Articles by JCS

Too Much Money

                                                                                                                                                     

 

Word count: 3952

Too Much Money, Too Few Ethics

In November of 2014, the famous Mayo Clinic added its voice to the issue of irrelevant ‘bad discs’ in asymptomatic people with a systematic review[1] of 33 previous MRI studies from around the world and found the consensus that ‘bad discs’ were commonplace in the aging process and highly prevalent among pain-free people of all ages.

The following list from the Mayo review shows the prevalence of ‘bad discs’ in pain-free, asymptomatic people of all ages:

  • Asymptomatic disc degeneration was exceedingly common and its prevalence increased with age from 37% of 20-year-olds to 96% of 80-year-olds.
  • The prevalence of a disc bulge rose from 30% of 20-year-olds to 43% of 80-year olds.
  • The prevalence of a disc protrusion climbed from 29% of 20-year-olds to 43% of 80-year-olds.
  • The prevalence of asymptomatic annular fissures rose from 19% of 20-year-olds to 29% of 80-year-olds.
  • More than 50% of the asymptomatic individuals older than 40 years had a “black discs” (i.e. disc signal loss on MRI).
  • Even more impressively, 86% of those aged 60+ years had a black disc.

The Mayo Clinic review was clear that ‘bad discs’ were part of the normal aging process, unassociated with pain, and did not need surgery:

“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.

“Our study suggests that imaging findings of degenerative changes such as disc degeneration, disc signal loss, disc height loss, disc protrusion, and facet arthropathy are generally part of the normal aging process rather than pathologic processes requiring intervention.”

Other spine journalists are adding to the chorus of criticism, in particular, Mark Schoene, editor of TheBACKLetter, a leading international spine research journal and a publication of Lippincott Williams & Wilkins. He also commented on the Mayo review:

“The largest systematic review to date drives home the point that spinal degeneration visualized on imaging scans often has no relationship to low back pain—and should not be routinely viewed as evidence of the source of low back symptoms.”[2]

To illustrate the ubiquitous nature of ‘bad discs’, a study at the Sydney 2000 Olympic Games found these elite athletes had a greater prevalence and greater degree of lumbar disc degeneration than the normal population, yet they were among the healthiest and best athletes in the world![3]

Obviously it is easy to find a ‘bad disc’ in most anyone, including elite athletes, showing these disc changes are not significant and certainly do not require surgery. Donald R. Murphy, DC, Clinical Director, Rhode Island Spine Center, and Clinical Assistant Professor at the Alpert Medical School of Brown University, adroitly described the use of the ‘bad discs’ diagnosis as “red herrings” to scare patients into surgery.[4]

Mute Media

Usually when the Mayo Clinic speaks, most people listen. However, after this latest Mayo review was released, this study went completely unreported in the mainstream media. When I Googled this topic, the only article that appeared was my own, Bad Discs” Pronounced Dead, Again.

The fact that the Mayo Clinic review received no traction in the media speaks volumes. This topic remains the ‘elephant in the news room’ that goes unseen at CNN, FOX News, all television network news programs, NPR programs like Science Friday, Morning Edition or All Things Considered, none of the major newspapers or health magazines. For that matter, none have reported on the accumulating research over the past two decades discounting the ‘bad disc’ concept.

Certainly when the lay media did not pick up on this important scientific consensus, it was a sigh of relief for spine surgeons and hospital administers considering the income from hospitalization for spinal fusion surgeries alone is the largest expenditure for any hospital-based surgery at over $40 billion annually.[5]

Nor do they want to public to know spinal manipulation is recommended before drugs, shots, or surgery. Spinal manipulative therapy was deemed in 1994 as a “proven treatment” in the Patient Guide by the Agency for Health Care Policy & Reform (AHCPR).[6] This guideline specifically mentioned, “Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulation.”[7] 

This AHCPR guideline also states:

Within the first 3 months of low back symptoms, only patients with evidence of serious spinal pathology or severe, debilitating symptoms of sciatica, and physiologic evidence of specific nerve root compromise corroborated on imaging studies can be expected to benefit from surgery. With or without surgery, 80 percent of patients with sciatica recover eventually.

The actual need for spine surgery is very remote. In one study of 1190 subjects, only four patients proved to have a ‘red flag’ condition: two had a disc herniation requiring surgery, one had a vertebral tumor secondary to breast cancer, and one had spinal nerve damage related to surgery for ovarian cancer.[8]

 “Epidemiological and clinical studies show that most lumbar disc prolapses resolve naturally with conservative management and the passage of time,” according to Gibson and Waddell. Surgery is generally reserved for the minority of patients whose recovery is unacceptably slow.[9]

Great Disc Debate

Considering back pain is widespread, extremely costly, the leading cause of disability, and spine disc fusions are riddled by poor outcomes[10], one might assume in this era of healthcare reform the press would be interested in stories about lowering costs and improving outcomes, especially with back surgery, the largest expenditure in healthcare today.[11]

Since no one in the mainstream media spoke of this Mayo Clinic review debunking the ‘bad disc’ theory, I wrote an op-ed piece to bring to light this important research via my local newspaper, the Macon Telegraph:

Too much unnecessary back treatments due to ‘bad discs’

Special to The Telegraph, February 13, 2015  

Golfing great Tiger Woods withdrew from another tournament still suffering with his bad back despite having spine surgery last year. Hundreds of thousands have back surgery for ‘bad discs’ and like Tiger, many are never the same, which poses the question: if ‘bad discs’ are the cause of pain, why do many still hurt after disc surgery?

 Conversely, research at the Mayo Clinic recently found there are people with ‘bad discs’ who have no pain at all, a concept that began 25 years ago with MRI research by Scott Boden, MD, Director of the Spine Center at Emory University.[12] He found ‘bad discs’ in pain-free people confirming early suspicions that herniated, bulging, or degenerated discs were “coincidental” and not the holy grail of back pain causation.[13]

 Since nearly $100 billion is spent annually on treatments for bad backs, healthcare reformists are looking closely at this huge expense to reduce costs and improve outcomes. For example, spinal fusion begins around $75,000 and can range closer to $100,000 with the extra costs of the operating room time, anesthesia bill, specialist fees, and especially if there is instrumentation involved that may cost half as much as the surgery itself.[14]

 At the Mayo Clinic Waleed Brinjikji, MD, and his colleagues performed a systematic review of all studies that reported on the prevalence of lumbar degenerative findings on MRI scans among individuals with no history of low back pain. The researchers found 33 studies of 3110 individuals published through April of 2014 and found the vast prevalence of ‘bad discs’ in pain-free people and no more significant than “gray hair or crow's feet around their eyes.”[15]

 The reviewers concluded: “Our study suggests that imaging findings of degenerative changes such as disc degeneration, disc signal loss, disc height loss, disc protrusion, and facet arthropathy are generally part of the normal aging process rather than pathologic processes requiring intervention.”

 Obviously debunking the ‘bad disc’ diagnosis is huge, but a revelation that remains unknown to the public. For example, medical reporter Dr. Sanjay Gupta at CNN is also a neurosurgeon at Emory alongside Dr. Boden who has never told his viewers that the ‘bad disc’ diagnosis is dead, perhaps illustrating his conflict of interest as a reporter who will never blow the whistle on his fellow spine surgeons who continue to sell ‘bad discs’ fusions to unsuspecting patients.

 The best advice for anyone diagnosed with a ‘bad disc’ is to follow the evidence-based guidelines that call for conservative (non-drug, non-surgical) chiropractic spinal manipulation first. This includes nearly 90% of cases where spinal mechanics, principally joint dysfunction, is the main cause of back pain.

 According to the guidelines, the only people who need spine surgery are those who suffer from cancer, fractures, serious infection like TB or staph, cauda equina, or the one in 100 disc case that doesn’t respond to chiropractic care.[16]

 So, the next time you hear someone way, “I have a slipped disc and need surgery,” tell them the truth that ‘you don’t slip discs, but you can slip joints,’ and encourage them to seek chiropractic care before drugs, shots, or surgery as the guidelines recommend.

 JC Smith, MA, DC, is a Warner Robins chiropractor.

Throughout the years I have had many op-ed pieces in the Macon newspaper, short articles in magazines, television infomercials, and letters to organizations, but rarely does anyone respond. ‘Don’t confuse us with the facts,’ seems to be the attitude of the medical industrial complex, completely content with their questionable treatments making billions of dollars while “leaving more tragic human wreckage in its wake than any other operation in history.”[17]

Realistically, I understand that the medical industrial complex couldn’t care less about anything a lone-wolf chiropractor from the peach and pecan country of middle Georgia has to say. Certainly there is no wish on the part of spine surgeons and pill mill doctors to change the present drugs-shots-surgery based medical spine care system.

Indeed, how many doctors will give up their huge salaries because research doesn’t support what they do and the public will never know otherwise? As one observer put it: “This is a field where there is too much money and too few ethics.”[18]

However, my op-ed piece apparently did rile a local Macon orthopedist, Wayne Kelly, Jr, who responded with an essay that clearly revealed his typical medical chauvinism and avoidance of the research.

Leave back problems to the most trained professionals

Special to The Telegraph, March 1, 2015  

The recent article by J.C. Smith, (Too much unnecessary back treatment due to “bad discs”) on Feb. 13 seems more like an advertisement than public awareness article on spinal conditions. The article starts out stating, erroneously, that “Tiger Woods withdrew from the recent tournament suffering from his bad back despite having spine surgery.” Woods actually stated his back surgery was not the reason he withdrew from the tournament and that his back is feeling better every day.

Patients rely on good, honest advice from health care providers. The medical community relies on evidence-based medicine versus anecdotal treatments to provide the best treatment options for patients. Be careful about treatments recommended only through patient testimonials. This means we need good research data supporting our decisions on the best treatment options for our patients.

The highest quality of evidence-based medicine is generated by randomized, prospective multicenter trials. The sports trial that analyzed lumbar radiculopathy, lumbar spinal stenosis and degenerative spondylolisthesis is one of these trials that was conducted over two years with grant money totaling $15 million. The study includes patients who have been followed for eight years now with published results on the findings.

It has been demonstrated that patients with lumbar radiculopathy, lumbar spinal stenosis and degenerative spondylolisthesis have superior outcomes compared to non-operative treatments, and these results are maintained currently up to eight years. It also found that patients returned to work quicker after lumbar microdisectomy compared with non-operative treatments. Evidence also supports most of these conditions improve without treatment within six weeks.

The choice of a particular treatment should be based on evidence in the medical literature that supports its safety and efficacy.

As a medical doctor that specializes in orthopaedic spine care, I feel we have the most knowledge on how to take care of all spinal conditions, both operative and non-operative. Many of my patients with these spinal conditions never see the operating room and are treated non-operatively with great results. Taking care of spinal conditions takes a multi-modal approach with many different techniques to provide individualized care for each patients diagnosis. Not all conditions can be treated with one approach.

While spinal manipulation is one modality used to treat spinal conditions, there are no such guidelines as stated by J.C. Smith “that only patients with cancer, fractures, serious infections, cauda equina, or the one of 100 disc cases that don’t respond to chiropractic care should seek the care of a spine surgeon.”

Orthopaedic spine surgeons have more knowledge of spinal anatomy, physiology and biomechanics than any other health care specialist.

So whether you are experiencing back pain, lumbar radiculopathy, spinal stenosis or any other spinal condition, start with the physician that has the most knowledge for these conditions first.

Five key questions to ask your physician prior to treatment:

• What is my diagnosis?

• What else can this be?

• What will happen if I don’t do anything?

• What are my treatment options?

• What evidence is there in the medical literature that this treatment is safe and effective for my condition?

Dr. Wayne Kelley Jr. is an orthopaedic spine surgeon practicing in Macon.

I was struck by Dr. Kelly’s snarky reply mainly due to his chauvinistic attitude:

  • “As a medical doctor that specializes in orthopaedic spine care, I feel we have the most knowledge on how to take care of all spinal conditions, both operative and non-operative,” and
  • “Orthopaedic spine surgeons have more knowledge of spinal anatomy, physiology and biomechanics than any other health care specialist.”

While his self-aggrandizement is certainly annoying but not unexpected, he also totally ignored the new Mayo Clinic review critical of the ‘bad disc’ theory and the unnecessary need for spine fusions. He also ignored the plethora of research showing the poor outcomes of fusion surgery. His apples vs. oranges argument instead touted his “superior outcomes” with degenerative spondylolisthesis and stenosis during his infomercial that, in fact, are untrue according to the latest research.

Of course, I couldn’t let his remarks go without comment (no, not me), so I wrote a response to him that has not been published to date in the newspaper. My response is limited to approximately 500 words, which is hard for someone as long-winded as I am to ‘write short’, so I had to omit a few comments that were appropriate, such as an Associated Press article on March 14, 2015, “Woods won’t play at Bay Hill” due to on-going “tightness in his lower back,” that contradicts Dr. Kelly’s claim, “Woods actually stated his back surgery was not the reason he withdrew from the tournament and that his back is feeling better every day.” Any sports fan knows that is untrue, just one of many half-truths in his response.

Response to Dr. Wayne Kelly

Let me respond to Wayne Kelly’s essay, “Leave back problems to the most trained professionals,” in response to my initial article, “Too much unnecessary back treatments due to ‘bad discs’.”

Dr. Kelly missed the point that I highlighted concerning the systematic review of 33 studies of 3,110 individuals by Dr.  Brinijikji from the Mayo Clinic[19] that reported degenerative features are likely part of normal aging, unassociated with pain, and certainly not an indication for disc fusion surgery.

Instead, Dr. Kelly speaks of conditions such as stenosis and spondylolisthesis not addressed in the Mayo Clinic’s study or my letter. He also omits new research that does not support his optimistic position concerning surgery for spondylolisthesis or stenosis.

A recent study in Spine confirmed poor outcomes for disc fusion surgery: only 36.4% of the spondylolisthesis group and a mere 24.4% of degenerative disc disease group returned to work within two years, many still taking opioid painkillers.[20]

Dr. Kelly suggests surgery for stenosis had superior results, however, the latest SPORT study did not support his assumption in its conclusion that “Patients with symptomatic spinal stenosis show diminishing benefits of surgery…between 4 and 8 years…”[21] For most people stenosis seems to be a condition that demands good coping skills, but rarely a ‘treat and cure’ condition.

I agree with Dr. Kelly, “This means we need good research data supporting our decisions on the best treatment options for our patients.”

Inexplicably Dr. Kelly ignores a study concerning non-surgical management of lumbar spinal stenosis that found distraction manipulation and neural mobilization done by chiropractors was extremely beneficial with patient-rated percentage improvement in pain at 75.6% and the clinically meaningful improvement in disability for 73.2% of patients.[22]

Dr. Kelly recommends patients to see an orthopedist first. “I feel we have the most knowledge on how to take care of all spinal conditions, both operative and non-operative.”

The guidelines agree on the need for ‘best practices’, but not with his conclusion to use orthopedists first.

For example, a 2012 analysis of 1.4 million back pain patients determined, “When a patient consults a chiropractor first, spine care is characterized by low rates of imaging, Rx, injections, and surgery…more favorable solutions at more reasonable costs.” [23]

A Washington State workers’ comp study found injured workers who first saw a surgeon, 42.7% had surgery; in contrast, only 1.5% of those who saw a chiropractor eventually had surgery.[24]

Another study found back surgery rates increase with the number of surgeons. A study found back surgery per capita in the United States was more than five-times that in England and Scotland.[25]

I certainly agree with Dr. Kelly when he recommends patients should ask, “What are my treatment options?”

Unfortunately, evidence suggests patients are not provided with alternatives considering only 2% of MDs refer to chiropractors.[26] Indeed, the medical boycott is still very pervasive despite the research recommending chiropractic care, which may explain why back pain is the leading disability and most costly healthcare expenditure in our country.

Regards,

JC Smith, MA, DC

Warner Robins, GA

 

Medical Halos or Horns

Clearly Dr. Kelly completely ignored the thrust of my article about the Mayo Clinic review debunking the ‘bad disc’ concept; he never referred to it once. Certainly it’s easier to criticize a chiropractor than the Mayo Clinic.

Instead, he speaks from atop his medical pedestal assuming all will believe his sanctimonious sales pitch by denigrating me, ignoring the Mayo review altogether, and telling people to “start with the physician that has the most knowledge for these conditions first.”

I would suggest patients should start with the most effective conservative care (non-drug, non-surgical) treatments as the guidelines suggest, not what the most braggadocio doctor pitching surgeries has to say.

His medical chauvinism typifies the modus operandi of many MDs who rely upon intimidation to coerce patients into taking dubious opioid painkiller drugs, subjecting themselves to unproven and ineffective epidural shots, or having a questionable surgery before using conservative care as the guidelines suggest.

Many physicians rely upon the fact too many people, including those in the media, drop their natural skepticism and have an “unflinching faith in physicians and naïve optimism” about medical care as researchers have discovered about this acquiescence to forego a critical appraisal before having medical care.[27]

This capitulation is deemed the “halo effect” when patients appear to see a halo around their doctor, whatever he is selling—the new ‘wonder drug’ or ‘heroic surgery’—allthewhile “expecting it to deliver better outcomes than is reality,” according to the researchers.

This ‘halo effect’ of implied cultural authority empowered by medical chauvinism as Dr. Kelly exhibits makes for an ‘easy sell’ by spine surgeons to intimidate their naïve patients, and this certainly happens with many back pain patients when the surgeon gives his sales pitch.

“Just look right here on the MRI (or x-ray) at that ‘bad disc” (degenerative/herniated/bulging/slipped disc), that’s the cause of your problem and I can prove it, just look right here,” as he points to the false-positive DDD on the image, and then tells the gullible patient, “Just trust me. I’m a doctor!”  

What the saintly surgeon doesn’t tell the patient is that the research now admits these ‘bad discs’ appear in pain-free people, too. Patients have no idea these medical spine treatments are disproven, ineffective, addictive, or dangerous, so they swallow pills without pause or succumb to spine surgery without hesitation when their saintly physician tells them to do so with his strong-armed diagnosis.

Voodoo Diagnosis

It has been my experience over 35 years of practice that generally the ‘informed consent’ stipulation is not offered to patients by spine surgeons or pain management physicians who are legally required to discuss the nature of their treatments, risks, and alternatives, namely, chiropractic care.

Instead, when patients ask about seeing a chiropractor before surgery, many are given thevoodoo diagnosis with the inevitable warning: “If you’re stupid enough to go to a chiropractor, don’t come crawling back to me after you’re paralyzed.” I am not joking, either. This ‘patient safety’ issue has been a ploy in the medical war for decades to frighten patients and to defame chiropractors in order to corner the spine market.

Indeed, combining the Halo Effect with the ‘voodoo diagnosis’ makes for a strong tonic of malpractice and a good example of “too much money and too few ethics” in medical spine care.

However, just imagine a surgeon telling his patients the truth. “Studies have shown ‘bad discs’ appear in pain-free people and disc fusion for DDD has a 24% success rate after a two-year recovery period.” Unfazed by this obvious poor outcome while wearing his halo and knowing his voodoo has already invalidated chiropractic as a viable alternative, the surgeon then asks, “So, when can we schedule your surgery?”

Also imagine the PMR doctor honestly telling his patient, “Opioid painkiller drugs and epidural steroid injections are proven to be placebo since they do not correct the underlying cause of your pain and, in some cases, may make you worse because these treatments may become addictive, disabling, or even deadly. So are you ready to take these risks to mask your pain temporarily?”

Another important point neither the surgeon nor PMR doctors will never tell the patient is about the primary alternative to these drugs, shots, and surgery: “Or you might see a chiropractor first, as the guidelines recommend, who may be able to correct without drugs or surgery the underlying cause of your problem, which is probably joint dysfunction.”

Considering the sad state of healthcare in the US and back pain in particular as a huge public health problem, one might ask why this colossal discovery confirmed by the Mayo Clinic review remains ignored by a complicit medical media that refuses to report on this important research. I believe the problem rests with the obvious conflict of interest as we see with MD-reporters like Sanjay Gupta, MD, at CNN who will never ‘rat out’ his spine colleagues by revealing to the public that the premise of a ‘bad disc’ requiring fusion surgery is dead.

Bearing in mind the medical profession prides itself as practicing ‘scientific medicine,’ the answer is obvious why surgeons refuse to tell the truth because they are painfully aware of this issue. Again, there is simply “too much money and too few ethics” for spine surgeons to do the right thing informing patients of the ‘bad disc’ debacle or the recommendation to use conservative chiropractic care first.

Perhaps Dr. Jerry Groopman said it best in his article, “Knife in the Back,” in The New Yorker magazine when he asked his orthopedist about doing controversial disc fusions, "If I don't do them, they'll go around the corner and the other surgeon will.”[28]

 



[1] Brinjikji W, et al., Systematic literature review of imaging features of spinal degeneration in asymptomatic populations, American Journal of Neuroradiology, 2014, prepub ahead of print; www.ajnr.org/content/early/2014/11/27/ajnr.A4173.long.

[3] A Ong, J Anderson, J Roche, A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games, Br J Sports Med 2003;37:263-266 doi:10.1136/bjsm.37.3.263

[4] DR Murphy, Clinical Reasoning in Spine Pain volume 1, Primary Management of Low Back Disorders Using the CRISP Protocols © Donald Murphy 2013, p. viii

[5] HCUPnet. Agency for Healthcare Research and Quality. Available at: http://hcupnet.ahrq.gov/HCUPnet.jsp. Accessed October 30, 2014.

[6] Bigos S, Bowyer O, Braen G, et al.  Acute Low Back Problems in Adults.  Clinical Practice Guideline No. 14.  AHCPR Publication No. 95-0642.  Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.  December 1994. 

[7] The US Department of Health and Human Services, AHCPR Clinical Practice Guideline, Number 14, Acute Low Back Problems in Adults, http://d4c2.com/d4c2-000038.htm

[8] Serious Pathology: Seeking the Needle in the Haystack, The BACKLetter, Volume 22, Number 2, 2007

[9] Gibson JNA and Waddell G, Surgical interventions for lumbar disc prolapse, Cochrane Library,

John Wiley & Sons, Ltd., 2007;(1):CD001350. Gibson JNA et al., Surgery

[10] Anderson, Joshua T. BS; Haas, Arnold R. BS, BA; Percy, Rick PhD; Woods, Stephen T. MD; Ahn, Uri M. MD; Ahn, Nicholas U. MD, Single-Level Lumbar Fusion for Degenerative Disc Disease Is Associated With Worse Outcomes Compared With Fusion for Spondylolisthesis in a Workers' Compensation Setting, Spine: 01 March 2015 - Volume 40 - Issue 5 - p 323–331

[11] Thomas M. Kosloff, DC, David Elton, DC, Stephanie A. Shulman, DVM, MPH, Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Amanda Solis, MS, Conservative Spine Care: Opportunities to Improve the Quality and Value of Care, Popul Health Manag. Dec 1, 2013; 16(6): 390–396.

[12] 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.

[13] MC Jensen, MN Brant-Zawadzki, N Obuchowski, MT Modic, D Malkasian, and JS Ross, “Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain,” NEJM, 331/2 (July 14, 1994):69-73

[14] The Cost of Spinal Fusion Surgery, 02 December 2010, http://www.spinalfusioninfo.com/the-cost-of-spinal-fusion-surgery/

[15] Brinjikji W, et al., Systematic literature review of imaging features of spinal degeneration in asymptomatic populations, American Journal of Neuroradiology, 2014, prepub ahead of print; www.ajnr.org/content/early/2014/11/27/ajnr.A4173.long.

[16] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

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

[18] Unsavory Publicity for U.S. Spine Surgeons, The BACKLetter, Volume 22, Number 2, 2007

[19] Brinjikji W, et al., Systematic literature review of imaging features of spinal degeneration in asymptomatic populations, American Journal of Neuroradiology, 2014, prepub ahead of print; www.ajnr.org/content/early/2014/11/27/ajnr.A4173.long

[20] Anderson, Joshua T. BS; Haas, Arnold R. BS, BA; Percy, Rick PhD; Woods, Stephen T. MD; Ahn, Uri M. MD; Ahn, Nicholas U. MD, Single-Level Lumbar Fusion for Degenerative Disc Disease Is Associated With Worse Outcomes Compared With Fusion for Spondylolisthesis in a Workers' Compensation Setting, Spine: 01 March 2015 - Volume 40 - Issue 5 - p 323–331

[21] Jon D. Lurie, MD, MS, Tor D. Tosteson, ScD, Anna Tosteson, ScD, William A. Abdu, MD, MS, Wenyan Zhao, PhD, Tamara S. Morgan, MA, James N. Weinstein, DO, MS, Long-term Outcomes of Lumbar Spinal Stenosis, Eight-Year Results of the Spine Patient Outcomes Research Trial (SPORT), Spine. 2015; 40(2):63-76.

[22] 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 Feb 23;7:16.

[23] Thomas M. Kosloff, DC, David Elton, DC, Stephanie A. Shulman, DVM, MPH, Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Amanda Solis, MS, Conservative Spine Care: Opportunities to Improve the Quality and Value of Care, Popul Health Manag. Dec 1, 2013; 16(6): 390–396.

[24] Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM.,

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State.,Spine (Phila Pa 1976). 2012 Dec 12. 

[25] DC Cherkin, RA Deyo, et al. “An International Comparison Of Back Surgery Rates,” Spine, 19/11 (June 1994):1201-1206.

[26] Matzkin E, Smith MD, Freccero DC, Richardson AB, Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am 2005, 87-A:310-314

[27] Hoffman TC, Del Mar C, Great expectations: our naïve optimism about medical care, The Conversation: Academic Rigor, Journalistic Flair, December 22, 2014; see http://theconversation.com/great-expectations-our-naive-optimism-about-medical-care-33845

[28] The New Yorker magazine by Dr. Jerry Groopman, "Knife in the Back,“ (April 8, 2002)

 





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