Riddle of Back Pain


Riddle of Back Pain


JC Smith, MA, DC

There is a quandary concerning a huge silent epidemic plaguing Americans that has nothing to do with germs, genetics, or cholesterol. It rarely makes the news nor are there television programs about it. This epidemic has not responded to drugs, shots, or surgery; it remains the most disabling condition nowadays in the workplace and is second only to heart disease among seniors. Do you know what it is?

Epidemiologists agree that 90% of American adults will suffer from this disabling condition during their lifetime.[1] Although not lethal, it can make your life miserable and the costs to treat the pain and cope with the disability reach over $100+ billion annually. Do you need more hints?

The problem begins with the American lifestyle itself. Our society of sedentary citizens who sit too much in front of screens and exercise too little has led to not only epidemics of obesity, heart disease, and diabetes, it has led to this silent epidemic. Combined with childhood playground accidents, sport injuries, car accidents, and bad lifting habits, this problem is widespread, expensive, disabling, and only getting worse. Still clueless?

The answer to this riddle is, of course, back pain. It is also a puzzle to many medical doctors since many of the traditional medical approaches have proven to be costly and ineffective. According to new studies, patients with back pain are routinely misdiagnosed, mistreated, and mis-informed about this crippling disorder.

Gordon Waddell, orthopedic surgeon, warned, “Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem.”[2] Quite an admission from a leading spine surgeon that only compounds the dilemma of back pain treatments.

“It’s amazing how much evidence there is that fusions don’t work, yet surgeons do them anyway,” said Sohail Mirza, a spine surgeon who chairs the Department of Orthopaedics at Dartmouth Medical School. “The only one who isn’t benefitting from the equation is the patient.”[3]

If you are among the millions who suffer daily with back pain, the challenge is to find the best treatment among the 200+ therapies, drugs, shots, or surgery now available. Scott Haldeman, DC, MD, PhD, and leading spine researcher, believes that “navigating this selection without an informed guide is analogous to shopping in a foreign supermarket without understanding the product labels.”[4]

Not only is proper treatment a confusing and daunting task, new research concerning the high costs and poor patient outcomes have led investigative reporters and health insurance executives to criticize the traditional medical treatments for back pain. Two recent articles in The Wall Street Journal about unnecessary spine surgery[5],[6] as well as similar articles on NPR[7], MSNBC[8], and the Bloomberg News[9]to name a fewhave published similar critical articles about the over-use, ineffectiveness, and expense of spine surgery.

At the core of this problem is the conflict between medical ethics vs. income. Jerry Groopman, MD, author of a revealing article, “Knife in the Back,” published in The New Yorker magazine, wrote of this quandary about back surgery while seeking care for his own back pain problem when his orthopedist admitted to him, “If I don’t do them, they’ll go around the corner and the other surgeon will.”[10]

The average annual salary of a spine surgeon is now the highest paid of all doctors at $806,000 according to Bloomberg News.[11] This salary does not include the royalties and commissions paid by surgical hardware manufacturers that often top the million dollar level as The Wall Street Journal revealed in an article, “Top Spine Surgeons Reap Royalties, Medicare Bounty.”[12]

Another problem with spine surgery rests with new evidence that fails to support the medical rationale for disc fusion. What makes these cases difficult for medical doctors to diagnose and treat is the basic medical premise of back pain—the abnormal disc theory—is now suspect as the major cause of back pain. Ironically, the reliance upon the disc theory has become the leading cause of failed back surgery syndrome.

This evidence began emerging as far back as the early 1990s when MRI studies by Scott Boden, MD, at Emory University in Atlanta, found many symptomatic patients with completely healthy spines.[13] Spine researchers now agree disc abnormalities are ubiquitous and part of the normal aging process—equivalent to finding grey hair—and certainly not a surgical condition. Researchers now agree the vast majority of back pain cases have no apparent pathoanatomical disorders like disc disease, cancer, fracture, or serious infection like spinal tuberculosis.

These pathoanatomical cases, however, comprise only 3% of back pain cases according to Richard Deyo, MD, MPH, who believes 97% of back pain is “mechanical” in nature, and disc abnormalities account for only 1% of back problems.[14] Not only are the vast majority of back pain cases misdiagnosed, the number of back surgeries are also unwarranted. Another study conducted by Deyo in 1994 compared international rates of back surgeries and found the startling fact that the rate of American surgery was at least 40% higher than any other country and was more than five-times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopedic and neurosurgeons in that country.[15]

If the federal government officials are concerned about Medicare going broke, it might look more closing at the escalating number of back surgeries being done that are unnecessary. The figures involved with spine surgery are staggering and escalating. With the average total cost of spine fusion surgery reaching nearly $100,000, back surgery has become the most costly operation and an unsustainable burden to healthcare reform.[16]

CBS Evening News aired a segment, “Attacking Rising Health Costs,” stating 30-40% of surgeries are unnecessary, mainly spinal fusions, angioplasty, hip replacement, and knee replacement.[17] The problem, according to Dr. Elliott Fisher of The Dartmouth Institute of Health Policy, is that patients are not given good information to make an “informed consent” decision as to alternatives and inherent risks of each procedure.

The dramatic increases in usage and cost have finally gained the attention of insurance payers who have questioned the cost effectiveness of spine surgeries. Moreover, in January, 2011, a policy change by the North Carolina Blue Cross Blue Shield shocked the spine care industry when it said it would not pay for spinal fusion if the sole indication is disc degeneration or herniation.[18] 

There are, however, clinical indications for lumbar fusion in the statically few cases of fracture, cancer, spondylolisthesis of 50% or more, scoliosis greater than 50 degrees with loss of function, persistent radicular pain or persistent neurogenic claudication unresponsive to conservative care, or serious infections such as spinal tuberculosis.[19]

Despite the call for restraint in spine fusion surgeries, a 2006 study indicated the shocking cost increase of 500 percent between 1992 and 2002 from $75 million to $482 million. [20] As Deyo suggests, “It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just six years.” He mentioned one strong motivation included “financial incentives involving both surgeons and hospitals.”[21]

Indeed, back pain treatment is a dilemma for both patients and practitioners.  This era of evidence-based healthcare now has cast criticism on many traditional medical methods as well as rekindled interest in another old healing art—spinal manipulation as done by doctors of chiropractic.

The evidence that led experts to believe disc abnormalities are incidental is sweet music to chiropractors who have long championed the key to a healthy spine is how the spine functions—in other words, the alignment of the spinal vertebrae, the core strength of spinal muscles, and the normal flexibility of spinal and pelvic joints.

These non-specific (meaning there are no pathoanatomical issues) back pain disorders are pathophysiologic cases that have in common musculoskeletal issues like vertebral misalignment, soft-tissue weakness or injury, joint motion problems, or any mechanical problem such as disc compression that makes it painful to sit, twist, or bend. According to chiropractors, the key is how the spine functions, not necessarily the amount of arthritis or anatomical disorders.[22]

Indeed, nearly 80-85% of non-specific, mechanical low back pain problems are cases that chiropractors most likely can help.[23],[24] Even if just half of this figure is true, that is still a huge reduction in costs and post-operative disability. Considering the nearly 500,000 spine surgeries done annually, the savings are obvious considering the majority of these cases could be helped with chiropractic care.

Perhaps the largest reason for this escalating problem rests with the illegal medical boycott of chiropractic care that has been shown to be among the most effective treatments. This back pain epidemic began with the antitrust activities stemming from the virtual boycott of chiropractic care by the American Medical Association. For nearly a century, the AMA waged war to “contain and eliminate” the chiropractic profession as a competitor, including an illegal boycott of chiropractors from public hospitals. Although a 1987 federal court decision in Chicago {Wilk et al. v. AMA et al.} found this to be a violation of antitrust laws, the social stigma has never been removed from the image of chiropractors. Even the federal judge admitted, “The AMA has never made any attempt to publicly repair the damage the boycott did to chiropractors’ reputations.”[25]

Sadly, beginning nearly a century ago, too many Americans fell victim to the medical prejudice to boycott what is now deemed as one of the most effective type of spine care for the majority of non-specific back problems. American and international guidelines for low back pain now recommend “conservative care” such as chiropractic care with active physical therapy for an extended period before spine surgery is considered.

This is a trend that began in 1994 with the US Public Health Service’s Agency for Health Care Policy and Research that conducted the most thorough analysis on acute low back pain and recommended spinal manipulation (SMT) in its guideline as a “proven method.”[26] Other current American guidelines such as the Milliman Care Guidelines® that provide treatment options that include chiropractic care prior to lumbar fusion.[27] The American College of Physicians and the American Pain Society published in 2007 a Joint Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain that also concluded spinal manipulation to be effective for both acute and chronic low back pain.[28]

Even the North American Spine Society guideline recommends spinal manipulation before surgery, noting that recent “studies suggest that 5 to 10 sessions of spinal manipulative therapy administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions.”[29]

A recent 2010 study over a two-year span from 85,000 Blue Cross Blue Shield beneficiaries in Tennessee with low back pain found that treating for low back pain with chiropractic alone saves 40% on the cost of care. The study estimated that allowing DC-initiated episodes of care would have led to an annual cost savings of $2.3 million for BCBS of Tennessee. [30]

The era of evidence-based health care has finally recognized the value of conservative chiropractic care for the epidemic of back pain. Anthony Rosner, PhD, testified before The Institute of Medicine: “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.”[31] As Dr. Rosner described, now the problem remains: how to convince the MDs who have developed a bad case of “professional amnesia”—those who ignore the ascendancy of chiropractic in this back pain epidemic.[32]

During this Medicare upheaval, chiropractors are poised to reduce costs and improve outcomes. If the guidelines on low back pain were followed, there would be a drastic decrease in drugs, shots, and spine surgeries that have been shown to be ineffective, costly, addictive, and disabling.

Indeed, when it comes to the question, “who’s got your back,” chiropractic remains the best type of care for the majority of back problems.

[1] 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): p. 90.

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

[3] Peter Waldman and David Armstrong, ibid.

[4] S Haldeman and S Dagenais, “A Supermarket Approach To The Evidence-Informed Management Of Chronic Low Back Pain,” The Spine Journal 8/1 (January-February 2008):1-7.

[5] John Carreyrou and Tom McGinty, Top Spine Surgeons Reap Royalties, Medicare Bounty,” The Wall St. Journal, Dec. 20, 2010

[6] John Carreyrou and Tom McGinty,  “Medicare Records Reveal Trail of Troubling Surgeries,”  The Wall St. Journal, March 29, 2011

[7] Joanne Silberner, “Surgery May Not Be the Answer to an Aching Back,” NPR, April 6, 2010.

[8] Linda Carroll,  “Back Surgery May Backfire on Patients in Pain,” MSNBC, Nov. 14, 2010

[9] Peter Waldman and David Armstrong, “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies,” Bloomberg News, Dec. 30, 2010.

[10] Jerry Groopman The New Yorker magazine, “Knife in the Back,”  (April 8, 2002)

[11] Peter Waldman and David Armstrong, “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies” Bloomberg News, Dec. 30, 2010.

[12] John Carreyrou and Tom McGinty, “Top Spine Surgeons Reap Royalties, Medicare Bounty,” Wall St. Journal, Dec. 20, 2010

[13] 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.

[14] Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70.

[15] DC Cherkin, RA Deyo, et al. “An International Comparison Of Back Surgery Rates,” Spine, 19/11 (June 2004):1201-1206.

[16] A Schlapia, J Eland, “Multiple Back Surgeries And People Still Hurt.” Available at http://pedspain.nursing.uiowa.edu/CEU/Backpain.html Accessed April 22, 2003.

[17] CBS Evening News, “Attacking Rising Health Costs,” June 9, 2006.

[18] http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/lumbar_spine_fusion_surgery.pdf

[19] http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/lumbar_spine_fusion_surgery.pdf

[20] JN Weinstein, JD Lurie, PR Olson, KK Bronner,  ES Fisher, “United States’ Trends and Regional Variations in Lumbar Spine Surgery: 1992-2003,” Spine 31/23 (1 November 2006):2707-2714

[21] “New Study Demonstrates a Three-Fold Increase in Life-Threatening Complications with Complex Surgery,” The BACKLETTER, 25/6 (June 2010):66

[22] DR Seaman, “Joint Complex Dysfunction, A Novel Term To Replace Subluxation/Subluxation Complex. Etiological And Treatment Considerations,” J. Manip Physiol Ther 20 (1997):634-44.

[23] G Jull, et alWhiplash, Headache, and Neck Pain, (Churchill Livingstone, 2008).

[24] RA Deyo, “Conservative Therapy for Low Back Pain: Distinguishing Useful From Useless Therapy,” Journal of American Medical Association 250 (1983):1057-62.  

[25]  Chester A. Wilk, James W. Bryden, Patricia A. Arthur, Michael D. Pedigo v. American Medical Association, Joint Commission on Accreditation of Hospitals, American College of Physicians, American Academy of Orthopaedic Surgeons, United States District Court Northern District of Illinois, No. 76C3777, Susan Getzendanner, Judge, Judgment dated August 27, 1987.Opinion p. 10

[26] SJ Bigos, O Bowyer, G Braea, K Brown, R Deyo, S Haldeman, 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; (1994) AHCPR publication no. 95-0642.

[27] Milliman Care Guidelines for Lumbar Fusion, “Low Back Pain and Lumbar Spine Conditions—Referral Management, Clinical Indications for Referral,” www.allmedmd.com

[28] R Chou, et al., “Diagnosis and Treatment of Low Back Pain:  A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society,” Low Back Pain Guidelines Panel, Annals of Internal Medicine 2 147/7 (October 2007):478-491

[29] MD Freeman and JM Mayer “NASS Contemporary Concepts in Spine Care: Spinal Manipulation Therapy For Acute Low Back Pain,” The Spine Journal  10/10 (October 2010):918-940

[30] Richard L. Liliedahl, Michael D. Finch, David V. Axene, Christine M. Goertz, “Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs. Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer,” Journal of Manipulative and Physiological Therapeutics (October, 2010)

[31] Testimony before The Institute of Medicine: Committee on Use of CAM by the American Public on Feb. 27, 2003.

[32] A Rosner, “Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient,” Dynamic Chiropractic, 20/25 (November 30, 2002)