Needless to say, Part 1 in my call for a Moratorium on Back Surgeries met a flurry of mixed reactions. Chiropractors and other CAM providers relish their long-overdue ascension in the guidelines from the outhouse to the penthouse. Finally some positive press!
On the other hand, spine surgeons are the wealthiest of all MDs who scoff at the idea, smiling like Cheshire cats enjoying their view from atop the medical pedestal. To these fat cats, a moratorium is as likely as a snowball in hell no matter the mounting scientific criticism of spine surgery or the new guidelines recommending conservative care first.
And why should they worry? People are convinced “bad discs” cause their pain, for-profit insurers with “fee-for-service” perverse incentives pay surgeons well, chirophobia has undermined public confidence in chiropractors, and inept MDs untrained in MSDs who created the opioid crisis are mute with pain patients about nondrug treatments, nor have medical newsmen mentioned the research debunking “bad discs” as the primary problem with most back pain.
Charging Up Capitol Hill
Despite the seemingly uphill battle in the medical war, there is a growing list of ethical researchers who admit the tsunami of opioids, epidural steroid injections, and spine surgery have finally been found to be addictive, ineffective, “underwhelming”, unnecessary, dangerous, often deadly, and very expensive.
No longer can spine surgeons rest assured atop their pedestal without feeling the shaking from critics below, especially by the elite medical researchers demanding reform.
To my surprise, I found I was not alone in my call for a moratorium; in fact, I am Johnny-come-lately. In 2004 noted spine researchers Rick Deyo, Alf Nachemson, and SK Mirza also mentioned the need for restraint in their article, “Spinal-Fusion Surgery — The Case for Restraint”, published in the New England Journal of Medicine:
“The use of spinal-fusion surgery is increasing rapidly in the United States. Most of these expensive, complex procedures are now being done for back pain and degenerative disease. Spinal fusions require long operations and are associated with an increase in the rate of complications, particularly in older patients. The benefits of surgery may be only modest, and pain relief is affected by many factors besides the anatomy. The authors of this article argue for restraint in the use of spinal-fusion surgery and for controlled trials to define more clearly the associated benefits and the indications.”
In 2006, Ms. Reed Abelson wrote The Spine as Profit Center in the New York Times revealing spine fusion surgery is among the most profitable areas for two reasons: very costly surgery and accessory hardware:
Spinal-fusion surgery is one of the most lucrative areas of medicine. An estimated half-million Americans had the operation this year, generating billions of dollars for hospitals and doctors.
But there have been serious questions about how much the surgery actually helps patients with back pain and whether surgeons’ generous fees might motivate them to overuse the procedure. Those concerns are now heightened by a growing trend among some surgeons to profit in yet another way — by investing in companies that make screws and other hardware they install. The parts can be highly profitable. A single screw that goes into the spine, for example, sells for about $1,000 — at least 10 times the cost of making it.
Such doctors face “an awfully pernicious conflict of interest,” said Dr. Richard A. Deyo.
The Death of Spine Surgery
I also discovered a fascinating YouTube presentation “Future Of The Neurosurgery: What It Will Be Like?” by James Ausman, MD, PhD, Emeritus Editor in Chief Surgical Neurology International. He also wrote an editorial, “The Death of Spine Surgery, Sequel–2014,” that made my comments seem pale in comparison.
Here’s an excerpt from his editorial where he portrays the Secretary of Health addressing the spine care fiasco (I seriously doubt Sec. Tom Price shares his sentiments):
“In 2003, I wrote an Editorial on “The Death of Spine Surgery”, which was received with denial by spine surgeons and still is today. If I were the Secretary on Health in any government concerned about costs for healthcare and I was informed about the 15× increase in complex surgery, 3× higher costs with no increase in the disease process, my first question to my assistant would be, “Where is the evidence to justify these costs? The answer would be “There is no scientific justification”. In fact there is evidence that too much surgery is being done at too great a cost. The first action I would take, as would any 6th grader, would be to stop payments for the complex procedures until justification was established.
Dr. Ausman admonished his colleagues by suggesting they “read the newspaper headlines of tomorrow” with accusatory headlines:
“Doctors Conspire with Industry to Use Unnecessary Treatments.”
“Patients Receiving Unnecessary Treatments from Neurosurgeons, Orthopedists, and Pain Doctors.”
“Healthcare Costs Escalated by Doctors and Industry.”
“Congress Calls for More Controls on Physicians.”
He concluded, “If you do not see where this is headed, you are in denial.”
Dr. Ausman was prophetic with his headlines considering the following articles have appeared in the lay media over the past few years that were very critical of medical spine care:
- “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies” by Peter Waldman and David Armstrong, Bloomberg News, Dec. 30, 2010
- “Surgery May Not Be the Answer to an Aching Back,” by Joanne Silberner, NPR, April 6, 2010
- “Why You Should Never Get Fusion Surgery For Plain Back Pain” by Robert Langreth, Forbes, Jan. 10, 2011
- “Tapping Into Controversial Back Surgeries” by Ben Eisler CBS News April 24, 2014
- “Worsening Trends in the Management and Treatment of Back Pain.” Investigation in the JAMA Internal Medicine July 29, 2013
- “Outpatient Back Pain Treatments: Not What the Doctor Should Order,” The New England Journal of Medicine published an editorial, August 20, 2013, by Jaime Toro, MD, stating, “Treatment of back and neck pain increasingly relies on strategies that run counter to published guidelines.”
- “Spinal Fusions Serve As Case Study For Debate Over When Certain Surgeries Are Necessary” by Peter Whoriskey and Dan Keating, Washington Post, October 27, 2013
- “Beware of Unnecessary Surgery” by Dr. Julian Whitaker
- “The Truth About Back Surgery,” by Toni Gerber Hope and Susan Ince, Good Housekeeping, October 14, 2009; “Of the 56 million Americans who have back pain, only 5 percent need surgery. Here’s how to protect yourself and find relief that really works.”
- “Doctors Perform Thousands Of Unnecessary Surgeries” by Peter Eisler and Barbara Hansen, USA TODAY, June 19, 2013
- “Why ‘Useless’ Surgery Is Still Popular” by 3, 2016:
Before a drug can be marketed, it has to go through rigorous testing to show it is safe and effective. Surgery, though, is different. The Food and Drug Administration does not regulate surgical procedures…
Take what happened with spinal fusion, an operation that welds together adjacent vertebrae to relieve back pain from worn-out discs. Unlike most operations, it actually was tested in four clinical trials. The conclusion: Surgery was no better than alternative nonsurgical treatments, like supervised exercise and therapy to help patients deal with their fear of back pain. In both groups, the pain usually diminished or went away.
As you can see from the dates on these articles, the criticism about spine fusion surgery is not a new issue, just one that has been ignored by the powers to be. This on-going ruse by spine surgeons will continue to stab patients in the back, boycott chiropractors, and get paid handsomely with the blessing of Sec. Price.
Guideline Bandwagon Grows
The recent litany of research-based guidelines adds to the growing evidence against medical spine care methods by promoting conservative care first, a fact Anthony Rosner, PhD, concluded 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: “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.”
New guidelines finally agree with Dr. Rosner:
- The updated American College of Physicians guidelines for treating nonradicular low back pain with nondrug, nonsurgical conservative care were published in the Annals of Internal Medicine on Feb. 14, 2017:
The American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline published in Annals of Internal Medicine that physicians and patients should treat acute or subacute low back pain with non-drug therapies such as superficial heat, massage, acupuncture, or spinal manipulation.
- On April 11, 2017, appeared the JAMA study, “Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis” also recommending SMT before medical spine care.
Findings: In this systematic review and meta-analysis of 26 randomized clinical trials, spinal manipulative therapy was associated with statistically significant benefits in both pain and function, of on average modest magnitude, at up to 6 weeks. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported in more than half of patients in the large case series.
After the ACP and JAMA guidelines were released, Consumer Reports published two positive articles, but keep in mind in 1975, a year before the Wilk v. AMA trial began, Consumer Reports published a two-part article, “Chiropractors: Healers or Quacks?” Does this title give you a hint of the bias at CR? It’s nice to see a new generation of writers at CR has taken a positive attitude:
- Stop Back Pain Without Drugs by Sally Wadyka, Consumer Reports, February 14, 2017.
For the first time, the American College of Physicians is advising treating back pain with nondrug measures like tai chi, yoga, chiropractic, and massage before resorting to over-the-counter or prescription pain relievers.
- Spinal Manipulation Can Ease Your Aching Back by Teresa Carr, Consumer Reports, April 11, 2017.
A new analysis finds that the hands-on technique works as well as pain drugs and is safer, too.
When you wrench your back, your first impulse may be to rummage through the medicine cabinet for an over-the-counter pain drug or even ask your doctor to prescribe a strong opioid painkiller such as Percocet or Vicodin. But an analysis published April 11 in the Journal of the American Medical Association finds that spinal manipulation can ease your backache and get you moving again without the risk of medication side effects.
- The North American Spine Society (NASS) has its own guidelines supportive of chiropractic care:
- In 2007, the NASS published Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. This study provides Level IV therapeutic data suggesting that distraction manipulation and neural mobilization may be beneficial in the treatment of lumbar spinal stenosis.
- In 2010, the NASS released “Contemporary Concepts in Spine Care: Spinal Manipulation Therapy for Acute Low Back Pain” recommending spinal manipulation—5 to 10 sessions over 2 to 4 weeks—should be considered before surgery.
- In 2012, the NASS also published Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy that found
“patients with lumbar radiculopathy due to lumbar disc herniation, 60% will benefit from spinal manipulation to the same degree as if they undergo surgical intervention. For the 40% that are unsatisfied, surgery provides an excellent outcome.”
- Even the Joint Commission has promoted chiropractors from the ranks of the medical zombies to the head of the table in chronic spine care with its Revisions to pain management effective January 1, 2015:
Both pharmacologic and nonpharmacologic strategies have a role in the management of pain.
The following examples are not exhaustive, but strategies may include the following:
- Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy.
- In its attempt to reign in the opioid crisis caused by primary care physicians, local pharmacists, and Big Pharma, in May, 2017, the Food and Drug Administration issued its FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain:
The FDA released its blueprint on educating health care providers about treating pain suggesting they “should be knowledgeable about the range of available therapies, when they may be helpful, and when they should be used as part of a multidisciplinary approach to pain management.”
[To illustrate the FDA’s naïveté with our profession, in Section II Nonpharmacologic Therapies, it listed us as “chiropracty” (is this equivalent to Trump’s “covfefe”?). Considering our profession is the third-largest physician-level health profession in the world that deals specifically with nondrug solutions to pain, this misspelling typifies the medically-minded FDA. Indeed, would the FDA ever issue a report with the moniker of “orthopedy” for orthopedists?]
It is also difficult for medical allies in the media to withhold their bias.
- For example, on May 10, 2017, after the release of the FDA’s proposed changes on educating health care providers about treating pain, the online newsletter STAT could not contain its bias in the report filed by Megan Thielking, FDA Proposes that Doctors Learn about Acupuncture for Pain Management:
“Chiropractors and acupuncturists who have lobbied for a bigger role in treating pain have won a preliminary endorsement from federal health officials.
“The Food and Drug Administration released proposed changes to its blueprint on educating health care providers about treating pain. The guidelines now recommend that doctors get information about chiropractic care and acupuncture as therapies that might help patients avoid prescription opioids.
“The suggested changes come as chiropractors and other alternative medicine providers have stepped up lobbying Congress and state legislatures to elevate their role in treating chronic pain. They’ve scored several big victories in recent years.”
First of all, why isn’t “chiropractic” in this headline instead of “acupuncture”? I daresay there is more evidence endorsing chiropractic care for the pandemic of LBP and MSDs than there is for acupuncture. It would have been more appropriate if the downtrodden chiropractic profession had gotten long-overdue notoriety in the headline, again illustrating the chirophobia at STAT.
Secondly, the writer portrays the endorsement by the FDA as a political success rather than a clinical victory. Undoubtedly Megan Thielking must be aware of the strong political lobbying by the medical industrial complex so it is inconceivable she would expect any guideline endorsing nondrug and nonsurgical treatments to be a function of politics, not science. There is no way chiropractors can out-leverage the AMA on Capitol Hill. Indeed, it has taken decades for science to overcome the ill-wind of medical politics blowing over Capitol Hill starting in the days of the Medical Mussolini in the 1930s.
Too bad the FDA report didn’t include advice how to overcome chirophobia that is well embedded in the minds of many MDs, newsmen, and public sector. It’s one thing to have guidelines, but another issue to follow them or to report them honestly to motivate a skeptical public.
Indeed, all of these articles and guidelines I cited were in the news one day and then gone forever more. Did we see a rush of new patients or referrals from MDs? Okay, stop laughing. We will not achieve the tipping point until this information becomes ingrained into the public’s mind with a constant effort, not a one night stand.
Stay tuned for Part 3: The Fall of the Disc Dynasty