to support fusion surgery in this era of evidence-based healthcare. Finally the light of media transparency shined on the medical spine industry and found it corrupt, ineffective, often driven by economics, and preying on unsuspecting patients.
The response to the Bloomberg News article was fast and critical from International Society for the Advancement of Spine Surgery (ISASS) that issued on January 10, 2011, its “Advocacy Alert: Journalists Using Sensationalistic Stories to Bias Public Opinion about Spinal Fusion Surgery,” in which it denounced the Bloomberg article as “unscientific and based on incomplete information.”
The Bloomberg article is based primarily on sensationalistic anecdotal patient stories, not on a review of the scientific medical evidence. Although patient stories are always highly captivating to read, the medical world considers them to be one of the worst forms of evidence to use as a basis for evaluating treatment or making healthcare decisions. The patients presented by the Bloomberg article are not representative of the usual outcomes of fusion surgery, and they cannot be properly assessed in a news article devoid of all their relevant medical data, x-rays, and so on. Assessments of lumbar fusion should be based on fair and balanced reviews of the published scientific evidence, not on sensationalistic journalism.
This letter was a smokescreen of propaganda considering the “published scientific evidence” is overwhelmingly against spine fusion that the spine surgeons have ignored for nearly twenty years when the initial international studies were released in 1994 when the Agency for Health Care Progress and Reform (AHCPR) guideline #14 on acute low back pain in adults recommended spinal manipulation and mentioned that urged restraint on back fusions. 
At that time the NASS created an ad hoc committee which attacked the literature review and the subsequent AHCPR practice guideline on acute care of low back pain. In a letter published in 1994 in their journal Spine, the committee not only criticized the methods used in the literature review, they also expressed concern that the conclusions might be used by payers or regulators to limit the number and types of spinal fusion procedures. This was its real agenda—to keep its cash cow alive and protected from regulation.
AHCPR was also confronted with a bogus third-party advocacy group, the Center for Patient Advocacy, whose main goal was to get it de-funded. In reality, this was not an actual “patient” group, but were members of NASS formed by Neil Kahanovitz, MD, a back surgeon from Arlington, Virginia. They organized a letter-writing campaign to gain congressional support for its attack on AHCPR.
A member of the AHCPR panel, Richard Deyo, MD, MPH, co-authored an article in The New England Journal of Medicine, “The Messenger Under Attack: Intimidation of Researchers by Special Interest Groups.” In it, he commented of this heavy-handiness to thwart progressive researchers. “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.”Intimidation has been the cornerstone of medical politics as with the spine issue or the healthcare reform efforts by President Clinton or Obama.
It is also disconcerting that the ISASS criticism of “sensationalistic anecdotal patient stories” concerning dissatisfied patients greatly suffering from failed back surgery is frowned upon by the ISASS. This callous attitude unfortunately seems to place profits over patients’ well-being whose lives were turned upside-down from failed back surgery syndrome that were mostly unnecessary and ineffective. A study in Surgical Neurology by E. Berger showed that 71 percent of patients with a single surgery and 95 percent of lumbar fusion patients who had multiple surgeries never returned to work. The recent newspaper articles also suggested the abuse of spine surgery.
The result of this medical mismanagement has led to an epidemic of failed back surgery victims unlike the world has ever known. According to Gordon Waddell, DSc, MD, FRCS, “back surgery has been accused of leaving more tragic human wreckage in its wake than any other operation in history.” As director of an orthopedic surgical clinic for over twenty years in Glasgow, Scotland, he determined “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.”  Yet this human tragedy is ignored by the ISASS and considered unscientific.
Similar to the Bloomberg News article, the WSJ articles painted a very dark picture of the corruption of the spine surgery profession. The WSJ reporters were able to name five surgeons who all worked at Norton Hospital in Louisville, KY, who, in the first 9 months of 2010, received a combined $7 million in royalty and consulting payments from Medtronic manufacturer of the equipment used for spinal fusion surgery. A single surgery can use up to $20,000 worth of devices: pedicle screws that can sell for up to $2,000 each cost just $100 to make. Medtronic has been involved in lawsuits over alleged sham consulting agreements with surgeons who took payoffs in exchange for using the spinal-device products. For Medtronic alone, spinal fusions brought in $3.5 billion annually in sales—roughly half the total spinal implant market.
The inducement to do more complex and expensive surgeries became obvious to the WSJ reporters when they discovered that while the national average for spinal fusion surgery for patients with degenerative disc disease is 17%, at Norton Hospital 24% of fusions surgeries were for degenerative disc disease. According to the WSJ article, “Medicare pays the surgeon a much higher fee to do the more-hardware-intensive form of surgery, giving both the surgeon and the device maker a strong financial incentive to do more of these procedures than is strictly necessary.”
In fact, the epidemic of unnecessary spine fusion surgery has made spine surgeons the best paid doctors in the U.S. according to the Bloomberg News. At nearly $100,000+ per spine fusion, spine surgery is equivalent to hitting the lottery many times every day for surgeons and hospitals. Their average annual salary is $806,000, more than three times the earnings of a pediatrician. This does not include royalties and consulting fees offered by spine device manufacturers like Medtronic and Charite, all of which are now drawing attacks for unethical inducements of surgeons as well as the overuse of complex surgeries with hardware.
As Richard Deyo, MD, MPH, suggested, “It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just six years,” and a strong motivation was “financial incentives involving both surgeons and hospitals.”
Recently the editors of TheBACKLETTER®, a newsletter from the Department of Orthopedic Surgery at Georgetown Medical Center in Washington, DC, criticized spine surgeons in its March, 2011, lead article, “Standoff Over Spinal Fusion Surgery Highlights the Poor Quality of Back Care in the United States.” What makes this newsletter’s comments sting is the fact it is written by orthopedists. Not only has this newsletter been critical of spine surgeries, but also narcotic medications, epidural shots, and the excessive use of MRI scans—in other words, the mainstay of the medical spine care.
This is not the first time this newsletter has published critical articles of the medical mismanagement of back pain, but this alarm has now reached a new peak. According to the recent article, the main issues concern (1) the overuse of fusion surgery for non-specific back pain, (2) overuse of expensive surgery when simpler surgery might suffice, and (3) widespread financial conflicts of interest.
Surprisingly, little was said of the collateral damage done to patients of failed back surgery syndrome in terms of disability, impairment, and suffering left in the wake of these ineffective surgeries. Apparently the damaged patients remain a secondary concern to all, even to the medical critics.
Incidentally, this newsletter made no mention of chiropractic care as an alternative despite the fact that Scott Haldeman, Jay Triano, Dana Lawrence, William Meeker, Silvano Mior, and Haymo Thiel, all with DC degrees are on its editorial board.
In fact, on Feb. 4, 2011, I wrote a letter to Sam W. Wiesel, MD, executive director, Marcia Serepy, publisher, and Mark L. Schoene, editor of the TheBACKLETTER® stating, “Let me first say that I am a big fan of THE BACKLETTER. It’s refreshing to see the truth about back treatments come forth, finally. As a chiropractor, however, I must add that I’m saddened by the lack of information about my profession. It seems chiropractic is the 800-pound gorilla in the back pain industry that you have ignored. I can’t recall ever seeing the word ‘chiropractic’ mentioned in your newsletters; certainly never in an in-depth report. Perhaps the traditional medical bias is still prevalent...Nonetheless, when will your newsletter give credit to chiropractors in this war against back pain?”
The dramatic increases in usage and cost have now gained the attention of insurance payers who are taking a hard look at these surgeries and have finally questioned the cost effectiveness of spine procedures. Although criticism of spine surgery has been growing lately among the professional journal editors, spine researchers, and the mass media, the big blow occurred when Blue Cross Blue Shield of North Carolina announced in January, 2011, that it would no longer pay for spinal fusion for back pain in the presence of only disc degeneration or disc herniation. This is a huge policy change that will hopefully have a ripple effect among all state BC/BS and other insurance companies to curtail payment for this epidemic of ineffective spine surgery.
The official North Carolina BC/BS website states: 
Lumbar spinal fusion is also considered not medically necessary if the sole indication is any one or more of the following conditions:
• Disk Herniation
• Degenerative Disk Disease
• Initial diskectomy/laminectomy for neural structure decompression
• Facet Syndrome
This NC BC/BS guideline did include coverage for “participation in physical therapy (including active exercise)” that includes DCs, but the critical component is the statement, “active exercise” according to Eugenie Komives, MD, Vice President and Senior Medical Director. “Neither modality treatment by a physical therapist nor chiropractic manipulative treatment meets that criteria.”
Another highly regarded reference tool for MDs, the Milliman Care Guidelines® provides options for care and indications for referral of patients from primary care providers to specialists. This highly regarded reference authority also reaffirmed lumbar fusions are not medically necessary for disc herniation or degeneration or as a procedure following primary disc excision, including patients with a herniated lumbar disc causing radiculopathy.
There are, however, many indications for lumbar fusion in the cases of fracture, cancer, spondylolisthesis of 50% or more, scoliosis greater than 50 degrees with loss of function, persistent radicular pain or persistent neurogenic claudication unresponsive to conservative care, or serious infections such as spinal tuberculosis.
If and when every state’s BCBS follows suit, implementing this policy nationwide would save billions of dollars and help millions of patients avoid failed back surgery syndrome. In fact, this call for reform in spine care could become the tipping point for doctors of chiropractic and other conservative non-surgical practitioners who have long awaited the day when clinical and cost-effectiveness would overcome the profit motive in medicine.
But this policy change did not come without a fight. A coalition of spine societies has already voiced its opposition on December 15, 2010 before the NC BC/BS announcement occurred in January of 2011. This group included all the major spine groups, including the American Association of Neurological Surgeons (AANS), the American Association of Orthopaedic Surgeons (AAOS), the Congress of Neurological Surgeons (CNS), the AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves, the International Society for the Advancement of Spine Surgery (ISASS), the North American Spine Society (NASS), the North Carolina Neurosurgical Society (NCNS), the Pediatric Orthopaedic Society of North America (POSNA) and the Scoliosis Research Society (SRS).
Remarkably, in the coalition’s consensus letter attempting to thwart the policy change to Don W. Bradley, MD, Senior Vice President, Healthcare & Chief Medical Officer at NC BC/BS, this group pleaded that “no reasonable spine surgeon would recommend a fusion,” and only faintly insinuated to the epidemic of unnecessary and ineffective spine surgeries: “We feel strongly that the scope of patients with low back pain from degenerative disease without neurological compression, neurological symptoms, or mechanical instability should be much more limited than it has in the past.”
In other words, they agree there may be too much surgery, but they still want sole discretion and do not want to be limited by even those who pay. The notion of self-restraint, “the physician doing his or her due diligence,” offered by this spine group’s letter is perplexing considering the 15-fold increase during 2002-2007.
Obviously the notion of self-restraint flies in the face of reality. Jerry Groopman, MD, author of a revealing article, “Knife in the Back,” published in The New Yorker magazine, wrote of this quandary about back surgery while seeking care for his own back pain problem when his orthopedist admitted to him, “If I don't do them, they’ll go around the corner and the other surgeon will.” The fact that spine surgeons are the highest paid of all doctors speaks volumes about the lack of self-restraint.
“It’s amazing how much evidence there is that fusions don’t work, yet surgeons do them anyway,” said Sohail Mirza, a spine surgeon who chairs the Department of Orthopaedics at Dartmouth Medical School. “The only one who isn’t benefitting from the equation is the patient.” Finally, an ethical orthopedist speaks the truth. Undoubtedly he will not be a popular attendee at the next meeting of the North American Spine Society.
To be sure, the spine surgeons are now squawking after decades atop the physician pecking order undeterred while making millions. A business website for orthopedists and spine physicians, Becker’s Orthopedic & Spine, has published several articles relating to the recent attack on spine fusions, including “Spine Fusions Face an Uncertain Future.” The tone of these articles is one of disbelief that the sacrosanct surgeons were under attack rather than admitting to the overuse of surgery and advocating restraint. A quick scan of its website shows the business of spine surgery is its objective, not due diligence or ethical concerns.
However, this website did admit that “four years after surgery, the fusion patients were four times more likely to need additional surgery and half of those operations were necessary because of new disc complications occurring at adjacent levels to the fusion.” From a business viewpoint, however, re-operations were another source of income in the ruse of unnecessary fusions. Failed back surgery has yet to be viewed as malpractice nor does it fall under the Lemon Law statutes. Whereas every product has warranties or product liability, medicine does not.
“We have a very strange system in the U.S., where you don’t pay for quality, you pay for service,” according to Rachel Weissburg of The Leapfrog Group, a nonprofit organization that pushes for reform in hospitals. “Asking hospitals to commit to normal customer-service principles should not be radical, but it is.”
Considering the high percentage of ineffective spine surgeries and the fact that 20% of spine surgeries have reoperations, how can hospitals and surgeons charge for these failed surgeries over and over again? Imagine if hospitals were required to offer guarantees or warranties to patients, just as other product manufacturers are required to do, many would go broke.
By now the medical model of back pain focusing on disc abnormalities and pathoanatomical disorders has lost credibility, plus medical treatments consisting of drugs, shots, and surgery have not fared well after evidence-based scrutiny. The disc theory is highly questionable, drugs, shots and surgery are now considered costly and ineffective, and overuse and abuse abound costing the healthcare system billions of dollars.
On the other hand a recent study found that for low back pain, starting with chiropractic saves 40% on care:
A study published in 2010 revealed data over a two-year span from 85,000 Blue Cross Blue Shield beneficiaries with low back pain in Tennessee. The patients had open access to MDs and DCs through self-referral, and there were no limits applied to the number of visits allowed and no differences in co-pays. Results show that paid costs for episodes of care initiated by a chiropractor were almost 40 percent less than care initiated through an MD. They estimated that allowing DC-initiated episodes of care would have led to an annual cost savings of $2.3 million for BCBS of Tennessee. 
Allthewhile, the medical profession has besmirched the chiropractic profession that has finally been vindicated as more effective and less costly in comparative studies. This has created a unique situation for doctors of chiropractors who as the proverbial last resort have witnessed the devastating impact of failed back surgery syndrome. For too long spine surgeons have been unregulated prescribing unnecessary drugs in pill mills, administering ineffective shots in pain management clinics, and doing costly fusions while discouraging patients from seeking natural, safe, and effective chiropractic care. This is not merely an oversight and should be viewed as medical malpractice with the lack of informed consent.
Today guidelines, including the North American Spine Society (NASS) and the American Pain Society (APS) recommend conservative care as the first resort to stave off this epidemic of unnecessary spine fusions, a fact ignored by most spine surgeons who apparently suffer from “professional amnesia” when they forget to mention this fact to suffering patients.
The NASS recommended spinal manipulation should be considered before surgery in the October, 2010, edition of The Spine Journal:
Several RCTs (random controlled trials) have been conducted to assess the efficacy of SMT (spinal manipulative therapy) for acute LBP (low back pain) using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone.  (emphasis added)
Considering the endorsement from every major international guideline on low back pain as well as the recommendations by NASS and APS prove the sad fact that most patients were discouraged from seeking chiropractic help beforehand is tantamount to fraud. The typical tactic used by unscrupulous surgeons is to demonize chiropractic care as dangerous, which is ridiculous considering the huge difference in malpractice rates. 
The fact is malpractice insurance companies know which doctors are hurting patients since they pay the settlements from litigation. The actuaries show that chiropractors have the lowest malpractice rates among all spine practitioners. Chiropractors pay approximately $1,600 annually compared to spine surgeons who typically derive as much as 62 percent of all of their professional income from performing surgical procedures on the lumbar spine and will pay approximately $71,000 to over $200,000. This clearly suggests the lower level of risk of care provided by chiropractors, yet many spine surgeons continue to lie to patients in order to scare them into surgery.
The consequence of this medical mismanagement and professional slander against chiropractors is difficult to comprehend historically since transparency of this travesty has only recently surfaced. Imagine the millions of patients who were misdiagnosed with such disc abnormalities and mistreated by spinal fusions, but who still suffered with joint dysfunction or sacroiliac problems that went undetected and remain uncorrected. Imagine the billions of dollars spent on ineffective spine surgeries when spinal adjustments were appropriate but ignored. Imagine the suffering that could have been prevented if chiropractors were used as the primary providers for these ailments instead of MDs who are principally unschooled about musculoskeletal disorders and whose treatments are now proven ineffective, dangerous, and costly.
This has been confirmed by a recent study. A December 2010 study by Paul B. Bishop, et. al, in The Spine Journal found patients with acute mechanical low back pain enjoyed significant improvement with chiropractic care, but little to no improvement with the usual care they receive from a family physician. The study found that after 16 weeks of usual care by MDs, patients saw almost no improvement in their disability scores, were likely to still be taking pain drugs, saw no benefit with physical therapy, and yet were unlikely to be referred to a doctor of chiropractic. However, researchers found that treatment including chiropractic spinal manipulative therapy is associated with “significantly greater improvement in condition-specific functioning" than usual care provided by a family physician.
Despite the NASS and APS recommendations for spinal manipulation before fusion, in reality this rarely happens as chiropractors know too well. In fact, two issues have been overlooked concerning the proliferation of spine surgery—patient intimidation by surgeons and the lingering medical bias against chiropractors.
In the real world, many back pain sufferers have heard of the poor outcomes and high costs of spine surgery, but are rarely told about the chiropractic alternative to surgery. If the patient has the courage to ask about chiropractic care, often he will experience the surgeon’s wrath and ridicule: “If you’re stupid enough to go to a chiropractor, don’t come crawling back to me when you’re paralyzed.”
This bullying works to scare many patients into unnecessary and ineffective surgery—the evil Marcus Welby effect, if you will. Honest notification of options to surgery in the form of informed consent about chiropractic care is rarely told to patients by biased medical professionals. The medical consensus letter revealed this professional bias and professional amnesia when it failed to mention the third-largest physician-level profession in the country that specializes in non-drug, non-surgical conservative spine care—chiropractic.
If the spine surgeon community had followed the NASS and APS advice to use conservative spinal manipulation first, there would not be an epidemic of spine fusions or the consequences of failed back surgery syndrome, drug addiction, and disability that we see today. Indeed, it must be difficult for them to admit their basic disc premise is controversial and their treatments are costly and often ineffective. It must also be tormenting for medical professionals to admit their rivals and medical heretics—those disparaged chiropractors—may have been right all along.
Fortunately, not all medical professionals have the American bias toward chiropractors. A major 2009 evidence-based study in England by the National Institute for Clinical Excellence (NICE) in its latest comparative effectiveness guideline concluded that patients with back pain should receive acupuncture and spinal manipulation through it National Health Services. From among 200 treatments and devices claimed to help a bad back, NICE determined that x-rays, ultrasound, and steroid injections are out and chiropractic spinal manipulation and acupuncture are in. they also recommended that surgery should only be considered after a complete program of conservative care first. 
Other important American guidelines also recommend spinal manipulation. The Milliman Care Guidelines® provide options that include chiropractic care prior to lumbar fusion. The American College of Physicians and the American Pain Society published in 2007 a Joint Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain that also concluded spinal manipulation to be effective for both acute and chronic low back pain.
Unfortunately, American medical-industrial complex has no interest in slowing down this billion dollar gravy train despite whatever the media, their own researchers, the NASS, professional guidelines, or any US Public Health Service guideline might say. Only the conductor of this train—the insurance payer—and an informed consumer can derail this gravy train for surgeons. As this policy change spreads across America among other BC/BS providers and eventually every health insurance provider, this may be the tipping point the chiropractic profession has long awaited in this era of evidence-based healthcare.
Indeed, the tide has finally turned against the tsunami of the drugs, shots, and surgical spine care. Despite the scientific evidence and the outcry from researchers and the mass media alike, many MDs still have difficulty to acknowledge the effectiveness of their rival chiropractors. It remains the challenge of this profession to tout itself to the public and the media as the once maligned but vindicated answer to the billion dollar back pain epidemic.
Possibly now the old adage “It never hurts to get a second-opinion” will take on a new meaning and provide a truly viable option for patients and a respite for a beleaguered health care system.
 Smith JC, Back Surgery: Too Many, Too Costly, Too Ineffective. Dynamic Chiropractic, 2011 Mar. 26,;29 (7):1
 Manga P, Angus D, Papadopoulos C, Swan W, The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain, 1993 August:104
 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
 Meade TW, Letter To The Editor, British Medical Journal 1999 July 3; 319 (57).
 Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW, Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects: A Prospective Investigation, J Bone Joint Surg Am. 1990 ;72:403–408.
 Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS, Magnetic Resonance Imaging Of The Lumbar Spine In People Without Back Pain, N Engl J Med. 1994 Dec 1;331(22):1525
 Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES, United States' Trends and Regional Variations in Lumbar Spine Surgery: 1992-2003, Spine 2006 November 1; 31(23):2707-2714
 Delamarter R, Zigler J, Goldstein J. 5-year results of the prospective, randomized, multicenter FDA investigational device exemption (IDE) ProDisc-L total disc replacement (TDR) clinical trial. Paper #3. Presented at Spine Week 2008. May 26-31, 2008. Geneva.
 Waldman Peter and Armstrong David, Highest-Paid U.S. Doctors Get Rich With Fusion Surgery Debunked by Studies, Bloomberg.com, Dec 30, 2010
 S Bigos, ibid. p. 8.
 Deyo RA, Psaty BM, et al. The messenger under attack -- intimidation of. researchers by special interest groups. NEJM April 17, 1997;336(16):1176-79
 Berger E, Late Postoperative Results in 1000 Work Related Lumbar Spine Conditions, Surgical Neurology August 2000; 54 (2):101-106.
 Waddell G. and OB Allan, A historical perspective on low back pain and disability, Acta Orthop Scand 60 (suppl 234), 1989
 Yin S, Spinal Fusions, Millions In Medtronic Royalties Look Fishy, Fierce Healthcare News, December 20, 2010
 Carreyrou and McGinty, Top Spine Surgeons Reap Royalties, Medicare Bounty, WSJ, 2010 Dec. 20,
 Waldman and Armstrong, ibid.
 Yin, ibid.
 “New Study Demonstrates A Three-Fold Increase N Life-Threatening Complications With Complex Surgery,” The BACKLETTER, 2010 June; 25(6):66
 Eugenie Komives via private communication with JC Smith, April 10, 2011.
 Milliman Care Guidelines for Lumbar Fusions, Low Back Pain and Lumbar Spine Conditions—Referral Management, www.allmedmd.com
 Milliman Care Guidelines for Lumbar Fusions, Low Back Pain and Lumbar Spine Conditions—Referral Management, www.allmedmd.com
 Groopman Jerry, Knife in the Back, The New Yorker magazine, 2002 April 8
 Waldman and Armstrong, ibid.
 Miller L, Spine Fusions Face an Uncertain Future, Becker’s Orthopedic & Spine.com, 2011 January 18
 Miller L, Dr. Rick Delamarter: Artificial Disc Replacement Effective, Costs Less Than Spinal Fusions, Becker’s Orthopaedic, Spine, and Pain Management, 2011 March 23
 Fulmer M, Hospitals Won't Get To Bill For Errors, MSN website, March 8, 2008.
 Liliedahl RL, Finch MD, Axene, DV. Goertz C M, Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs. Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer, Journal of Manipulative and Physiological Therapeutics 2010 Nov-Dec;33(9):640-3
 Chou R, 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 2007 October 2; 147 (7):478-491
 Rosner A, Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient, Dynamic Chiropractic, 2002 November 30; 20 (25)
 Freeman MD and Mayer JM, NASS Contemporary Concepts in Spine Care: Spinal Manipulation Therapy For Acute Low Back Pain, The Spine Journal 2010 October ;10 (10):918-940
 Smith, J, http://www.medicalwaragainstchiropractors.com/Two%20Big%20Medical%20Lies.pdf
 National Chiropractic Mutual Insurance Company rate (2009) for JC Smith, DC.
 The Burton Report, Why Spine Care is at High Risk for Medical-Legal Suits, www.burtonreport.com/infforensic/MedMalSpCommonCause.htm
 Bishop PB, Quon JA, Fisher CG, Dvorak MF, The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: 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, J. Spine 2010 Dec; 10 (12):1055-64.
 Editorial Staff, Acute Low Back Pain Patients Demonstrate Significantly Greater Improvement With Chiropractic Than "Usual Care," Dynamic Chiropractic 2011 March 12;29 (6)
 Laurence J, NHS pins its hopes for treating back pain on acupuncture, The Independent, May 2009.
 Milliman Care Guidelines for Lumbar Fusion, “Low Back Pain and Lumbar Spine Conditions—Referral Management, Clinical Indications for Referral,” www.allmedmd.com
 Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-91.