Back Surgery: Too Many, Too Costly, Too ineffective, Part 4
By J.C. Smith, MA, DC
Treatment of Choice
The truth is now emerging. There is now broad agreement internationally that surgery should not generally be considered until there has been a trial of conservative nonsurgical care.83-85 Pran Manga conducted two studies in the 1990s and noted, “There should be a shift in policy now to encourage the utilization of chiropractic services for the management of low back pain, given the impressive body of evidence on the effectiveness and comparative cost-effectiveness of these services, and on the high levels of patient satisfaction.”86 As well, an editorial in the Annals of Internal Medicine published jointly by the American College of Physicians and the American Society of Internal Medicine (1998) noted that “spinal manipulation is the treatment of choice”:
“The Agency for Health Care Policy and Research (AHCPR) recently made history when it concluded that spinal manipulative therapy is the most effective and cost-effective treatment for acute low back pain87 … Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement. One might conclude that for acute low back pain not caused by fracture, tumor, infection, or the cauda equina syndrome, spinal manipulation is the treatment of choice.”88 (Emphasis added)
More spine experts are emerging from the medical closet to express their support for chiropractors, although most remain cautious with the fear of reprisal from their surgical peers who profit greatly from spine surgery.
William Lauerman, MD, chief of spine surgery, professor of orthopedic surgery at Georgetown University Hospital, has stated: “I’m an orthopedic spine surgeon, so I treat all sorts of back problems, and I’m a big believer in chiropractic.”89
Richard Deyo, MD, MPH, has mentioned chiropractic as a solution: “Chiropractic is the most common choice, and evidence accumulates that spinal manipulation may indeed be an effective short-term pain remedy for patients with recent back problems.”90
Gordon Waddell, MD, also has suggested chiropractic care as a solution: “There is now considerable evidence that manipulation can be an effective method of providing symptomatic relief for some patients with acute low back pain.”91
Jo Jordan, PhD, wrote that spinal manipulation may be the “lone ray of light” for back pain treatment.92
The Back Letter editorial staff also noticed the stubbornness of physicians to implement the new guidelines for low back pain, which includes the use of spinal manipulation as a first route of treatment before surgery.93
Although most MDs and many in the public remain convinced that a disc problem requires surgery, most guidelines now recommend nonsurgical care before surgery. The North American Spine Society (NASS), the same organization that attacked the AHCPR findings in 1994, has now published online a Public Education Series that includes “Spinal Fusion.” Remarkably, this explanation proved to be very accurate, including the opinion that “[f]usion under these conditions is usually viewed as a last resort and should be considered only after other conservative (nonsurgical) measures have failed.”94
The admission by NASS that fusion should be a last resort is a huge warning that has been unheard by the public. More surprisingly, NASS again admitted that 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.“95 (Emphasis added)
Indeed, it is past time for every physician to follow this advice and stop prescribing pain pills, muscle relaxers, epidural steroid injections and MRI scans that lead to unnecessary spine surgeries. It is time for all primary care MDs to refer patients to chiropractors for their hands-on care before any drugs, shots or surgery is suggested. It is past time for physicians to follow the Hippocratic Oath to do no harm, and the current medical practice for back pain is doing great harm to many patients.
Dr. Rick McMichael, president of the American Chiropractic Association, recently spoke on this important issue with regard to reducing costs for health care:
“America cannot expect to significantly change its health care outcomes and the costs of health care unless we are willing to make some significant changes in how we deliver health care services. We must reduce the excessive use of pain meds and unnecessary surgeries. Positioning doctors of chiropractic as first-contact, portal-of-entry, primary care providers for a larger segment of the nation’s patient population holds great promise as one very important change that could significantly impact health care outcomes and reduce health care costs.
“We must press forward for full implementation of Section 2706 of the Patient Protection and Affordable Care Act to stop the discrimination against DCs and other licensed health care providers. Full implementation of this new law will change our health care system dramatically, offer patients a real choice of health care and provider type, improve patient outcomes and satisfaction levels, and reduce overall health care costs. This change is long past due!”96
Resolving Back Pain Without Surgery: Get the Message Out
Chiropractors, once the forbidden fruit of the medical world, today have become the fiscal darlings in the medical world who can reduce the huge expense as well as save thousands of patients from unnecessary spine surgery. Of course, the medical profession has no interest in seeing this evidence-based approach cut into its billion-dollar spine surgery business, especially by chiropractors.
The AHCPR battle with NASS on Capitol Hill was evidence of the medical resistance to evidence-based research. Indeed, American medicine is renowned for its intransigence considering it takes 17 years for a new method to be incorporated into the mainstream while it takes 44 years for an ineffective method to be removed.97
Indeed, this begs the question: Will it take 44 years before the tsunami of back surgeries ends and people finally learn that chiropractic care is the preferred choice of treatment for the majority of back pain cases?
It is our duty to bring this message to the public. The facts are clear that drugs, shots and spine surgery have not stopped the rising tide in the tsunami of back pain, and reliance upon these treatments may actually be worsening the problem; indeed, medical spine care today is a shot in the dark with suspect treatments, unreliable outcomes and at great expense.
On the other hand, there are ethical orthopedists who are well-aware of the misfortune of back surgery. Jens Ivar Brox, MD, lead investigator of the Norway Spine Study, reported that he and his colleagues “no longer perform spinal fusion specifically for ‘degenerative disc disease’ because they do not regard it as a clearly diagnosable entity.”98
Dr. Brox admitted some of the orthopaedic surgeons in his department have recurrent back pain and disc degeneration, but these surgeons refuse to have fusion surgery or recommend fusion surgery for their family members. “So the question is: Why should we recommend these procedures for our patients?” Finally, an honest surgeon speaks.
Every American spine surgeon should ask themselves the same question: will they be so quick to do surgery on their own family members (or have it done on oneself) as they do on their patients?
If this evidence-based health care reform movement seriously wants to lower costs and improve outcomes in the epidemic of back pain, the chiropractic profession stands as fiscal and health care conservatives to help solve this huge issue. Of course, this back pain issue has not discussed other ways chiropractors can help, such as with wellness care, neurogenic illnesses, pediatric, geriatric, sport injuries or the many issues that fall under our scope of practice – all important issues the public needs to learn.
Until the day finally arrives that chiropractic care escapes the fog of skepticism, “buyer beware” is the best advice for patients until they understand that chiropractic, as Dr. Rosner mentioned, “at least for back pain, appears to have vaulted from last to first place as a treatment option.”99
83. Weber H. The natural history of disc herniation and the influence of intervention. Spine, 1994;19:2234-2238.
84. Saal J. Natural history and nonoperative treatment of lumbar disc herniation. Spine, 1996;21:2S-9S.
85. Postacchini F. Results of surgery compared with conservative management for lumbar disc herniations. Spine, 1996;21:1383-1387.
86. Manga P, et al. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Ontario Ministry of Health, 1993.
87. Bigos SJ, et al. Acute Low Back Pain Problems in Adults: Clinical Practice Guideline No. 14. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1992. AHCPR publication no. 95-0642.
88. Micozz MS. Complementary care: when is it appropriate? Who will provide it? Annals of Internal Medicine, July 1998;129(1):65-66.
89. McClain B. “Mainstream Makes Adjustment.” The Washington Post, July 17, 2007.
90. Deyo RA. “Low -Back Pain.” Scientific American, August 1998:49-53.
91. Waddell G, Allan OB. A Historical perspective on low back pain and disability. Acta Orthop Scand, 1989;60(suppl 234).
92. Jordan J, et al. Herniated lumbar disc. Study in BMJ Clinical Evidence, quoted in The Back Letter, July 2010;25(7):76-77
93. “Evidence-Based Care That Includes Chiropractic Manipulation More Effective Than Usual Medical Care.” The Back Letter, 2008;23(1):3.
94. Spinal Fusion. North American Spine Society Public Education Series. www.spine.org/documents/fusion
95. Freeman MD, Mayer JM. NASS contemporary concepts in spine care: spinal manipulation therapy for acute low back pain. The Spine Journal, October 2010:918-940
96. Rick McMichael, DC, President, American Chiropractic Association, via private communication Jan. 28, 2011.
97. “Refuting Ineffective Treatments Takes Years.” The Back Letter, 2008.
98. Brox JJ, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine, 2003;28:1913-1921.
99. Testimony before the Institute of Medicine Committee on Use of CAM by the American Public, Feb. 27, 2003.