More Malarkey @ CNN.com
The continuing flurry of news articles has revealed the abuse, expense, and “inefficient” nature of medical spine care (opioids, ESIs, and fusions).
The following is a short list of recent news articles critical of medical spine care:
“Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies” by Peter Waldman and David Armstrong, Bloomberg News, Dec. 30, 2010
“Surgery May Not Be the Answer to an Aching Back,” by Joanne Silberner, NPR, April 6, 2010
“Why You Should Never Get Fusion Surgery For Plain Back Pain” by Robert Langreth, Forbes, Jan. 10, 2011
“600,000 Americans have back surgery each year,” TODAY, September 11, 2012
Study Says Back Surgery Often Makes Things Worse, The Daily Hit, Oct 14, 2010
New Study Reveals That Back Surgery Fails 74% of the Time[1] SPINE 2011 (Feb 15);36 (4):320–331
“Back Pain Eludes Perfect Solutions” by Leslie Berger, The New York Times, May 13, 2008
“Epidural steroid shots debated amid meningitis scare,” USA Today, Oct 6, 2012
“Opioid Painkiller Prescriptions Pose Danger Without Oversight,” Barry Meier, The New York Times, April 8, 2012
“Back Surgery May Backfire on Patients in Pain,” by Linda Carroll, MSNBC.COM, Oct. 14, 2010
“Top Spine Surgeons Reap Royalties, Medicare Bounty,” by John Carreyrou And Tom McGinty, Wall St. Journal, Dec. 20, 2010
“Medicare Records Reveal Trail of Troubling Surgeries” by John Carreyrou and Tom McGinty, Wall St. Journal, March 29, 2011
“How Back Pain Turned Deadly” by Elisabeth Rosenthal, The New York Times, November 17, 2012
“Fee-for-service rewards volume: Our view” The Editorial Board, USA TODAY, July 7, 2013
“Back pain: Doctors increasingly ignore clinical guidelines,” The LA Times, July 29, 2013
“Patients with back pain often get the wrong treatment,” USA Today, July 29, 2013
“Worrisome Trends in Back Pain Management,” Medscape Medical News, July 30, 2013.
“New solutions for long-lingering back pain – CBS News,” CBS This Morning, July 31, 2013.
Former Hospital CEO, Calif. Senator Charged in Insurance Fraud Case, California Healthline, Feb. 24, 2014
Recently on August 20, 2013, even The New England Journal of Medicine published an editorial, Outpatient Back Pain Treatments: Not What the Doctor Should Order, by Jaime Toro, MD, stating, “Treatment of back and neck pain increasingly relies on strategies that run counter to published guidelines.”
Now we can add another article to this growing list with the September 18, 2013, publication of an op-ed piece @ CNN.com entitled, “The Back Pain Most Surgeons Won’t Find” by Dr. Nick Shamie, Chief of Orthopaedic Spine Surgery at Ronald Reagan UCLA Medical Center as well as professor of orthopedic surgery and neurosurgery at UCLA School of Medicine. He is also President of the American College of Spine Surgery.
Although Dr. Shamie’s article may be the first critical article about spine surgery published @ CNN.com, his own bias as a spine surgeon could not be concealed. Yes, he did admit to the failings of spine surgeons who focus on abnormal discs and overlook the SI joint as a source of low back pain, a concept well-known by chiropractors for over a century, but he dismisses chiro care and, as a neurosurgeon, endorses fusion of the SI joint.
Another neurologist from UCLA, Scott Haldeman, MD, DC, PhD, a world-renown multi-disciplinary researcher from UCLA, confirms that “virtually all guidelines” on spine care now advocate conservative care first:
“The paradigm shift has already taken place. Non-surgical, non-invasive care is already the first choice for treatment for spinal disorders in the absence of red flags for serious pathology in virtually all guidelines.”[2]
Obviously the concept of SI joint dysfunction may be new to Dr. Shamie whose comments were not only dated, but contradictory to the prevailing research.
Here is a sampling of Dr. Shamie’s comments with my responses in brackets:
“Most spine surgeons, however, aren’t trained to look at the sacroiliac joint; they generally don’t learn about it during their residency or fellowships.”
[He’s absolutely right: surgeons look for the “incidentalomas” such as bad discs to convince folks they need fusions since that’s where the money is; plus, med schools do not teach PCPs classes on MSDs nor do they teach the benefits of our brand of spine care—in fact, they demonize chiro care.]
“As a result, many people progress through the usual stages of back pain treatment, from physical therapy and chiropractic treatment to injections, laser procedures and finally to surgery, without ever addressing the true source of the pain.”
[Excuse me, but more than half of my practice is adjusting SI joints. We DCs have addressed the problem of SI joint dysfunction for over a century. Just because it may be new to MDs and Dr. Shamie does not mean SIJ is new to DCs.]
“One study found that among “failed” spinal fusion patients — people who had their lumbar vertebrae fused and were still in pain afterward — the SI joint was the real culprit in more than half the cases.”
[Here Dr. Shamie is admitting to Medical Malpractice = misdiagnosis + mistreatment + lack of informed consent]
“However, a new, minimally invasive procedure is now available that uses small titanium implants to stabilize the joint. The tiny incisions mean patients recover much more quickly. The procedure is being done regularly here at UCLA and at other top spine centers around the country.”
[Where are the RCTs and long-term studies to justify yet another new fangled, untested, and possibly unnecessary spine surgery? Recall the accolades for artificial discs, fusion cages, pedicle screws, lasers, or BMP-2 that turned into busts?]
“If you are suffering from lower back pain, make sure to ask your doctor to examine your SI joint in addition to the routine examination.
[Why ask a medical PCP who is inept about MSDs? He should have recommended seeing a DC first since we are America’s primary spine care providers best trained to handle these conditions.]
“Ask the surgeon directly if he/she has experience operating on patients with SI dysfunction in the past year.”
[Dr. Shamie already admitted “Most spine surgeons, however, aren’t trained to look at the sacroiliac joint,” so why doesn’t he refer patients to DCs first as virtually every guideline now suggests?]
“And don’t accept a lumbar fusion surgery performed for back pain alone (versus leg pain) without having your SI joint checked out by an expert.”
[Good warning to avoid lumbar fusion, but the “expert” in this case is a chiropractor, not another poorly educated MD posing as an MSD specialist ready to sell the naïve patient a ticket on the medical railroad with destinations to opioid painkillers, epidural steroid injections, and some sort of spine surgery.]
Although Dr. Shamie seems well-intentioned, his omissions were as obvious as his admissions. Once again this article @ CNN.com illustrates its inability to acknowledge what virtually every guideline recommends—to use conservative care first before medical spine care.
Although Dr. Shamie’s comments are refreshing for CNN.com, they are not new and they are still misleading. He quotes from a 2005 article, “Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment” by Steven P. Cohen, MD, from Pain Management Divisions at Johns Hopkins Medical Institutions and Walter Reed Army Medical Center:
“Sacroiliac (SI) joint pain is a challenging condition affecting 15% to 25% of patients with axial low back pain, for which there is no standard long-term treatment.”
Abstract
Sacroiliac (SI) joint pain is a challenging condition affecting 15% to 25% of patients with axial low back pain, for which there is no standard long-term treatment. Recent studies have demonstrated that historical and physical examination findings and radiological imaging are insufficient to diagnose SI joint pain. The most commonly used method to diagnose the SI joint as a pain generator is with small-volume local anesthetic blocks, although the validity of this practice remains unproven. In the present review I provide a comprehensive review of the anatomy, function, and mechanisms of injury of the SI joint, along with a systematic assessment of its diagnosis and treatment.
From the medical perspective, the new standard for long-term treatment has become opioid medications that have led to the Hillbilly Heroin epidemic that Dr. Sanjay Gupta @ CNN highlighted in his exposé, Deadly Dose. But Dr. Cohen overlooks another standard long-term treatment called comprehensive chiropractic care that includes SMT with spinal rehab exercises to stabilize the spine.
Dr. Cohen also admits, “In summary, there is no infallible, universally accepted method for diagnosing pain originating in the SI joint(s)”.
He does acknowledge:
“For SI joint pain resulting from altered gait mechanics and spine malalignment, physical therapy and osteopathic or chiropractic manipulation have been reported to reduce pain and improve mobility (85,86).
Nonsurgical stabilization programs have been advocated for SI joint pain. However, there are no prospective, controlled studies supporting these modalities.” [3]
This claim is clearly wrong. Apparently the empirical evidence eludes him that for over a century chiropractors have adjusted SIJ with great success. As well, there are studies from Medline showing the efficacy of SMT for SIJ and low back pain in general:
Galm R, Fröhling M, Rittmeister M, Schmitt E.
Sacroiliac joint dysfunction in patients with imaging-proven lumbar disc herniation. Eur Spine J. 1998;7(6):450-3.
We conclude that in the presence of lumbar and ischiadic symptoms our presented data suggest consideration of SIJ dysfunction, requiring manual medicine examination and, in the presence of SIJ dysfunction, appropriate therapy, regardless of intervertebral disc pathomorphology.
Shearar KA, Colloca CJ, White HL.
A randomized clinical trial of manual versus mechanical force manipulation in the treatment of sacroiliac joint syndrome. J Manipulative Physiol Ther. 2005 Sep;28(7):493-501.
The results indicate that a short regimen of either mechanical-force, manually-assisted or high-velocity, low-amplitude chiropractic adjustments were associated with a beneficial effect of a reduction in pain and disability in patients diagnosed with sacroiliac joint syndrome.
Bronfort G, Haas M, Evans RL, Bouter LM.
Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004 May-Jun;4(3):335-56.
Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP.
This list is just a quick scan, so obviously Dr. Shamie failed to do his homework when he states there are no proven nonoperative treatments for SIJ dysfunction. Unfortunately, instead of the whole truth, we see a continuation of misleading statements by some who stand to profit by spine surgery.
Additionally, a study involving the correction of SIJ dysfunction in patients at a chiropractic center in one day found an incidence of 57 percent for SIJ dysfunction.[4]
I also find it interesting that Dr. Shamie failed to reference Dr. Cohen’s ambivalence for standard medical procedures of intraarticular SI joint blocks and SIJ surgery:
Yet without a diagnostic “gold standard,” there is no way of determining how many true positives were false positives and how many false positives were actually true positives…In summary, there is no infallible, universally accepted method for diagnosing pain originating in the SI joint(s).
Such an confusing statement could be the source of another Abbott and Costello comedy routine similar to Who’s on First?
In fact, there are studies on SI joint dysfunction that apparently eludes Dr. Cohen. As far back as a 1992 study by orthopedist JL Shaw, MD, speaking at the First Interdisciplinary World Congress on Low Back Pain and its Relation to the Sacroiliac Joint, suggested most low back pain and disc abnormalities began after the sacroiliac joint (SIJ) becomes dysfunctional:
“The conventional wisdom is that herniated discs are responsible for low back pain, and that sacroiliac joints do not move significantly and do not cause low back pain or dysfunction. The ironic reality may well be that sacroiliac joint dysfunctions are the major cause of low back pain, as well as the primary factor causing disc space degeneration, and ultimate herniation of disc material.”[5]
A study done in Germany investigated the role of SIJ dysfunction in back and leg pain.[6] The aim of this study was to evaluate the frequency and significance of SIJ dysfunction in patients with low back pain and sciatica and imaging-proven disc herniation.
Researchers examined the SIJ of 150 patients with low back pain and sciatica; all of these patients had herniated lumbar disks, but none of them had sensory or motor losses. Forty-six patients were diagnosed with dysfunction of the SIJ. The remaining 104 patients had no SIJ dysfunction. Dysfunctions were resolved with mobilizing and spinal manipulative techniques. Regardless of SIJ findings, all patients received intensive physiotherapy throughout a 3-week hospitalization.
At the 3 weeks follow-up, 34 patients of group with SIJ dysfunction (73.9%) reported an improvement of lumbar and ischiadic pain; 5 patients were pain free. Improvement was recorded in 57 of the patients with no SIJ problems (54.8%); however, nobody in this group that only received intensive physiotherapy was free of symptoms.
Clearly this study confirmed what Dr. Shaw found–the importance of the SIJ dysfunction in low back and leg pain syndromes. The German study also showed that spinal manipulative therapy proved superior to physiotherapy alone in these cases; again demonstrating the need to adjust spinal joints first and foremost.
The major medical problem with adequate spinal diagnosis rests with the medical anatomy analysis rather than a chiropractic physiology analysis. In other words, spine problems should not be considered solely by an abnormal image but more by how the spine functions—bears weight, moves, twists, etc.
In this light, spinal diagnosis for mechanical back pain is more a function of joint motion than merely anatomical abnormalities. Chiropractors have proved this dilemma of anatomy versus physiology daily by successfully restoring joint motion in spines that often have arthritis, bad discs, or degeneration.
Just imagine the millions of patients with SIJ pain who underwent spine surgery that was ineffective and left them disabled when, in all possibility, if they had seen a chiropractor first to have their SI joints adjusted, this tragedy could have been avoided as many chiropractors well know.
Although Dr. Shamie was partially correct in his analysis, his failure to realize mechanical spine problems are principally functional disorders that require treatments to restore joint play followed by spinal rehab therapy to stabilize the spine and then followed by ergonomic information to maintain it.
Foremost, the main goal with joint dysfunction treatment is to restore proper joint motion, not to immobilize it via fusion by small titanium implants as Dr. Shamie recommends, which is antithetical to normal spine function.
Dr. Cohen also admits:
“In patients with SI joint pain unresponsive to more conservative measures, several investigators have advocated surgical stabilization. Unfortunately, all published reports on SI joint fusion have been small case series or retrospective studies.”[7]
It’s past time for Dr. Shamie and other spine surgeons to follow the evidence-based guidelines and give chiropractors credit for their good work in the pandemic of back pain.
It’s also time for CNN.com to give chiropractors equal time to inform the public to a condition that affects millions of patients daily. Rather than harping on the one in a million of SIJ patients who may benefit from titanium implants, medical journalists should instead focus on the 85% who would benefit from spinal adjustments.
[1] Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects: An Historical Cohort Study, SPINE (Phila Pa 1976) 2011 (Feb 15);36 (4):320–331
[2] Private communication with JC Smith, 7/10/2013
[3] Steven P. Cohen, MD, Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment, Anesthesia & Analgesia, November 2005, vol. 101 no. 5: 1440-1453
[4] HA Gemmell, BJ Heng, “Low Force Method of Spinal Correction and Fixation of the Sacroiliac Joint,” The Amer Chiro (Nov 1987):28-32.
[5] JL Shaw, “The Role Of The Sacroiliac Joints As A Cause Of Low Back Pain And Dysfunction,” proceedings of the First Interdisciplinary World Congress on Low Back Pain and its Relation to the Sacroiliac Joint, University of California, San Diego, (Nov.5-6, 1992)
[6] R Galm, M Fröhling, M Rittmeister, E Schmitt Sacroiliac, “Joint Dysfunction in Patients with Imaging-Proven Lumbar Disc Herniation,” Eur Spine J. 7/6 (1998):450-3. Spine Clinic, Bad Homburg, Germany.
[7] Steven P. Cohen, MD, Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment, Anesthesia & Analgesia, November 2005, vol. 101 no. 5: 1440-1453