Hammer & Nails


Hammer & Nails

The Rest of the Story was a classic radio program originally hosted by Paul Harvey who told quaint human interest stories with a twist-ending that he would conclude with his legendary tag line, “And now you know the rest of the story.”

Another human interest story with a surprise-ending can be added to the growing list of news articles critical of medical spine care 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, President of the American College of Spine Surgery.

This headline piqued my interest as a DC for 30+ years since MDs routinely misdiagnose back pain by overlooking common mechanical joint disorders of the spine, referred to as vertebral subluxations by DCs, spinal lesions by DOs, or joint dysfunction by non-surgical orthopedists.

Instead spine surgeons are solely focused on abnormal discs in order to justify spinal fusions. Dr. Shamie now admits they also overlook sacroiliac joint (SIJ) dysfunction that is undetected in 20% to 25% of these cases.

To his credit, Dr. Shamie’s article may be one of few critical articles about disc fusion surgery ever published @ CNN.com but, true to his nature, he still cannot conceal his bias as a spine surgeon. Rather than disc fusion, Dr. Shamie recommends fusion of the SI joint with titanium screws.

Oh well, as the old saying goes, “if your only tool is a hammer, everyone looks like a nail.”

Slipped Joints, Not Discs

The irony of Dr. Shamie’s admission is that he fails to mention that any fusion, including that of the SIJ, is still antithetical to the best solution to help back pain, which is restoring normal joint alignment and motion, not further restricting motion via fusion.

Nearly 40 years ago in federal court testimony, John McMillan Mennell, MD, said it best at the Wilk v. AMA antitrust trial in 1976 when he spoke of joint dysfunction as a major source of pain that was only amendable via spinal manipulation:

“If you don’t manipulate to relieve the symptoms from this condition of joint dysfunction, then you are depriving the patient of the one thing that is likely to relieve them of their suffering.”[1]

Not only are the two SI joints potential sources of severe pain, there are over 300 joints in the entire spinal column that may be additional sources as every chiropractor knows, which explains why spinal manipulative therapy to restore joint motion has always been so effective.[2]

Dr. Shamie’s admission certainly is not a new discovery and, most notably, he omits the obvious fact that chiropractors have been treating SIJ dysfunction for over a century with great results.

But even that major omission is not the rest of this story.

Point / Counter Point

Here is a sampling of Dr. Shamie’s other controversial 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 on MRIs for the “incidentalomas” such as bad discs as “selling points” 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 typically 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 “the true source of the pain” of SI joint dysfunction for over a century.[3] Plus, just as Dr. Shamie admits not all MDs are qualified to treat the spine, not all DCs are equal in ability, technique, and experience to treat SIJ disorders.]
  • “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.”
    • [I agree, but it appears that Dr. Shamie is actually admitting to Medical Malpractice = misdiagnosis (“bad discs” diagnosis) + mistreatment (lumbar disc fusion) + lack of informed consent (no mention of chiropractic care initially).]
  • “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.”
    • [Where are the RCTs and long-term studies to justify yet another new fangled, untested, expensive, and possibly unnecessary spine surgery?]
  • “The procedure is being done regularly here at UCLA and at other top spine centers around the country.”
    • [Sadly, too many spine surgeries are done regularly at these “top spine centers,” but it doesn’t mean they are necessary or successful. Dartmouth admits 40% of all back surgeries are unnecessary[4]; I daresay more than that could be prevented by chiropractic adjustments of the SI joint.]
  • “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 considered “inept” about diagnosing or treating MSDs?[5] He should have recommended seeing a DC first since we are America’s primary spine care providers best trained with the best treatments to handle most of these conditions, certainly SIJ problems.]
  • “Ask the surgeon directly if he/she has experience operating on patients with SI dysfunction in the past year.”
    • [Dr. Shamie already admits “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 such as the AHCPR study on acute low back pain in adults?[6]]
  • “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, ultimately, to some sort of spine surgery.]

Gold Standard or Fool’s Gold?

Many of Dr. Shamie’s comments are certainly refreshing admissions to read @ CNN.com, however, some of his opinions are also very misleading. A check of his references found he bases much of his argument on a 2005 study, “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.

Although Dr. Shamie is keen on putting more screws into patients, Dr. Cohen points to the lack of evidence for SIJ fusion:

“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]

Dr. Shamie also failed to mention Dr. Cohen’s uncertainty for the standard medical “gold standard” of intraarticular SI joint blocks to diagnose the need for 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.”

Whether “true positives” or “false positives,” it does appear they are very confused about both the diagnosis and treatment of SIJ dysfunction. This confusion stems from the medical emphasis on patho-anatomical problems rather than patho-physiological issues like joint alignment and movement that cannot be seen on an image.

Indeed, their quandary appears to be more like “fool’s gold” and totally unreliable since the real “gold standard” for both the diagnosis and treatment of SIJ dysfunction is the ability to detect misalignment and loss of joint play via motion palpation and correcting it via SMT (spinal manipulative therapy).

Instead of emphasizing evidence-based non-drug, non-surgical treatments such as SMT, we’ve seen a constant flow of new drugs, injections, surgeries, and devices that get a lot of hoopla in the medical press, but never seem to pan out because they ignore the primordial problem of restoring joint play.

Recall the accolades that turned into busts, such as artificial discs, fusion cages, pedicle screws, vertebroplasty, kyphoplasty, plates, laser surgery, silicon nitride implants, PEEK plastic spacers, IDET, ESI, discograms, percutaneous image-guided lumbar decompression (PILD), BMP-2, and now titanium screws.

Unfortunately the holy grail of complete relief remains elusive despite the growing menu of surgical options because none of these procedures offer a high rate of cure. Indeed, back surgery has been accused of leaving more “tragic human wreckage in its wake than any other operation in history.”[8]

In light of this tsunami of “inefficient medical spine care,”[9] I applaud Dr. Shamie’s courage to cast more light upon spine surgeons who continue to use “bad discs” as selling points to warrant often unnecessary disc surgery for unsuspecting low back pain patients. However, switching fusion from the lumbar disc to the SI joints is not the answer in the vast majority of LBP patients.

Despite the growing admonition from numerous research studies showing the “false-positive” nature of “bad discs” as a source of back pain, nearly 800,000 spine surgeries will be done in the US annually based on this outdated disc ruse. In fact, spine fusions escalated 15-fold from 2002 to 2007 according to Dr. Rick Deyo despite the accumulating evidence debunking the “incidentalomas” found on MRIs.[10]

Even spine journal editor Mark Schoene admits “Spinal medicine in the US is a poster child for inefficient spine care”[11] and opines “such an important area of medicine has fallen to this level of dysfunction should be a national scandal. In fact, this situation is bringing the United States disrespect internationally.”[12]

One might think Mr. Schoene’s opinion is the rest of this important story, but it’s only one more shocking clue leading to the twist ending.

The Rest of the Story

Although Dr. Shamie seems well-intentioned, his omissions were as obvious as his admissions.

Once again this article @ CNN.com illustrates another spine surgeon’s inability to acknowledge what virtually every guideline recommends—to use conservative chiropractic care first before any mention of spine surgery (excluding the red flags that occur in 10% of cases such as cancer, fractures, infections or the rare disc case non-responsive to conservative care.)

The real story in medical journalism today should be why the medical news staff @ CNN.com ignores this paradigm shift in spine care in light of the growing list of critical scientific and lay newspaper articles.

For example, the latest newsworthy article that went viral recently was completely ignored @ CNN.com: “Back pain, doctors increasingly ignore clinical guidelines.” This article dealt in part with the same issues I’m discussing now, sans the technical reasons why fusions fail.

Indeed, why is it so difficult @ CNN.com to mention this paradigm shift in spine care? The obvious reason is the political nature of Dr. Sanjay Gupta, chief medical correspondent at CNN. Without question, healthcare is extremely political not only in terms of Obamacare and the Republican v. Democrats battle, but as a neurosurgeon/journalist Dr. Gupta has the ability to censor his rivals in the chiropractic profession competing for the huge back pain market.

This economic motivation combined with the old medical propaganda that once defamed chiropractic as “a dangerous unscientific cult” has been thoroughly disproved, but lingers on in the medical media mindset that ignores the recent victories in the court of scientific opinion that call for conservative care first and medical spine care last.

Hopefully this paradigm shift will not be ignored forever because the facts are growing:

  • disc theory has been debunked,
  • medical spinal care has been deemed “inefficient” and a “national scandal” by a leading international spine journal editor,
  • chiropractic care has been deemed a “proven treatment” by an agency of the USPHS [13], and
  • half of back care in the US is now delivered by chiropractors alone.[14]

Moreover, chiropractors now comprise the third-largest physician-level health profession in the nation and practice a remarkably enjoyable healing art. Recently an article in The Wall Street Journal, “Best and Worst Jobs of 2013,” reviewed 200 jobs in America and chiropractors were ranked #11. I can only imagine medical naysayers choking on this list considering “general physician” ranks #45 and “surgeon” ranks #51.[15]

In this changing spine paradigm, chiropractors today lay claim as “America’s primary spine care providers[16] in this pandemic of back pain that has now become the #1 disabling condition in the nation[17], principally due to the illegal medical war against chiropractors that discouraged its popularity for nearly a century, thus depriving patients of an effective “proven” treatment.

Today, however, patients have the legal right to be informed they have choices that include conservative treatments other than narcotic painkillers, epidural steroid injections, and disc or SIJ fusion, but often they are rarely informed by MDs to see a chiropractor first.

Twist Ending

Instead of mentioning this paradigm shift and new evidence-based guidelines for care, medical journalism @ CNN.com continues with its trend of biased articles such as:

  • R. Paul Offit’s Opinion: Alternative healing or quackery? that slams CAM providers as “worrisomely popular” as well as his snide remarks that “the therapist makes a fortune off your misfortune,” and “the therapist promotes ‘magical thinking’.”  
  • Dr. Nick Shamie’s article, “The Back Pain Most Surgeons Won’t Find,” that tells only a small part of the back pain solution by excluding the benefits of SMT for SIJ pain.
  • Dr. Sanjay Gupta’s CNN Special, Deadly Dose, requested by former President Bill Clinton who called for “a national conversation” to solve this onslaught of addictive and often deadly opioid painkillers that are taken mostly for chronic low back pain.

As a chiropractor, I am only too eager to add to this national conversation by talking about the most obvious omission in Deadly Dose—the absence of any mention about chiropractic care as a non-drug alternative to prescription pain killer drugs that Dr. Gupta and President Clinton bemoan.

The rest of the story is the censorship of news coverage for chiropractic care @ CNN.com to give chiropractors equal coverage to inform the public to a condition that affects millions of patients daily. Rather than harping on the one in a million SIJ patient who may benefit from titanium implants, medical journalists @ CNN.com should focus on the 90% who would benefit from chiropractic spinal adjustments.

 The twist-ending to the rest of this story in spine care is the research that now vindicates chiropractic care as the most clinical and cost-effective treatment for the majority of back pain that has been the focus of more than 1000 RCTs over the last 25 years.[18]

Just as Dr. Shamie warned patients not to follow the advice of MDs not trained in SI joint surgery, I urge patients not to follow the advice of any MD using outdated medical treatments of opioid painkillers, ESIs, and spine fusion of any type before recommending a chiropractor first, just as the guidelines suggest.

Now that’s the rest of this story, indeed!

[1] Transcript of testimony of John McMillan Mennell, M.D., Wilk v AMA transcript pp. 2090-2093.

[2] G Cramer,  Dean of Research, National University of Health Sciences, via personal communication with JC Smith (April 29, 2009)

[3] HA Gemmell, BJ Heng, “Low Force Method of Spinal Correction and Fixation of the Sacroiliac Joint,” The Amer Chiro (Nov 1987):28-32.

[4] Elliott Fisher, MD, on the CBS Evening News, “Attacking Rising Health Costs,” June 9, 2006.

[5] Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH, “Musculoskeletal Curricula in Medical Education– Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/ 11 (November 2004).

[6] 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)

[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

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

[9] The BACKPage editorial vol. 27, No. 11, November 2012.

[10] J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR (April 6, 2010)

[11] The BACKPage editorial vol. 27, No. 11, November 2012.

[12] US Spine Care System in a State of Continuing Decline?, The BACKLetter, vol. 28, #10, 2012, pp.1

[13] 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)

[14] Should Back Pain Patients Consider More Nonmedical Care? The BACKPage, vol. 28, #10, 2013, p. 120

[15] Joe Light, “The Best and Worst Jobs,” The Wall Street Journal, (January 4, 2011)

[16] Donald R Murphy, Brian D Justice, Ian C Paskowski, Stephen M Perle, Michael J Schneider, The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States, Chiropractic & Manual Therapies 2011, 19:17

[17] The Burden of Musculoskeletal Diseases in the United States Bone and Joint Decade, Copyright © 2008 by the American Academy of Orthopaedic Surgeons. ISBN 978-0-89203-533-5, pp. 21.

[18] US Spine Care System in a State of Continuing Decline?, The BACKLetter, vol. 28, #10, 2012, pp.1