The Fall of the Disc Dynasty

No, this Part 3 in the series on Moratorium on Spine Surgery is not about the fall of the ancient Chinese Ming Dynasty (1368-1644) that built the Great Wall of China. Rather, this commentary is about the Great Wall of Medical Spine Care that has begun to show signs of collapse since 1934 when two surgeons, WJ Mixter and JS Barr, did the first disc surgery at Boston General.

The medical profession had its chance to help chronic back pain, but that ultimately led to a “wake of disability” among surgical patients and an opioid crisis killing 30,000 Americans annually.

These cracks in the medical Great Wall are becoming more apparent as we’ve witnessed with the growing call for reform by the  American College of Physicians and JAMA guidelines endorsing SMT and CAM treatments to lessen the back pain pandemic and opioid crisis.

Let me be clear no one is suggesting all spine fusions are unnecessary, just most of them. Disc surgery is an effective and reasonably safe procedure if there is a simple straightforward clinical picture such as an obvious disc fragment sitting on a nerve root, pain in a clear radicular pattern, destabilizing spine problems, severe trauma, fracture, cancer or neurological catastrophe that comprise only 10-15 percent of cases.

But most spine surgery is most often done in murky situations such as DDD, disc bulge only, combination of radicular and back pain, long-term symptoms, simple spinal stenosis, etc.

More remarkable is the closely held secret among surgeons that “bad discs” appear in pain-free people. Today the “bad disc” theory has become the most misleading diagnosis in American spine medicine, but remains the mortar to the Great Wall that is crumbling.

Not only are back problems often misdiagnosed from an MRI, so are other orthopedic problems according to an article in the New York Times, Sports Medicine Said to Overuse MRI’s:

Dr. James Andrews, a widely known sports medicine orthopedist in Gulf Breeze, Fla., wanted to test his suspicion that MRIs, the scans given to almost every injured athlete or casual exerciser, might be a bit misleading. So he scanned the shoulders of 31 perfectly healthy professional baseball pitchers.

The pitchers were not injured and had no pain. But the MRIs found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent.

“If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI,” Dr. Andrews says.

He and other eminent sports medicine specialists are taking a stand against what they see as the vast overuse of magnetic resonance imaging in their specialty.

MRIs can be invaluable in certain situations — finding serious problems like tumors or helping distinguish between competing diagnoses that fit a patient’s history and symptoms. They also can make money for doctors who own their own machines. And they can please sports medicine patients, who often expect a scan.

But scans are easily misinterpreted and can result in misdiagnoses leading to unnecessary or even harmful treatments.

“An MRI is unlike any other imaging tool we use,” Dr. Bruce Sangeorzan said. “It is a very sensitive tool, but it is not very specific. That’s the problem.” And scans almost always find something abnormal, although most abnormalities are of no consequence.

“It is very rare for an MRI to come back with the words ‘normal study,’ “ said Dr. Christopher DiGiovanni, a professor of orthopedics and a sports medicine specialist at Brown University. “I can’t tell you the last time I’ve seen it.”

Bad Disc Scam

Regrettably, we see the same situation in spine care where too much emphasis is placed on imagery showing abnormalities that have been shown to be ubiquitous in pain-free people.

The initial MRI research by Drs. Scott Boden and Sam Wiesel in 1990 finding “bad discs” and age-related pathologies in pain-free people began the investigation into the failure of disc surgery that continues today.

This controversy came to light again in November, 2014, when the Mayo Clinic released its review by Waleed Brinjikji, MD, and his colleagues, “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations.”[1] This Mayo review found a consensus among 33 MRI studies from around the world that undermines the rationale for fusion surgery based solely on this ‘bad disc’ idea that is used to lure unsuspecting patients into disc fusion surgery.

This revelation has become the largest crack in the Great Wall of the Disc Dynasty as the primary cause of back pain, but this medical myth remains very much alive to railroad patients into questionable back fusions.

It’s now time for the chiropractic profession to discuss the many research studies showing wrong diagnosis, unnecessary surgery, and failed back surgery syndrome. As well, the natural resorption of discs is rarely mentioned nor is the fact chiropractic care has been shown to help avoid fusion surgery as well as helping failed back surgery patients—all important points rarely discussed by surgeons.

Cracks in Great Wall of the Disc Dynasty

1. Since “bad discs” are ubiquitous in pain-free people, studies now suggest the large amounts of unnecessary spine surgeries:

Nancy Epstein, neurosurgeon and editor at Surgical Neurology International (SNI), suggested:

“Increasingly, patients, spine surgeons, hospitals, and insurance carriers should not only be questioning whether spinal operations are ‘unnecessary’, but also whether they are ‘wrong’ (e.g., overly extensive, anterior vs. posterior operations) or ‘right’ (appropriate).”

• In 2013, Epstein and Hood concluded in their study, Are recommended spine operations either unnecessary or too complex? Evidence from second opinions, that of 183 second opinions seen over 20 months, the second opinion surgeon documented that previous spine surgeons recommended “unnecessary” (60.7%), the “wrong” (33.3%) or the “right” (6%) operations. This study suggests 94.0% of cases were given unnecessary or wrong recommendations.
• In 2012, FW Gamache in his study, The value of “another” opinion for spinal surgery: A prospective 14-month study of one surgeon’s experience, found of the 155 second opinion patients seen over a 14-month period who were told by outside spine surgeons they needed surgery, the second opinion surgeon (Gamache) found 69 (44.5%) those operations to be unnecessary.

2. Not only are many spine surgeries unnecessary, many are unsuccessful; failed back surgery syndrome (FBSS) remains another problem patients encounter:

• A 2017 study by Clancy et al., The Aetiologies of Failed Back Surgery Syndrome: A systematic review, found up to fifty percent of patients will develop Failed Back Surgery Syndrome (FBSS) following lumbar spine surgery. 
• Another 2017 study, Prevalence, characteristics, and burden of failed back surgery syndrome: the influence of various residual symptoms on patient satisfaction and quality of life as assessed by a nationwide Internet survey in Japan, to assess the prevalence and characteristics of failed back surgery syndrome (FBSS) found 1842 lumbar surgery patients revealed the prevalence of FBSS to be 20.6%. The prevalence of low back pain, dull ache, numbness, cold sensations, and paresthesia after surgery was 94.0%, 71.1%, 69.8%, 43.3%, and 35.3%, respectively.

• A 2012 study in the British Journal of Pain, The Economic Impact of Failed Back Surgery Syndrome, found up to 50% of patients may have an unsuccessful outcome following lumbar spinal surgery. The impact of FBSS on an individual’s health-related quality of life and its economic cost to society are considerable and more disabling than other common chronic pain and chronic medical conditions, such as heart failure and motor neuron disease.

3. Not only are misdiagnosis and FBSS problematic, patients also are rarely told that chiropractic care is a viable alternative before or after spine surgery for many cases of lumbar disc herniation causing radiculopathy:

• A 2010 study, Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study, compared the clinical efficacy of spinal manipulation against microdiskectomy in patients with sciatica secondary to lumbar disk herniation (LDH). Forty consecutive consenting patients who met inclusion criteria (patients must have failed at least 3 months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture) were randomized to either surgical microdiskectomy or standardized chiropractic spinal manipulation.

“Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted.”

• A 2016 study by James Cox et al., Chiropractic Distraction Spinal Manipulation on Post-surgical Continued Low Back and Radicular Pain Patients: A Retrospective Case Series, examined 69 post-surgical continued pain (FBSS) patients who afterwards received Cox Technic Flexion Distraction (CTFD). Results showed greater than 50% pain relief following CTFD chiropractic distraction spinal manipulation was seen in 81% of post-surgical patients receiving a mean of 11 visits over a 49-day period of active care. At 24-month follow-up, of 56 patients available, 44 (78.6%) had continued pain relief of greater than 50% and 10 (18%) reported 50% or less relief.
• A 2011 study by RA Kruse and J Cambron, Chiropractic Management of Post-surgical Lumbar Spine Pain: A Retrospective Study of 32 Cases, showed improvement for patients with low back pain subsequent to lumbar spine surgery who were managed with chiropractic care including Cox flexion distraction technique. A change was observed in the mean pretreatment and post-treatment Numeric Pain Scale (NPS) pain scores of 6.4 to 2.3, a reduction of 4.1 of 10. The mean number of treatments was 14, with a range of 6 to 31. When stratified by surgical type, the mean change in pain was most remarkable in patients who underwent a surgery that combined lumbar discectomy, fusion, and/or laminectomy, with an average NPS pain reduction of 5.7 of 10. No adverse events were reported for any of these post-surgical patients.
• The clinical-effectiveness of chiropractic care over medical spine care was also shown in a Washington State workers’ comp 2013 comparative study that found for patients whose first provider was a chiropractor, only 1.5 percent had surgery in contrast to 42.7 percent of workers who went through the typical medical system inevitably had surgery.[2]

4. Not only are many patients misdiagnosed, often mistreated, and routinely misinformed about chiropractic care, they are not told there is a chance of natural reduction for many herniated discs and to wait before surgery:

• A 2017 study in Spine, by Panagopoulos et al, Do MRI Findings Change Over a Period of up to 1 Year in Patients With Low Back Pain and/or Sciatica?, reported the natural reduction of herniated discs: “15% to 93% of herniations reduced in size or disappeared without surgery, with higher rates typically reported at longer follow-up periods.
• Another 2017 study by Zhong et al, Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis,found lumbar disc herniation (LDH) is often treated conservatively, frequently resulting in spontaneous resorption of the herniated disc: “The phenomenon of LDH reabsorption is well recognized. Because its overall incidence is now 66.66% according to our results, conservative treatment may become the first choice of treatment for LDH.”

5. Not only are many herniated discs able to heal without intervention, patients are also rarely told by MDs there are effective nondrug and nonsurgical multidisciplinary treatments available by conservative care practitioners as the guidelines now recommend:

• Vijay Yanamadala, MD, said in presenting the study, Multidisciplinary Evaluation Leads to the Decreased Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study, at the American Association of Neurological Surgeons 2017 Annual Meeting, “When non-surgeons are empowered to make decisions, nearly 60% of patients who were recommended surgery were found to have nonsurgical options.”

Just Say No!

With this litany of research supporting SMT and conservative care over medical spine care, the call for a moratorium grows louder and explains why on April 26, 2016, the Medical Journal of Australia InSight newsletter published, Spinal Fusion Surgeries Questioned, was painfully clear on the 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.”

Even the renowned medical curmudgeon, NM Hadler, MD, author of Stabbed the Back, mentioned the need for a moratorium:

“Prominent investigators from various disciplines have taken pen in hand and published articles in very prominent medical journals calling for a rethinking of the use of surgery in regional low back pain, if not a moratorium on laminectomy/discectomy with or without fusion.”

In conclusion, Anthony Rosner, PhD, was prophetic about the superiority of chiropractic care over fourteen years ago when he testified before The Institute of Medicine: Committee on Use of CAM by the American Public on February 27, 2003:

“Despite the fact that chiropractic has existed as a formal profession worldwide for over a century, most of what we consider to be rigorous, systematic research in support of this form of health care has emerged only in the past two-and-a-half decades. In 1975, Murray Goldstein of the National Institute of Neurological Diseases and Stroke concluded that there was insufficient research to either support or refute chiropractic intervention for back pain and other musculoskeletal disorders. Nearly 30 years later, we now can review with great satisfaction how back pain management has been assessed by government agencies in the U.S.; Canada; Great Britain; Sweden; Denmark; Australia; and New Zealand. All of these reports are highly positive with respect to spinal manipulation. Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”[3]

Now that numerous medical guidelines recommend SMT for LBP, it’s time to tout this paradigm shift to the public with an onslaught of disruptive journalism where the chiropractic profession finally goes on the offensive to end the Disc Dynasty.

Stay tuned for Part 4: This Price is Not Right