Overtreating Back Pain

Back Surgery
3 Failed Back Surgeries

Back Surgery: Too Many, Too Costly, Too Ineffective

By J.C. Smith, MA,DC

If the present course for health care does not radically change, America will be financially crippled as President Obama warned: "paying more, getting less, and going broke."1 As example, recently Blue Shield of California announced its plans to raise rates by as much as 59 percent, and as the bellwether Golden State goes, so does the nation.2

Dr. David Himmelstein, the lead author of the study and an associate professor of medicine at Harvard, commented: "Unless you're Bill Gates you're just one serious illness away from bankruptcy. Most of the medically bankrupt were average Americans who happened to get sick."

"This study provides further evidence that the U.S. healthcare system is broken,"according to James E. Dalen, MD, MPH.5 The Harvard study underscored President Obama's argument for health care reform legislation. In a letter to Democratic Senate leaders, the president said:

back surgery"Healthcare reform is not a luxury. It's a necessity we cannot defer. Soaring healthcare costs make our current course unsustainable. It is unsustainable for our families, whose spiraling premiums and out-of-pocket expenses are pushing them into bankruptcy and forcing them to go without the checkups and prescriptions they need."6

Not only are costs and bankruptcy skyrocketing, so is accountability. During the Obama health care reform debate of the Patient Protection and Affordable Care Act, it was notable that the medical industrial complex – the American Medical Association (AMA), the HMOs, Big Pharma, and the American Hospital Association – was not called before Congress to explain why there is a health care crisis wrought with high costs and poor outcomes.

Unlike the Detroit auto executives and Wall Street bankers, whose feet were held to the fire at congressional hearings, the medical cartel avoided such public humiliation and offered no explanations. Instead, the medical alliance continued to mislead Congress and the public by claiming to be the "best health care system in the world," a notion also told all too often by conservative news media. However, the facts belie that claim.

Some pundits claim America has arguably the best doctors, the best medical schools, and the best hospitals. Undoubtedly those many countries whose health statistics are superior to America's might disagree and argue that high-tech medical diagnostic tools and highly trained surgeons are not the real issues to the health care dilemma. The actual question is, how well does the American health care delivery system really work outside of the operating room?

As the statistics show, inside the operating room is nothing less than a boondoggle. In 2006, doctors performed at least 60 million surgical procedures of all types, one for every five Americans. No other country does nearly as many operations on its citizens.7

Not only are surgeries rampant, but many are also ineffective and dangerous. Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, reported that medical care is now the third-leading cause of death in the U.S., causing 225,000 preventable deaths every year as tools to make them safer go unused.8-9

Over 100,000 people die each year from complications of surgery – far more than die in car crashes; deaths from prescription drugs now rank fourth only to cancer, heart disease, and diabetes, and when added to deaths from botched surgery, over 3,000 Americans die weekly.10 Such deaths accounted for 23 percent of overall deaths in men and 32 percent of deaths in women.11

Not Much Bang for Bucks

It would seem logical that if Americans spend the most on health care and have the best educated doctors, we would have the healthiest citizens and best health care system in the world, but we do not. According to the World Health Organization (WHO), in 2000 the U.S. ranked #1 in cost, #72 in population health, #37 in health care delivery, with 48 million Americans lacking sick-care coverage.12 In contrast, France ranked #4, #4 and #1, with only 1 percent uninsured.13 Obviously the French are getting more bang for their francs than we are getting for our bucks, despite the fear-mongering in the media about socialized medicine.

The present system was described by TIME magazine: "[W]hat a sinkhole the country's healthcare system has become: the U.S. spends more to get less than just about every other industrialized country."14 Dr. Ezekiel Emanuel, health adviser to President Obama, also addressed the question whether or not America has the best health care in the world, a mistaken belief held by many people:

"Let's bury this one once and for all. The United States is No. 1 in only one sense: the amount we shell out for health care. We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name."15

To put this cost into perspective, the U.S. spent twice as much on sick-care as it did on food in 2006 and more than China's 1.3 billion citizens consumed altogether. In addition, the increase in U.S. health care spending in the three-year period is more than the amount U.S. consumers spent on oil and gasoline during all of 2006 when energy prices began to reach new heights.16

These facts did not escape the attention of President Obama: "Today, we are spending over $2 trillion a year on health care – almost 50 percent more per person than the next most costly nation. And yet, for all this spending, more of our citizens are uninsured; the quality of our care is often lower; and we aren't any healthier. In fact, citizens in some countries that spend less than we do are actually living longer than we do."17 (Emphasis added)

Back Pain Dilemma

Undoubtedly the annual cost of health care, nearly $2.4 trillion, could be reduced substantially if unnecessary treatments were decreased. Of the Top 10 list of diseases in America, "back pain" stands at number eight, which according to Forbes.com costs over $40 billion annually for treatment costs alone;18 other estimates that include disability, work loss, and total indirect costs range between $100 and $200 billion per year.19 Back pain sent over 3 million people to emergency rooms in 2008 at a cost of $9.5 billion, making it the ninth most expensive condition treated in U.S. hospitals.20

"Work-related musculoskeletal disorders remain the leading cause of workplace injury and illness in this country," according to OSHA head David Michaels.21 Although not the killer that heart disease or cancer is, crippling back pain is expensive, disabling, and often leads later in life to osteoarthritis, which ranks ahead of back pain on the Top 10 list at $48 billion; when combined, these two musculoskeletal conditions rank fourth on the list at $88 billion.22

Recently a new wave of data by researchers has revealed the high cost and ineffectiveness of most medical back treatments. Yet these revelations have fallen on deaf ears in the medical profession as the use of opioids, epidural steroid injections, and spine surgeries has radically increased despite these warnings.

Ironically, now the chiropractic profession, long ostracized by the medical profession, has emerged as a fiscal conservative to champion this call for reducing costs in health care. Despite the historic medical prejudice, spinal manipulation has now been shown to be the most clinically and cost-effective method for the epidemic of low back pain, which happens to be the single largest cause of disability today.23

According to Pran Manga, PhD, MPhil, health economist, "There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management."24 He is not alone in his assessment. Numerous international and American studies have shown that for nonspecific back pain, manipulation was heads above all other treatments. In fact, 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."25

Chiropractic care not only has catapulted to the top of the list for back pain care, chiropractic patients are also extremely positive about their treatments. TRICARE, the health program for military personnel and retirees, has evaluated patients' response to chiropractic care. The enormously high patient satisfaction rates astounded the TRICARE administrators with scores of 94.3 percent in the Army; the Air Force tally was also high with 12 of 19 bases scoring 100 percent; the Navy also reported ratings of 90 percent or higher; and even the TRICARE outpatient satisfaction surveys (TROSS) rated chiropractors at 88.54, which was 10 percent "higher than the overall satisfaction with all providers" (78.31 percent). But despite these glowing satisfaction rates for chiropractic care, TRICARE continues to limit access to chiropractors at only 42 of 131 military treatment facilities due to an intransigent medical bureaucracy within the Department of Defense.26

Not only are patients well satisfied with chiropractic care, in fact, the more investigators look into this back pain epidemic, the more the medical management has come under attack and, remarkably, that chiropractic treatment has been found best for the vast majority of nonspecific low back and neck pain.

After nearly a century of warfare against the chiropractic profession, defaming it as an "unscientific cult" that deserved to be "eliminated,"27 research now has shown chiropractic care to be very effective and, ironically, now seriously questions the efficacy of the medical management of back pain – opioid drugs, epidural steroid injections, and spine surgery. Indeed, the claim to be unscientific and dangerous now seems to be on the other (medical) foot.

The Call for Restraint in Spine Surgery

It must be bitter medicine to swallow for the medical profession to realize that back surgery "has been accused of leaving more tragic human wreckage in its wake than any other operation in history," according to Gordon Waddell, DSc, MD, FRCS. As director of an orthopedic surgical clinic for over 20 years in Glasgow, Scotland, he determined: "Low back pain has been a 20th century health care disaster. Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem."28

Richard Deyo, MD, MPH, also mentioned the problems with medical treatments and physician incompetence in diagnosis and treatment of low back treatments: "Calling a [medical] physician a back-pain expert, therefore, is perhaps faint praise – medicine has at best a limited understanding of the condition. In fact, medicine's reliance on outdated ideas may have actually contributed to the problem."29

Undoubtedly, another knife in spine surgeons' backs occurred in 1994 when the U.S. Public Health Service's Agency for Health Care Policy & Research (AHCPR) conducted the most thorough investigation into acute low back pain in adults and concluded the following finding in its Patient Guide:

"Even having a lot of back pain does not by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.30(Emphasis added)

The AHCPR study also concluded that spinal manipulation was the preferred initial professional treatment for acute low back pain. The Patient Guide stated: "This treatment (using the hands to apply force to the back to 'adjust' the spine) can be helpful for some people in the first month of low back symptoms. It should only be done by a professional with experience in manipulation."31

This recommendation was, in effect, an endorsement of chiropractic care, since chiropractors do 94 percent of all spinal manipulation in the U.S.32 After a century of defamation, it was a sweet vindication for the chiropractic profession finally to be endorsed by the U.S. Public Health Service. Of course, the North American Spine Society, consisting primarily of spine surgeons, took a dim view of this precedent and politicked to have the AHCPR's mission to establish guidelines eliminated with help from Newt Gingrich's Republican Congress. It should be noted that of the 14 guidelines done by AHCPR, the acute low back pain guideline was the only one attacked by the medical profession.

Despite the medical resistance, these warnings are escalating as the call for restraint is growing from a whisper into a roar. Certainly when leading medical professionals from prestigious universities, journals, and the U.S. Public Health Service openly criticize the onslaught and ineffectiveness of spine surgery, this has become an epidemic of legitimate concern for payers and patients alike.

References

  1. Text of President Obama's health care speech, June 15, 2009, reprinted by MarketWatch.
  2. Calvan CC."Blue Shield Stands By California Health Care Premium Hikes." The Sacramento Bee, Feb. 11, 2011.
  3. Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical Bankruptcy in the United States, 2007: results of a national study. The American Journal of Health, August 2009;122(8):741-746.
  4. Arnst C. "Study Links Medical Costs and Personal Bankruptcy, Harvard Researchers Say 62% of All Personal Bankruptcies in the U.S. in 2007 Were Caused by Health Problems -- and 78% of Those Filers Had Insurance." Business Week, June 4, 2009.
  5. "Harvard Study: 60% of Bankruptcies Caused by Health Problems." Consumer Affairs, June 4, 2009.
  6. Arnst C, Op Cit.
  7. Gawande A. "The Cost Conundrum." The New Yorker Magazine, June 1, 2009.
  8. Starfield B. "Is US Health Really the Best in the World?" JAMA, July 26, 2000;284(4):483-485.
  9. Nalder E, Crowley CF. "Patients Beware: Hospital Safety's a Wilderness of Data. Hearst Newspapers, March 21, 2010.
  10. Gawande A, Op Cit.
  11. Dunham W. "France Best, U.S. Worst in Preventable Death Ranking," Reuters, Jan. 8, 2008.
  12. World Health Organization. The World Health Report 2000: Health Systems--Improving Performance, 2000.
  13. Rodwin VG. "The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States." Am J Public Health, January 2003;93(1): 31-37.
  14. Tumulty K. "Can Obama Find a Cure?" TIME, Aug. 10, 2009.
  15. Emanuel E, Brownlee S. "Myths About Our Ailing Health-Care System," Washington Post, Nov. 23, 2008.
  16. Farrell DM, Jensen ES, Kocher B. "Accounting for the Cost of U.S. Health Care: A New Look at Why Americans Spend More." McKinsey Global Institute, Nov. 8, 2008.
  17. Text, Op Cit.
  18. Van Dusen A. "America's Most Expensive Medical Conditions," Forbes.com, Feb. 6, 2008.
  19. Guyer RD. "The Paradox In Medicine Today--Exciting Technology and Economic Challenges." The Spine Journal, March/April 2008;8(2):279-285.
  20. AHRQ News and Numbers: "Aching Back Sends More Than 3 Million to Emergency Departments." Feb. 3, 2011.
  21. "Anti-Regulatory Forces Launch Full Assault on Public Protections." OMB Watch, Feb. 8, 2011.
  22. "Top 10 Most Expensive Treatment-Disease Costs."www.mostexpensiveworld.com/diseases/top-10-most-expensive-treatment-disease-costs.html
  23. Woolf AD, Pfleger B. "Burden of Major Musculoskeletal Conditions.Bull World Health Organ, 2003;81(9):646-656.
  24. Manga P, Angus D, Papadopoulos C, Swan W. "The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain." Funded by the Ontario Ministry of Health, August 1993.
  25. Testimony before the Institute of Medicine: Committee on Use of CAM by the American Public, Feb. 27, 2003.
  26. Chiropractic Care Study, Senate Report 110-335 accompanying the National Defense Authorization Act for FY 2009; letter sent to Congressmen by Ellen P. Embrey, Deputy Assistant Secretary of Defense, Sept. 22, 2009.
  27. Memo from Robert Youngerman to Robert Throckmorton, Sept. 24, 1963; plaintiff's exhibit 173, Wilk.
  28. Waddell G, Allan OB. "A Historical Perspective on Low Back Pain and Disability." Acta Orthop Scand, 1989;60 (suppl 234).
  29. Deyo RA. "Low-Back Pain." Scientific American, August 1998:49-53
  30. Bigos S, et al. Acute Low Back 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, AHCPR Pub. No. 95-0642; December 1994. Patient Guide, (1992):12.
  31. Ibid, p. 7.
  32. Shekelle PG, et al. RAND Corporation Report: The Appropriateness of Spinal Manipulation for Low-Back Pain.
Back Surgery: Too Many, Too Costly, Too Ineffective, Part 2

David Spodick, MD, professor of medicine at the University of Massachusetts, has stated: "Surgery is the sacred cow of our health-care system and surgeons are the sacred cowboys who milk it."33 Indeed, spine surgery has become the cash cow in the medical world and will only grow larger unless sensibility prevails over profiteering.

In reality, doctors and hospitals are making huge profits off the backs of unsuspecting patients who are not told there may be better and cheaper ways to solve their back pain with chiropractic care or other non-invasive methods. The costs of back surgeries are among the most expensive, and these costs do not include hospitalization, imaging, drugs or medications:34

  • Anterior cervical fusion: $44,000
  • Cervical fusion: $19,850
  • Decompression back surgery: $24,000
  • Lumbar laminectomy: $18,000
  • Lumbar spinal fusion: $34,500

Deyo found that the mean hospital costs alone for surgical decompression and complex fusions ranged from $23,724 for the former to $80,888 for the latter.35 When combined with surgical costs, medications, MRIs, rehab, and disability, every spine surgery case approaches $100,000 or more. The direct costs are astronomical and may reach as high as $169,000 for a lumbar fusion, and for a cervical fusion as high as $112,480.36

operating roomResearch suggests that of the 500,000-plus disk surgeries performed annually, as many as 90 percent are unnecessary and ineffective.37 This is unsustainable, and yet growing at incredible rates. Deyo noted, "It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just six years," and he mentioned one strong motivation included "financial incentives involving both surgeons and hospitals."38

In the current era of evidence-based medicine, it is difficult to understand the huge increase in spine fusions considering their high costs, poor outcomes and increased disability costs. Indeed, it certainly appears we have now entered into the era of economic-based medicine instead of evidence-based. Despite the huge increase in numbers and costs for spine surgery, the evidence shows this has been a waste.

In 2010, researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers' Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in the hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.39

After two years, only 26 percent of those who had surgery returned to work compared to 67 percent of patients who did not have surgery. Of the lumbar fusion subjects, 36 percent had complications and the reoperation rate was 27 percent for surgical patients. Permanent disability rates were 11 percent for cases and 2 percent for nonoperative controls. In what might be the most troubling finding, researchers determined that there was a 41 percent increase in the use of painkillers, with 76 percent of cases continuing opioid use after surgery. Seventeen surgical patients died by the end of the study.40

The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs do not work, according to the study's lead author, Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine. His study concluded: "Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a Workers' Compensation setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor return to work status."41

Commenting on spine surgery, Nguyen said, "The outcomes of this procedure for degenerative disc disease and disc herniation make it an unfortunate treatment choice."42According to the editors of The Back Letter, a newsletter from the Department of Orthopedic Surgery at Georgetown Medical Center in Washington, D.C., "This form of surgery in workers' compensation subjects appears to be a gamble at best."

Deyo admitted to The New York Times that the spine profession is ignoring the call for restraint on drugs, shots and back surgery. "People say, 'I'm not going to put up with it,' and we in the medical profession have turned to ever more aggressive medication, narcotic medication, and more invasive surgery."43

In his 2009 article, "Overtreating Chronic Back Pain: Time to Back Off?" Dr. Deyo speaks of the shortcomings of the medical spine treatments in the U.S.:44

"Jumps in imaging, opioid prescriptions, injections, and fusion surgery might be justified if there were substantial improvements in patient outcomes. Even in successful trials of these treatments, though, most patients continue to experience some pain and dysfunction.

"Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain. We must rethink chronic back pain at fundamental levels."

Dr. Deyo is not alone in his call for reform in spine care. The editors of The Back Letteragreed with his frustration with the medical approach:45-46

The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate ... There is growing frustration over the lack of progress in the surgical treatment of degenerative disc disease. Despite a steady stream of technological innovations over the past 15 years – from pedical screws to fusion cages to artificial discs – there is little evidence that patient outcomes have improved ... Many would like to see an entirely new research effort in this area, to see whether degenerative disc disease and/or discogenic pain are actually diagnosable and treatable conditions. (Emphasis added)

Another study conducted by Deyo and Cherkin in 1994 compared international rates of back surgeries and found the startling fact that the rate of American surgery is unusually excessive and directly attributed to the supply of spine surgeons:47

"The rate of back surgery in the United States 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." (Emphasis added)

"While many surgeons are careful about which patients they recommend for spine operations, some are not so discriminating," says Dr. Doris K. Cope, professor and vice chair for pain medicine at the University of Pittsburgh School of Medicine. "It's a case of, if you have a hammer, everything looks like a nail."48

And be certain that spine surgeons have been nailing patients for decades. Not only have spine surgeries skyrocketed, so have emerging treatments that have also not proven effective, although very profitable – the increased use of opioids and epidural steroid injections.

The recent growth in "pain management" clinics featuring epidural steroid injections (ESI) has received troubling criticism from medical experts like Robert J. Barth, a neuropsychologist, who believes these ESI treatments "reliably fail, the treatments seems to lead to a progressive worsening of the claimant's presentation, the ineffective treatment never ends, and the original treating doctors refer the claimants into pain management simple as a means of escaping from or 'dumping' a problematic patient."49

Barth believes "pain management does not accomplish anything but getting the patient addicted." He concludes that the "pain management situation in the U.S. is, indeed, horrific."50 Nonetheless, it is among the fastest growing segments in medicine today.

A similar review of pain management via ESI was regarded as "goofy" by R. Norman Harden, MD, in the American Pain Society Bulletin:51

"We practice at a time when unproven experimental, invasive, and expensive procedures are often compensated without question. Many of the surgical and interventional techniques have never been subjected to evidence based inquiry. Oddly, the FDA approves devices and procedures relatively easily ... in this context, there has been a proliferation of extremely goofy therapies, which are expensive at best, and downright dangerous at worst."

Another criticism of ESI appeared in the American Pain Society Bulletin by Steven H. Sanders, PhD, who revealed nerve blocks for back pain are not supported by scientific research: "From the current review, we must conclude injections and nerve blocks produce a large amount of money with very little science to support their application."52

Not only have epidural injections come under criticism; so has the widespread use of opioids in the long-term treatment of back pain. "There is increasing recognition that this massive treatment movement may have been a mistake," opined the editors of The Back Letter. "The proven benefits of opioids do not extend to the long-term treatment of chronic pain ... Editorials and commentaries in medical journals are starting to pose the question, 'How could this have happened?'"53

A new study on opioid use from Denmark reveals more disturbing news. Although proponents of opioid drugs speculate they provide significant pain relief, improve function, and enhance quality of life over the long term, a new study by Per Sjogren, MD, and colleagues refutes this claim. They found the use of opioids was associated with inadequate pain relief, poor quality of life, long-term unemployment, and high levels of medical care-seeking.54

"Furthermore, the results indicated that individuals with chronic pain using strong opioids had a higher risk of death than individuals without chronic pain," according to Sjogren."55

Chiropractic: The Best Buy

Not only can most medical spine treatments be avoided, but they also must be reigned in if America hopes to reduce its health-care spending crisis. This problem has become more apparent after research found that the Fortune 500 companies spent over $500 million a year on avoidable back surgeries for their workers and lost as much as $1.5 billion in indirect costs associated with these procedures in the form of missed work and lost productivity, according to a two-year study by Consumer's Medical Resource (CMR).56

This CMR study, "Back Surgery: A Costly Fortune 500 Burden," found one out of three workers recommended for back surgery said they avoided an unnecessary procedure after being given independent, high-quality medical research on their diagnosed condition and treatment options. In addition, those patients who refused surgery and opted for alternative and less invasive procedures to treat their back pain reported healthier and more personally satisfying outcomes.

As the TRICARE study found, patients are more satisfied with chiropractic care than medical care treatments for low back pain. T.W. Meade, MD, of the Wolfson Institute of Preventive Medicine, London, England, surveyed patients three years after treatment and found that "significantly more of those patients who were treated by chiropractic expressed satisfaction with their outcome at three years than those treated in hospitals – 84.7 percent vs. 65.5 percent."57

A recent comparative study of back pain treatments by Antonio P. Legorreta, MD, MPH, et al., "found cost savings relating to chiropractic treatment of common complaints such as neck and back pain. Focusing on low back pain diagnoses that were selected specifically for comparability between medical and chiropractic practice, our analysis found that patients with chiropractic coverage had significantly lower rates of use of resource-intensive technologies, such as x-ray examinations, MR image, and surgery, and lower use of more expensive patient care settings, such as inpatient care. This is reflected in the significantly lower cost, at both the episode level and the patient level, of providing care for back pain."58

Another study by Niteesh Choudhry, MD, PhD, from Harvard Medical School and Arnold Milstein, MD, from Mercer Health and Benefits consulting firm, also found, in terms of clinical and cost effectiveness, that "chiropractic physician care for low back and neck pain is highly cost-effective, represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds."59

Not only is manual therapy more clinically effective, another large study shows it is also less costly than medical care. A study published in 2010 revealed data over a two-year span from 85,000 Blue Cross Blue Shield beneficiaries with low back pain in Tennessee. The patients had open access to MDs and DCs through self-referral, and there were no limits applied to the number of visits allowed and no differences in co-pays. Results show that paid costs for episodes of care initiated by a chiropractor were almost 40 percent less than care initiated through an MD. They estimated that allowing DC-initiated episodes of care would have led to an annual cost savings of $2.3 million for BCBS of Tennessee.60

Not only are these spine surgeries very expensive and in many cases unnecessary; the latest research has shown that chiropractic care is more effective and less expensive. However, the medical profession has ignored this call for restraint and in many cases, continues its boycott of chiropractic care despite the evidence. Indeed, it appears to be a case of "don't confuse us with the facts."

References

35. "New Study Demonstrates a Three-Fold Increase in Life-Threatening Complications With Complex Surgery." The Back Letter, June 2010;25(6):66.

36. Schlapia A, Eland J. "Multiple Back Surgeries and People Still Hurt." April 22, 2003.

37. Finneson BF. A lumbar disk surgery predictive score card: a retrospective evaluation."Spine, 1979:141-144.

38. Ibid.

39. Carroll L. "Back Surgery May Backfire on Patients in Pain." MSNBC.com, Oct. 14, 2010.

40. Nguyen TH, Randolph, DC, et al. Long-term outcomes of lumbar fusion among workers' compensation subjects: an historical cohort study. Spine, Feb. 15, 2011;36(4):320-331.

41. Ibid.

42. "Dismal Results for Spinal Fusion Among Patients With Workers' Compensation Claims." The Back Letter, November 2010;25(11):121.

43. Kolata J. "With Costs Rising, Treating Back Pain Often Seems Futile." New York Times, Feb. 9, 2004.

44. Deyo RA, et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med, 2009;22(1):62-68.

45. The Back Letter, July 2994;12(7):79.

46. The BACKPage Editorial. The Back Letter, March 2005;20(7):84.

47. Cherkin DC, et al. An international comparison of back surgery rates. Spine, June 2004;19(11):1201-1206.

48. Carroll L, Op Cit.

49. Barth RJ. "Saying No!--Unjustified Surgeries, Pain Management and Tests." For the Defense, March 2006;48(3):33-39. Washington & Lee Law School Current Law Journal Content.

50. Ibid.

51. Harden RN. "Chronic Opioid Therapy: Another Reappraisal." APS Bulletin, January/February 2002;12(1). Pain and Public Policy, Corey D. Fox, PhD, Department Editor

52. Sanders SH, Vicente P. Medicare and Medicaid financing for pain management: the wrong message at the right time. The Journal of Pain, September 2000;1(3):197-198.

53. "How Could This Have Happened?" The Back Letter, 2011;26(1):7.

54. Per Sjogren, et al. A population-based cohort study on chronic pain: the role of opioids. Clinical Journal of Pain, 2010;26(9):332-9.

55. "Long-Term Opioid Therapy for Chronic Pain: Dismal Results in Real-World Settings?"The Back Letter, 2011;26(1):1.

56. "FORTUNE 500s Waste Over $500 Million a Year on Unnecessary Back Surgeries for Workers." Consumer's Medical Resource, July 21, 2008.

57. Mead TW. Letter to the Editor, British Medical Journal, July 3, 1999.

58. Legorreta AP, et al. Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs. Arch Intern Med, 2004;164:1985-1992.

59. Milstein A, Choudhry N. "Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans? An Evidence Based Assessmentof Incremental Impact on Population Health and Total Healthcare Spending." Funded by the Foundation for Chiropractic Progress.

60. Liliedahl, RL, Axene DV, Goertz CM. Cost of care for common back pain conditionsinitiated with chiropractic doctor vs. medical doctor / doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer. JMPT, December 2010.


Back Surgery: Too Many, Too Costly, Too ineffective, Part 3

Medical Myths

The reason for the ineffectiveness of spine surgeries in general for nonspecific back pain, which constitutes 85 percent of all low back pain cases,61 is not due to faulty surgical methods as much as it has to do with an outdated understanding of back pain itself.

Spine researcher Chien-Jen Hsu, MD, admitted in the Journal of Neurosurgery: Spine, "By far the number one reason back surgeries are not effective and some patients experience continued pain after surgery is because the disc lesion that was operated on is not, in fact, the cause of the patient's pain."62

Now studies show that the basic premise of abnormal disc surgery has come under criticism by medical researchers. In effect, the disc theory is now defunct, but kept alive by spine surgeons and the MRI industry.

Most physicians preach and laypeople still believe in the common medical lore of "pulled muscles" and "slipped discs" when it comes to back pain, ignoring the role of spinal joints and altered spinal mechanics in this pain process. This simplistic misunderstanding is the underlying cause of mistreatment for back pain that has been perpetuated far too long as a medical myth.

mri filmThis renaissance in spine diagnosis began in 1990 when research by Scott Boden, MD, et al.,63 followed in 1994 by a supportive study by Maureen Jensen, MD, et al.,64 found no clear correlation between disc abnormalities and back pain. Yet nearly every surgeon uses disc abnormalities as a selling point on images to convince the unsuspecting patient. "Here's your problem," they say, pointing to a degenerative or herniated disc on an MRI, "and if you don't have my surgery, you may be paralyzed." This may be the biggest con-job in modern medicine today.

Beginning in 1990, Dr. Boden, director and researcher at Emory University's Orthopaedics & Spine Center, was among the first to show abnormal discs were not the sole cause of back pain since asymptomatic patients had these problems too, but had no pain. On the other hand, many patients with back pain showed no signs of disc problems. Many spine experts now admit most back pain is due to joint dysfunction and not anatomical disorders like arthritis or disc abnormalities.

Dr. Boden's study performed MRI scans of sixty-seven asymptomatic patients who had never had low-back pain, sciatica or neurogenic claudication. These scans were interpreted by three neuroradiologists who had no knowledge about the subjects. About one-third of the subjects had a substantial abnormality. In the 60-years-or-older group, the findings were abnormal on about 57 percent of the scans: 36 percent had a herniated nucleus pulposus and 21 percent had spinal stenosis. 35 percent had degenerative or bulging discs.65 Yet none of these patients had any symptoms.

Many studies now admit the fallacy of using MRIs to detect abnormal discs to justify spine surgery: "You may have a bulging disc that shows up on an MRI scan, but that may not be the cause of your leg pain. You can have disc degeneration or other anatomical lesions that show up on the scan, but are not causing pain. Studies have shown that many people with no pain or other symptoms often have some sort of disc problem show up on an MRI scan."66 (Emphasis added)

Raj Rao, MD, director of spine surgery in the Department of Orthopaedic Surgery at the Medical College of Wisconsin, also spoke of this paradox in spine imaging. "You can look at the MRIs of two people, both showing degenerative discs, but in one case there is little to no pain, while in the other, extreme pain. On the other hand, you can see a healthy spine but the patient has severe pain."67

Indisputably, MRI scans have been used as effective selling points and have greatly increased the number of unnecessary surgeries. "In fact," says Dr. Richard Deyo, "back surgery rates are highest where MRIs are the highest. In a randomized trial, we found that doing an MRI instead of a plain x-ray led to more back surgery, but didn't improve the overall results of treatment."68

Dr. Deyo again debunked the disc theory that often leads to a "false positive" misdiagnosis when he concluded that "many of these abnormalities are trivial, harmless, and irrelevant, so they have been recently dubbed 'incidentalomas'," because it may be incidental to your pain. "And we know that bulging, degenerated, and even herniated discs in the spine are common among healthy people with no symptoms. When doctors find such discs in people with back pain, the discs may be irrelevant, but they are likely to lead to more tests, patient anxiety, and perhaps even unnecessary surgery."69 (Emphasis added)

As Boden and Deyo suggested, another 2009 Stanford University study found that the abundance of MRI scans lead to excessive back surgeries. According to Stanford University Medical Center, patients who live in areas with more MRI scanners are more likely to undergo spine surgery. "The worry is that many people will not benefit from the surgery, so heading in this direction is concerning," said senior author Laurence Baker, PhD.70

The Stanford study confirms the fear that greater access to MRI technology leads to more back surgeries. "The net result is increased risks of unnecessary surgery for patients and increased costs for everybody else," according to John Birkmeyer, MD, professor of surgery and a health policy researcher at the University of Michigan.71

In yet another workers' compensation study from Kentucky by Leah Carreon, MD, et al.,72 only 19 percent of patients had a clinically significant improvement in disability after fusion surgery. "Surgeons should be cautious in discussing the effectiveness of lumbar fusion for patients on workers' compensation," said Carreon. Considering 81 percent found no improvement or worsened, this is sage advice rarely told to unsuspecting prospective patients.

The fundamental flaw of spine surgery rests with the emphasis on MRIs to detectpathoanatomical disorders (disc abnormalities, arthritis, bone spurs) rather than the emphasis on pathophysiologic disorders (malfunctioning due to a combination of joint dysfunction, malalignment, loss of flexibility, muscle weakness and compression). What matters most from the chiropractic perspective is how the spine bears weight and functions, not just the amount of disc degeneration or other anatomical issues like bone spurs or arthritis.

Foremost, spinal problems are dynamic types of injuries, according to Drs. David R. Seaman and James F. Winterstein, who explained that joint complex dysfunction (JCD) is associated with spinal misalignment and aberrant joint motion that may subsequently cause a cascade of events such as reflex muscle spasms, disc inflammation, nerve compression, neurological dysafferentiation, vascular constriction, localized pain, and joint stiffness.73-74 Evidently, JCD is not as simple to understand as the slipped disc theory, but essential to comprehend why manipulative therapy is so effective.

In fact, most medical doctors and patients are unaware there are spinal joints or how abundant they are. Counting all the vertebral joints, sacroiliac joints, rib heads, and the pubic symphysis, new research now suggests the total is 313, a fact that is lost on most physicians. This total includes all synovial, symphysis and syndesmosis joints, according to Gregory D. Cramer, DC, PhD, dean of research at National University of Health Sciences.75

The Ignorance Factor

Not only has the focus of back pain shifted from discs to joints, but new studies also have confirmed that most primary care medical physicians are inept in their training on musculoskeletal disorders,76 more likely to ignore recent guidelines77 and more likely to suggest spine surgery than surgeons themselves.78 As well, some physicians suffer from "professional amnesia," as Anthony Rosner, PhD, described those who inexcusably forget to inform patients that chiropractic care is a recommended option to the often-ineffective medical methods.79

Scott Boden admits, "Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders." His belief is supported by the consensus that the poor medical outcomes stem from an antiquated disc theory, too many MRIs detecting incidentalomas, ineffectual medical treatments, and primary care physicians who are ill-trained to diagnosis. Indeed, the major obstacle to overcome in this epidemic of back pain originates with medical doctors themselves.80

This paradigm shift away from drugs, shots and spine surgery has been well-noted in medical research, but has been virtually ignored by the medical industrial complex that guards this multi-billion dollar market. If chiropractic care were substituted as a first-line treatment for low back and neck pain as recommended by many studies, the billion dollar expense could be reduced drastically. Not only would the cost of medical treatments decrease; so would disability costs and workers' compensation expenses.

The potential for realistically lowering costs with chiropractic care may be a large reason why hospitals controlled by a biased medical society may not want to include lower-cost providers such as doctors of chiropractic. When hospitals can charge $100,000 or more for radical back surgeries, the incentive to utilize lower-cost services is compromised. Realistically, why would a hospital with a perverse motivation to exploit patients want a chiropractor on staff who will earn a mere $800 per case on the average?81 While the payers and patients might enjoy this inexpensive resolution, the hospital administration surely would not.

President Obama noted the resistance to change when he mentioned:82 "We know the moment is right for health care reform. We know this is an historic opportunity we've never seen before and may not see again. But we also know that there are those who will try and scuttle this opportunity no matter what - who will use the same scare tactics and fear-mongering that's worked in the past. They'll give dire warnings about socialized medicine and government takeovers; long lines and rationed care; decisions made by bureaucrats and not doctors. We've heard it all before - and because these fear tactics have worked, things have kept getting worse." (Emphasis added)

The same problem can be found with the diagnosis and treatment of back pain. Despite the new research showing the efficacy of chiropractic care, the fear-mongering and scare tactics used by spine surgeons and primary care physicians has vilified this best option of care. The AMA's defamation of chiropractic was effective in creating unfounded fears and skepticism, and for all intents, eliminated competition as well as perpetuated ineffective medical treatments in this epidemic of back pain.

Editor's notePart 2 of this article appeared in the April 9 issue; part 4 (the final installment) will appear in the next (May 6) issue.

References

61. Deyo RA. Conservative therapy for low back pain: distinguishing useful from useless therapy. Journal of the American Medical Association, 1983;250:1057-62.

62. Hsu CJ, et al. Clinical follow up after instrumentation-augmented lumbar spinal surgery in patients with unsatisfactory outcomes. J Neurosurg: Spine, October 2006;5(4):281-286.

63 Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am, 1990;72:403-408.

64. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS.Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med, 1994;331:69-73.

65. Boden SD, et al., Op Cit.

66. Spine-health.com: Sciatica Symptoms. www.spine-health.com

67. Garfinkel P. "The Back Story." AARP: The Magazine, July/Aug 2009.

68. Deyo RA, Op Cit.

69. Deyo RA, Op Cit.

70. Welsh J. "MRI Abundance May Lead to Excess in Back Surgeries, Study Shows."Stanford University School of Medicine, Oct. 14, 2009.

71. Ibid.

72. Ibid.

73. Seaman DR, Winterstein JF. Dysafferentiation, a novel term to describe the neuropathophysiological effects of joint complex dysfunction: a look at likely mechanisms of symptom generation. J Manipulative Physiol Ther, 1998;21:267-80.

74. Seaman DR. Joint complex dysfunction, a novel term to replace subluxation/subluxation complex. Etiological and treatment considerations. J Manip Physiol Ther, 1997;20:634-44.

75. Cramer G, Dean of Research, National University of Health Sciences, personal communication with J.C. Smith (April 29, 2009).

76. Joy EA, Van Hala S. Musculoskeletal curricula in medical education-- filling in the missing pieces. The Physician And Sports Medicine, November 2004;32(11).

77. Bishop PB, et al. The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) study, part I: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. Spine J, December 2010;10(12):1055-64.

78. Bederman SS, Mahomed NN, Kreder HJ, et al. In the eye of the beholder: preferences of patients, family physicians, and surgeons for lumbar spinal surgery. Spine, 2010;135(1):108-115.

79. Rosner A. "Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient." Dynamic Chiropractic, Nov. 30, 2002.

80. Boden S, et al. Emerging techniques for treatment of degenerative lumbar disc disease. Spine, 2003;28:524-525.

81. Mushinski M. Average hospital charges for medical and surgical treatment of back problems: United States, 1993." Statistical Bulletin Metropolitan Life Insurance Co., Health and Safety Division, Medical Dept., April-June 1995.

82. Text of President Obama's health care speech, June 15, 2009, reprinted by MarketWatch.


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