Slipped Discs or Slipped Joints?
The unwavering commitment to traditional medical diagnosis and treatments dissuade many MDs to realize that joint dysfunction and mechanical issues may be the primary problems causing back pain as well as disc abnormalities. Certainly a disc doesn’t herniate or degenerate on its own, but only when bio-mechanical forces cause it do react.
According to Joseph Shaw, MD, orthopedist:
“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.” [[i]]
Dr. John McMillan Mennell, orthopedist, author, and medical professor testified in 1987 at the chiropractic v. AMA antitrust trial (Wilk case) about the nature of joint play, joint dysfunction, and manipulative therapy as the logical solution to this problem [[ii]]:
“To understand it, you would have to accept that the science of mechanics demands that joint play movement is prerequisite to normal pain-free functioning of movement…in the spine there are about 137 synovial joints between the lamina facets, the occipital condyles, the bottom of the skull as it rests on the atlas, the sacroiliac joints, the sacrococcygeal joints, the z-joints, even the joints of the fundusca in the neck.
“When you are dealing with manipulative therapy in the spine, your objective is to try to restore the proper motion joint play, which is prerequisite to the normal function in the spine…“I will say at some stage of recovery, there will be some local joint dysfunction in almost any patient. 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.”
The accumulative effect from traumatic injuries during childhood compounded in adulthood by the effects from gravity and obesity increasing spinal compression aggravated by prolonged sitting/standing, improper lifting, accidents, will develop a functional spinal lesion that causes a “segmental buckling effect,” according to research by John Triano, DC, PhD, et al. at the Texas Back Institute, an interdisciplinary clinic of MDs, DCs, and PTs offering comprehensive spinal care.[[iii]]
Once the joint buckles, neurologic problems commence, such as proprioceptors, nociceptors, and mechanoceptors all fire causing the pain, inflammation, and spasm associated with LBP. [[iv]] Spinal manipulative therapy to restore joint play and improve alignment relieves these neurologic issues to decrease disc herniation, nerve root compromise, muscle spasm and pain.
Many now question the medical model to view low back pain (LBP) primarily as a disc pathology. As research has shown, some people with disc abnormalities are perfectly pain-free while others with healthy spines suffer with back pain. Obviously there’s more to the diagnosis of back pain than merely disc abnormalities, spinal arthritis or most common-held beliefs that pathology alone is the root cause of most LBP.
Rather than looking at LBP as a static problem caused primarily by degeneration or pathologies, another approach is to view the spine as a dynamic, mechanical, weight-bearing column susceptible to overloads, injuries, repetitive stress, prolonged compression and leverage issues. Altered bio-physics such as joint dysfunction and disc compresson rather than pathologies alone may be the key to understanding LBP and treatment.
In fact, an article in JAMA suggested plain radiographs are as good as MRI for most patients with LBP [[v]]. “We recommend that rapid MRI not become the first imaging test for primary care patients with back pain.” According to NM Hadler, MD, “MRI joins the ranks of appealing innovations that have proved illusionary.”
A 15-member Spine Care Advisory Committee was formed on July 29, 2005. Margaret E. O’Kane, National Committee for Quality Assurance president, emphasized the importance of the new program: “In many cases, back pain is treated with unnecessary surgery that still leaves the patient in pain. This program will steer people to doctors who not only know how to diagnose back problems, but who also explain the pros and cons of treatment options, help them manage their condition and get well again.” [[vi]]
Conclusions. A significant proportion of the variation in rates of spine surgery can be explained by differences in the rates of advanced spinal imaging. The indications for advanced spinal imaging are not firmly agreed on, and the appropriateness of many of these imaging studies has been questioned. Improved consensus on the use and interpretation of advanced spinal imaging studies could have an important effect on variation in spine surgery rates.
“National Spine Care Advisory Committee Formed,” Dynamic Chiropractic September 14, 2005, Volume 23, Issue 19.
Rates of Advanced Spinal Imaging and Spine Surgery.
Spine. 28(6):616-620, March 15, 2003.
Lurie, Jon D. MD, MS
Conclusions. Primary care physician education regarding low back pain management can reduce use of imaging and specialty referrals without reductions in patient satisfaction, and implementation of a nonsurgical spine clinic for complex or chronic spine patients can significantly reduce spine surgery consultations and spine surgery rates.
Bridging the Gap Between Science and Practice in Managing Low Back Pain: A Comprehensive Spine Care System in a Health Maintenance Organization Setting.
Spine. 25(6):738-740, March 15, 2000.
Klein, Ben J. PhD; Radecki, Richard T. MD
Conclusions. Lumbar fusion rates rose even more rapidly in the 90s than in the 80s. The most rapid increases followed the approval of new surgical implants and were much greater than increases in other major orthopedic procedures. The most rapid increases in fusion rates were among adults aged 60 and above. These increases were not associated with reports of clarified indications or improved efficacy, suggesting a need for better data on the efficacy of various fusion techniques for various indications.
United States Trends in Lumbar Fusion Surgery for Degenerative Conditions.
Spine. 30(12):1441-1445, June 15, 2005.
Deyo, Richard A. MD, MPH *+[S]; Gray, Darryl T. MD, ScD
. The rate of back surgery in the United States was at least 40% higher than in 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 orthopaedic and neurosurgeons in the country.
An international comparison of back surgery rates. Spine. 1994 Jun 1;19(11):1201-6.
There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative management.
The Cochrane Review of Surgery for Lumbar Disc Prolapse and Degenerative Lumbar Spondylosis.
Spine. 24(17):1820, September 1, 1999.
Gibson, J. N. Alastair MD, FRCS;
“What Doctors Don’t Know (Almost Everything)”: This title is the actual
one for an article that appeared in the May 5, 2002 insert (“The New York
Times Magazine”) in The New York Times. The article, among other things, goes on in a subtitle to state: “Until recently, medicine was governed by the
educated guess. But a new emphasis on data is challenging that tradition – with
profound implications for both doctors and patients.” A key paragraph in the
article goes as follows: “But people, doctors included, have a tendency to see
what they expect to see. It’s the premise of every sleight-of-hand game. If
it makes sense that a treatment will work – or if one stands to make money
if a treatment works – then a doctor will, with alarming and disheartening
reliability, perceive that it does in fact work. What is surprising is that a
profession that dresses itself up in the garb of science has taken so long to
acknowledge a principle that every small-town carny understands. And…. “a
chain of command has existed since the profession (of medicine) found its
modern face – doctor’s orders – with the most senior and academic physician
experts directing the decisions of specialists, family physicians and ultimately
the patients. This order is now in the throes of a revolution (emphasis
added) known as evidence-based medicine, which asserts the supremacy of data over
authority and tradition.” And….”The instant the practitioner stops saying,
‘I think you should take this therapy,’ and starts saying, ‘The evidence is
that this therapy will work this percent of the time, with these
complications, this frequently; what do you want to do (emphasis added)?’ then the power hierarchy of doctor over patient is collapsed, and autonomy is assigned to the patient. …. Just as the idea of authority within medicine is rejected, so too, the idea of the profession of medicine itself having authority over the patient is rejected. Giving authority to the data, instead of other people,
empowers everyone, the movement (of evidence-based medicine) holds.” The
author of the article is Kevin Patterson, M.D.New York Times Magazine, New York Times, May 5, 2002.
Does lumbar surgery for chronic low-back pain make a difference?
Mohit Bhandari*, Brad Petrisor*, Jason W. Busse and Brian Drew
*Division of Orthopaedic Surgery, Department of Surgery; McMaster University; Spine Unit, Hamilton Health Sciences–General Hospital, Hamilton, Ont.
CMAJ • August 16, 2005; 173 (4). doi:10.1503/cmaj.050884.
Practice implications: Lumbar fusion surgery in patients with chronic low-back pain does not appear to offer any major benefit in outcomes over conservative rehabilitation programs incorporating physical activity and cognitive–behavioural therapy. Patients undergoing lumbar fusion may have a slightly lower but clinically unimportant decrease in disability scores in exchange for an increased risk of complications, higher medical costs and no difference in quality of life at 2 years after surgery.
[i] Shaw JL, “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, Sand Diego, Nov.5-6, 1992.
[ii] Wilk et al v AMA et al. US District Court Northern District of Illinois, No. 76C3777, Getzendanner J, Judgment dated August 27, 1987.
[iii] Triano J Biomechanics of spinal manipulation. Spine 2001;1:121-30
[iv] Seaman, D. Joint complex dysfunction, a novel term to replace subluxation/subluxation complex. Etiological and treatment considerations. J. Manip Physiol Ther 1997, 20:634-44.
[v] Jarvick, JG et al, JAMA. 2003;289:2810-2818,2863-2864.
[vi] “National Spine Care Advisory Committee Formed,” Dynamic Chiropractic September 14, 2005, Volume 23, Issue 19.
“The hype for artificial discs has attracted thousands of spine surgeons into taking introductory courses…Why does this situation continue to exist, given the fact that there are about 500,000 spine surgeries performed in the United States each year? Frankly, it is beyond the comprehension of this online journal, but the existence of hidden agendas and personal gain appear to be important reasons behind this problem.”
“Of further concern is the letter to the Editors of the North American Spine Society publication SpineLine by spine surgeon André van Ooij of the Netherlands, who has observed, in significant numbers of post-artificial disc implants that: “These patients represent the most disabled group of patients that I have personally have seen in 24 years of spine practice”. Dr. Ooij also expressed concern regarding overload of the facet joints as a consequence of removal of the anterior longitudinal ligament and anulus fibrosis producing axial rotational instability and related progressive degeneration of the facet joints.”