Chiropractic as the Solution for Mechanical Spine Failure and Failed Back Surgery.
By: William J. Owens DC, DAAMLP
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
A report on the scientific literature.
The latest CDC statistics show that in 2012, 54 out of 100 people had self-reported musculoskeletal conditions. By way of comparison, that is six times more than self-reported cases of cancer, double that of respiratory disease and one-third more than circulatory disorders. If we extrapolate that to a more current population in the United States of 321 million, that equates to 173 million people reporting musculoskeletal problems in 2012. Many of these are spine patients who suffer long-term without any type of biomechanical assessment or functional case management.
In 2013, Itz, Geurts, van Kleef, and Nelemans reported, “Non-specific low back pain [LBP] is a relatively common and recurrent condition with major medical and economic implications for which today there is no effective cure” (p. 5). The idea that spinal pain has a “natural history” resulting in a true resolution of symptoms is a myth and the concept that spine pain should only be treated in the acute phase for a few visits has no support in the literature. We don’t address cardiovascular disease in this manner, i.e. wait until you have a heart attack to treat, we don’t follow this procedure with dentistry, i.e. wait until you need a root canal to treat, and we certainly don’t handle metabolic disorders such as diabetes in this way, i.e. wait until you have diabetic ulcers or advanced vascular disease to treat. Why does healthcare fall short with spinal conditions in spite of the compelling literature that states the opposite in treatment outcomes?
The front lines of medical care for spine-related pain is typically the prescription of pain medication, particularly at the emergency care level, and then if that doesn’t work, a referral is made to physical therapy. If physical therapy is unsuccessful, the final referral is to a surgeon. If the surgeon does not intervene with surgery, then the diagnosis becomes “non-specific back pain” and the patient is given stronger medication since there is nothing the surgeon can do. In those surgical interventions that result in persistent pain, a commonly reported problem, there is an ICD-10 diagnosis for failed spine surgery, M96.1
A recent article Ordia and Vaisman (2011) described this syndrome a bit further stating the following, “We propose that these terms [post laminectomy syndrome or failed back syndrome] should be replaced with Post-surgical Spine Syndrome (PSSS)” (p. 132). They continued by reporting, “The incidence of PSSS may be reduced by a meticulous neurological examination and careful patient selection. The facet and sacroiliac joints should always be examined, particularly when the pain is predominantly in the lower back, or when it radiates only to the thigh or groin and not below the knee” (Orida & Vaisman, 2011, p. 132). The authors finally stated, “Adherence to these simple guidelines can result in a significant reduction in the pain and suffering, as also the enormous financial cost of PSSS” (Orida & Vaisman, 2011, p. 132). What they are referring to is a careful distinction between an “anatomical” versus a “biomechanical” cause of the spine pain.
According to Mulholland (2008), “[Surgery] Spinal fusion became what has been termed the “gold standard” for the treatment of mechanical low back pain, yet there was no scientific basis for this” (p. 619). He continued, “However whilst that fusion [surgery] may be very effective in stopping movement, it was deficient in relation to load transfer” (Mulholland, 2008, p. 623). He concluded, “The concept of instability as a cause of back pain is a myth. The clinical results of any procedure that allows abnormal disc loading to continue are unpredictable” (Mulholland, 2008, p. 624). Simply put, surgery does not correct the underlying biomechanical failure or the cause of the pain.
When a biomechanical assessment is lacking, the patient’s pain persists and allopathic medicine is focused on “managing the pain” vs. correcting the underlying biomechanical lesion/pathology/imbalance, the medication of choice at this point in care has been opioid analgesics. Back in 2011, the CDC reported, “Sales of OPR quadrupled between 1999 and 2010. Enough OPR were prescribed last year  to medicate every American adult with a standard pain treatment dose of 5 mg of hydrocodone (Vicodin and others) taken every 4 hours for a month” (p. 1489). That was 6 years ago, which was when people began to feel that treating musculoskeletal pain with narcotics was trending in the wrong direction. Now, in 2016, we can see there is a problem of epidemic proportions to the point that MDs are changing how they refer spine patients for diagnosis and treatment.
Dowell, Haegerich, and Chou (2016), along with the CDC, published updated guidelines relating to the prescription of opioid medication:
Opioid pain medication use presents serious risks, including overdose and opioid use disorder. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. In the past decade, while the death rates for the top leading causes of death such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased markedly.
…a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain and followed for up to 13 years revealed that one in 550 patients died from opioid-related overdose at a median of 2.6 years from their first opioid prescription, and one in 32 patients who escalated to opioid dosages >200 morphine milligram equivalents (MME) died from opioid-related overdose. (p. 2)
Clearly, there needs to be a nationwide standard for the process by which patients with spine pain are handled, including academic and clinical leadership on spinal biomechanics. The only profession that is poised to accomplish such a task is chiropractic.
In a recent study by Houweling et al. (2015), the authors reported, “The purpose of this study was to identify differences in outcomes, patient satisfaction, and related health care costs in spinal, hip, and shoulder pain patients who initiated care with medical doctors (MDs) vs those who initiated care with doctors of chiropractic (DCs) in Switzerland” (p. 477). This is an important study which continually demonstrates maintaining access to chiropractic care, for both acute and chronic pain is critical. We can also see from current utilization statistics that chiropractic care is underutilized on a major scale. The authors also state, “Although patients may be comanaged with other medical colleagues or paramedical providers (eg, physiotherapists), treatment for the same complaint may vary according to the type of first-contact provider. For instance, MDs tend to use medication, including analgesics, muscle relaxants, and anti-inflammatory agents, for the treatment of acute nonspecific spinal pain, whereas DCs favor spinal manipulative therapy as the primary treatment for this condition” (Houweling et al., 2015, p. 478). The continue by stating “This study showed that spinal, hip, and shoulder pain patients had modestly higher pain relief and satisfaction with care at lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs” (Houweling et al., 2015, p. 480). Overall, when taking cost into consideration, “Mean total spinal, hip, and shoulder pain-related health care costs per patient during the 4-month study period were approximately 40% lower in patients initially consulting DCs compared with those initially consulting MDs” (Houweling et al., 2015, p. 481). The authors concluded, “The findings of this study support first-contact care provided by DCs as an alternative to first-contact care provided by MDs for a select number of musculoskeletal conditions” (Houweling et al., 2015, p. 481).
Bases on the literature and outcome studies, backed up with 121 years of doctors of chiropractic and their patients’ testimonies, the time has never been better for the chiropractic profession to move into treating the 93% of the population that is not under care. Chiropractic must be moved from the accepted standard of biomechanical processes in the laboratory to the standard of care for spine beyond fracture, tumor or infection across all professions, inclusive of physical therapy. The outcomes overwhelmingly support that anything less perpetuates the epidemic of failed back treatments.
1. Centers for Disease Control and Prevention. (2015). National hospital discharge survey. Retrieved from: http://www.cdc.gov/nchs/nhds.htm
2. United States Census Bureau. (n.d.). Quick facts, United States. Retrieved from https://www.census.gov/quickfacts/
3. Itz, C. J., Geurts, J. W., van Kleef, M., & Nelemans, P. (2013). Clinical course of non‐specific low back pain: A systematic review of prospective cohort studies set in primary care. European Journal of Pain, 17(1), 5-15.
4. Ordia, J., & Julien Vaisman. (2011). Post-surgical spine syndrome. Surgical Neurology International, 2, 132.
5. Mulholland, R. C. (2008). The myth of lumbar instability: The importance of abnormal loading as a cause of low back pain. European Spine Journal, 17(5), 619-625.
6. Centers for Disease Control and Prevention. (2011). Vital signs: Overdoses of prescription opioid pain relievers - United States, 1999--2008. Morbidity and Mortality Weekly Report, 60(43), 1487-1492.
7. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain - United States, 2016. JAMA, 315(15), 1624-1645.
8. Houweling, T. A., Braga, A. V., Hausheer, T., Vogelsang, M., Peterson, C., & Humphreys, B. K. (2015). First-contact care with a medical vs chiropractic provider after consultation with a swiss telemedicine provider: Comparison of outcomes, patient satisfaction, and health care costs in spinal, hip, and shoulder pain patients. Journal of Manipulative and Physiological Therapeutics, 38(7), 477-483.