Efficacy of Chiropractic Treatment for Post-Surgical Continued Low Back and Radicular Pain
81% of chiropractic post-surgical patients showed greater than 50% reduction in pain.
Mark Studin DC
William J. Owens DC
A report on the scientific literature
Park et. Al (2016) reported that low back pain radiating into the lower extremities have greater impact on disability and time off work that any other medical condition. Vleggeert-Lankamp, Arts and Jacobs (2013) reported “The term ‘failed back surgery syndrome’ (FBSS) is used to describe a clinical condition defined by persistent or recurrent complaints of leg pain and/or back pain regardless of one or more surgical procedures of the lumbar spine. The definition of FBSS (failed back surgery syndrome) is modified by some authors by adding that at least one surgical intervention was to be performed and that pain should persist after the last surgical intervention, for at least one year.1 The term implies that the surgery plays a role in the cause of the pain, although in most cases the surgical intervention was technically successful. It is known that nearly 20% of patients undergoing spine surgery will require secondary surgery for persistent pain or surgery-related complications during the subsequent years.” (pg. 48) El-Badawy and El Mikkawy (2016) reported that failed back surgery syndrome occurs with lateral disc surgery upwards of 17%, spinal stenosis 29% and instability 14.8%.
Perhaps the reason for failed back surgery syndrome is what the surgeons have considered their “gold standard, fusion and the ensuing loss of mobility of the spinal motor unit. Mulholland (2008) reported “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.” (pg. 619) The history of spinal fusion is both fascinating and disturbing and reveals why chiropractic both helps post-surgical cases and should always be considered first, prior to surgery as an option.
Mulholland (2008) continued:
In 1962 Harmon presented a review paper at the western orthopaedic association meeting in San Francisco, in which the term “Instability” appears.
However, Harmon’s description of what he meant by instability (unfortunately in a footnote) is revealing “Spinal instability refers to a low back-gluteal-thigh clinical triad of symptoms that may be accompanied (overt cases) by incapacitating regional weakness and pain. This is the effect of disk degeneration with or without disc hernia. Some may be asymptomatic or slightly symptomatic when instability is compensated by muscle or ligament control. It does not refer to spinous process or laminal hypermobility which some surgeons like to demonstrate at the operating table nor does this clinical concept parallel the common spinal hypermobility, which is the product of intervertebral disc degeneration, demonstrable in flexion-extension filming of the region, since the anatomic hypermobility is not always productive of symptoms”
Sadly this description of instability appears to have been ignored, and the concept of mechanical instability as a cause of back pain was progressively accepted. Harmon’s view of the effect of fusion was that it cured pain by reducing the irritation of the neural contents produced by movement. His paper was influential as he emphasized the importance of appropriate investigations prior to fusion and the segmental nature of back pain but unfortunately his use of the term instability was interpreted as supporting the view that segmental abnormal movement was the cause of the pain.
In 1965 Newman in an editorial concerning lumbo-sacral arthrodesis (surgical immobilization) refers to the need to stabilize the lumbar spine in patients with back pain after discectomy for a lumbar root entrapment.
At the beginning of the seventies the perception was that disc degeneration led to abnormal translational movement, and this was painful.
McNab in 1971 who had done much work on the disturbance of movement in the degenerate disc described what he termed the “traction spur,” a particular type of anterior osteophytes which he said was related to an abnormal pattern of translational movement. This view again supported the concept of instability. He added the important caveat that it “was impossible to establish the clinical significance of the traction spur as a statistically valid investigation the traction spur was revisited in the late eighties and was shown to be no different to claw osteophytes, and often both would be present in the same patient. It was not related to abnormal movement.”
Although McNab used the term instability, he used it in the sense that the spine was vulnerable to acute episodes of pain, because the degenerate disc rendered it more easily injured. He did not view it as a cause of chronic back pain.
Kirkaldy Willis set out his views on instability in 1982. In “Instability of the Lumbar Spine” he described the process of disc degeneration as passing through a stage of dysfunction, (intermittent pain), instability which caused more persistent pain but then with time stabilizing to a painless state. This was his explanation for the observed fact that many very degenerate discs were painless. However, he at that stage was somewhat unhappy with an entirely mechanistic view for pain. Hence, he writes “Instability can be defined as the clinical status of the patient with a back problem who with the least provocation steps from the mildly symptomatic to a severe episode”. Further he writes “Detectable increased motion does not always solicit a clinical response, and that abnormal motion may be abnormal increase or abnormal decrease”. He further writes “It is insufficient to detect the abnormal increased motion, but the mechanism by which it precipitates the symptomatic episode must also be identified”. Indeed in the seven cases he reported only one patient had backache alone, the others were all radicular problems. His paper shows that identifying abnormal movement establishes the fact that the segment is disordered, but he does not in that paper indicate that movement itself is the cause of pain.
Subsequently in his very influential book “Managing Back Pain” in 259 pages just one page is devoted to the rationale of lumbar fusion. The only reason for fusion appeared to be that, other treatments had failed, that it was reasonable from the psychological viewpoint, and that instability was present. Instability is defined elsewhere in the book as increased abnormal movement, and this is illustrated by x-rays purporting to show abnormal rotations and various types of abnormal tilt. He accepts that such appearances may be entirely painless, but in the patient with back pain they identify the causative level, and fusion is justified.
However, in a joint paper with Depuis in 1985 entitled “Radiological Diagnosis of Degenerative Lumbar instability” they write “A lumbar motion segment is considered unstable when it exhibits abnormal movements. The movement is abnormal in quality (abnormal coupling patterns) or in quality (abnormal increase of movement...) Pain is a signal of impending or actual tissue damage-and when present it indicates that a mechanical threshold has been reached or transgressed. Repeated transgressions will damage the stabilizing structures beyond physiological repair, thus putting abnormal demands on secondary restraints”.
Hence from being a method of identifying an abnormal degenerate disc, abnormal motion itself became the injurious agent.
In 1985 Pope and Panjabi in a paper entitled “Biomechanical definition of spinal instability” wrote “Instability is a mechanical entity and an unstable spine is one that is not in an optimal state of equilibrium. (...In the spine stability is affected by restraining structures that if damaged or lax will lead to altered equilibrium and thus instability. Instability is defined as a loss of stiffness”. Panjabi’s views were generally accepted by basic scientists interested in this field.
Subsequently Panjabi concluded that increased movement was not necessarily a feature of what he termed instability, but reduction in the neutral zone was. However, in a more recent paper he has abandoned the concept of instability altogether and ascribes chronic back pain as being caused by ligament sub-failure injuries leading to muscle control dysfunction.
However, throughout the period from the fifties to the nineties, the Panjabi view held sway, and the term instability evolved from being a useful term to denote a segment that was abnormal due to a degenerate disc, to a term denoting a diagnosis of an abnormal, (usually increased) pattern of movement with a translational component. The abnormal movement was thought to be the cause of the pain and clearly fusion or stopping movement was a logical treatment.
However, the inability to show that abnormal or increased movement was a feature peculiar to the painful degenerate disc, combined with the fact that despite more rigid fusions using pedicle fixation, the clinical results of fusion had not improved, was increasingly casting doubt on the concept of instability. The paper by Murata combining MRI examination with flexion and extension films in patients with back pain, showed that increased angular and translational movement was a feature of the normal or mildly degenerate disc, not of the markedly degenerate disc, where movements were reduced. In 1998 Kaigle et al. demonstrated that comparing patients with normal subjects there was always less movement present in the degenerate spine. It was therefore generally accepted that the effect of disc degeneration was to reduce movement not to increase it, as the term “instability” would imply. It may be argued that, unfortunately, this reduction of movement is associated with abnormal patterns of movement, and this is the meaning of “instability”. However despite considerable efforts over many years, using flexion/extension films, no clear relationship has been established between pain and such abnormal movements. In other words, patients with degenerative disc disease may exhibit abnormal patterns of movement yet have no pain.
By the mid-nineties, instability was still the term used to describe the disorder that we treated by fusion, but the failure to improve results by the introduction of pedicle fixation, caused many surgeons to question the concept of instability, but surgeons were all aware that fusion although unpredictable in terms of clinical result, was the best surgical treatment for chronic low back pain. It was well recognized that clinical success was unrelated to the success of the fusion, pseudarthrosis was as common amongst successful patients as in those who had failed. Was there anything else that a fusion did to the intervertebral disc unrelated to the fact that it stopped movement? (pgs. 619-623)
Mulholland (2008) concluded with a powerful statement that perhaps sums up why chiropractic realizes significant result when treating post-surgical cases.
Abnormal movement of a degenerated segment may be associated with back pain but is not causative. 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. (pg. 624)
To underscore the point of fusion being a failed surgical paradigm in many patients, Gudavalli, Olding, Joachim, & Cox (2016) reported,
Surgical decompression of the lumbar spine in older patients had a 24% reoperation rate, and a 20-fold increase in lumbar surgical fusion rates among Medicare enrollees is reported. Lumbar cage fusion rates increased from 3.6% in 1996 to 58% in 2001, and the result was increased complication risk without improved disability or reoperation rates. Adjacent segment degenerative changes and instability at the level immediately above single-segment fusion with clinical deterioration are shown in up to 90% of the cases. The incidence of radiographic adjacent segment disease following fusion has been reported to be as high as 50% in the cervical spine and 70% in the lumbar spine at 10 years. However, the incidence of clinically relevant symptomatic adjacent segment disease is quite lower, estimated at 25% in the cervical spine and 36% in the lumbar spine at 10 years.
Comparing surgery with nonsurgical treatment for back and radicular pain shows that intensive rehabilitation is more effective than fusion surgery, and nonsurgical treatment of low back and radicular pain patients is reported to reduce lumbar disk surgery by approximately two-thirds. Chronic low back pain in 349 patients aged 18-55 years found no evidence that surgery was any more beneficial than intensive rehabilitation. A study of 600 single-operated low back patients showed that 71% did not return to work 4 years after surgery, and 400 multiple-operated backs showed that 95% did not return to work 4 years later. (pg. 124)
Gudavalli, Olding, Joachim, & Cox (2016) went on to report what has been found clinically effective in both pre and post-operative cases, "Treating lumbar disk herniation and spinal stenosis patients successfully with conservative care is documented. Chiropractic manipulation prior to spine surgery is appropriate. Previous reports of the biomechanical changes in the spine when CTFD (Cox technique, flexion-traction) spinal manipulation is applied include decreased intradiscal pressure; intervertebral disk foraminal area increase; increased intervertebral disk space height; and physiological range of motion of the facet joint." (pg. 124)
Regarding post-surgical care, Gudavalli, Olding, Joachim, & Cox (2016) concluded,
81% of the (post-surgical chiropractic) patients showed greater than 50% reduction in pain levels at the end of the last treatment. At 24-month follow-up, 78.6% had continued pain relief of greater than 50%. (pg. 121)
Although one of the goals of chiropractic care is pain relief, there are still the underlying biomechanical pathologies to consider that are concurrently treated while under chiropractic care. The more pressing issue in the post-surgical cases are “could these surgeries been avoided” in the first place with correcting the underlying biomechanical pathologies prior to surgery This underscores the overwhelming need for chiropractic as Primary Spine Care providers being the first treatment option. It goes back to the adage “drugless first, drugs seconds and surgery last.” It’s just common sense and chiropractic has been verified in numerous outcome studies proven to be the most effective 1st treatment option for spine.
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.