It never ceases to amaze me how much money is wasted in the treatment of back pain. In my practice alone, I see patients every day that have been through the most idiotic treatments just because their insurance covered it. It’s not their fault, but doctors out there that offer things like epidurals, facet blocks, spinal cord stimulators as well as some of the newer spinal fusion technologies just keep going until the patient is out of options.

This happens way more often then you think, and everyday my job is to try to regain the patients trust in doctors again and come up with a game plan to help them with their suffering.

Recently, in the April 7th Arizona Republic a small article discussed how complex spinal surgeries in older adults have gone up 15 times in the period between 2002 and 2007, and complex spinal fusions accounted for 14.6 percent of all back surgeries for Medicare patients in 2007. Compare this to just 1 percent in 2002.

There is no reason for this other then money. As these big medical manufacturing companies come up with new technology they persuade doctors to use the technology by showing them how much money they can make and next thing you know a patient who never would have been recommended for a fusion in the past is now getting a fusion.

There are better solutions out there, that don’t come with the risk associated with a spinal fusion. Treatments like high powered laser and spinal decompression. These treatments work for the majority of back pain patients and at a fraction of the cost of a spinal fusion. Not to mention they are safe.

It is interesting to say the least to hear from my patients about the different types of treatments and practitioners that they have endured in a quest to heal their back pain. These range from infomercial gadgets to spinal cord stimulators from massage therapist to Neurosurgeons and everything in between. So how is a person suffering from back pain supposed to decipher between these providers? How is one to know truly who to trust and who to stay clear from?

A recent commentary in The Spine Journal by Scott Haldeman DC, MD, PhD and Simon Dagenais DC, PhD addressed this very topic. In their estimation trying to choose a back pain treatment was akin to “shopping in a foreign supermarket without understanding the product labels.”

I think this analogy fits quite well and I definitely see the correlation in my practice. Many patients come to me out of desperation after other treatments have failed and as I mentioned I am often puzzled and at times outraged by what they have gone through.

Most really have no idea what is wrong or even a clue as to what the doctors think is wrong. The majority have never seen their MRI or really understand the nature and reasoning behind any treatment they have received.

In my practice I think it is imperative that the patient understand their problem in detail, what my program goals are and what can be expected. This sounds relatively straight forward and much like simple common sense, but according to my patients this is not what they’ve experienced.

When choosing a provider for your chronic back pain make sure the explanation of your problem (if you get one) makes sense and has merit. Make sure you feel confident with their level of knowledge and training. And finally make sure you feel comfortable with them, in this health care environment it has never been more important to work as a team and that team has to have trust. Good luck!

I find it very ironic, that many spine doctors are skeptical about certain procedures, yet run with something unproven because it fits into their little specialty box. I see every day in  my practice the poor people who’ve been caught in the trap of the current medical approach to back and neck pain. I can tell you with certainty that the typical treatment plan for back or neck pain includes the following; medication, physical therapy, spinal injection then surgery. That is as scientific as it gets, and you know what? This approach is a horrible failure.

Treatments like spinal decompression, manipulation under anesthesia and MedX spinal rehabilitation have all been proven more effective then any of those mentioned above, yet many pain sufferers know nothing about them. Why? Because their doctor was taught the above formula and breaking out of that paradigm is a difficult thing to do. It’s much easier to send a back pain patient elsewhere by writing a prescription, and let’s face it, most doctors don’t have time to educate themselves on the newest treatments on back pain, so they do what they’ve always done. Which is why we have a 90 billion dollar per year price tag on the treatment of back pain and more people are reporting severe functional limitations then ever.

Which brings me to the topic of this particular blog post, complications with neck surgery. You see very often new techniques or instruments are introduced into the spinal surgery world without adequate testing. For example two recent studies highlight this problem, referring to the inability of the current research and regulatory systems to monitor and restrain the spread of new technologies and avoid unnecessary safety problems related to their use.  These two studies found significant growth in the use of bone-morphogenetic proteins (BMP’s) in spinal fusion surgery. And the rapid uptake of the new technology has led to a rash of complications related to their premature use in anterior cervical spine surgeries. In fact one of the studies found  an approximately 50% higher complication rate after BMP use in anterior cervical fusion.

My point to all of this, is that technologies are used everyday in the spine world that unfortunately are unproven and even worse can lead to severe complications. Spinal decompression on the other hand, is safe and proven effective. It is beyond me why anyone would have spinal surgery without at least going through spinal decompression. My practice routinely saves patients from surgery and often gets people better after surgery has failed. So my advice, ask questions, look at the rationale behind treatments offered to you and look at the long term benefits as well as the potential complications.

In my practice it is rare to see a patient with lower back pain or neck pain, not exhibit some other condition. Whether it be knee pain, shoulder pain or some other type of joint or muscle pain. However most doctors are so narrow in their focus that they rarely look past the body part wherein they specialize.

This is unfortunate for many reasons. Usually as the back or neck pain improves the other area will begin to affect the person much more significantly and a referral to another specialist is usually made. This can be a source of frustration for most people because who wants to go to an endless series of doctors and specialists when their problem could have been taken care of in one place?

A recent study by Michael Korff PhD and colleagues found that about 20% of the population of the United States has chronic spinal pain at any given time. And of this population 87% reported at least one other musculoskeletal condition. However, these problems are not only an accessory condition but, create about 1/3rd of the persons disability in conjunction with the spinal pain.

Another article written in the journal Pain by Peter Croft MD states that humans are vulnerable to multiple forms of pain, and common conditions will inevitably occur together.

Because of this common thread my team here at the Arizona Back Institute is very well trained in the treatment of a variety of musculoskeletal conditions, injuries to the knee, the rotator cuff and conditions like carpal tunnel syndrome and neuropathy just to name a few. Of course our main focus is on chronic spinal conditions, but my philosophy is that their affect on other areas should be treated as part of the total injury and not as a separate case, requiring a referral.

While the rationale behind these injections makes some sense the medical research shows them to be ineffective. In fact several studies have come to the same conclusion, that essentially these injections are no better than a sham injection and do not give the patient any semblance of a long term result.

The problem however with any study is that the treatment is often applied to a more generalized group, lower back pain in this example. What needs to happen in order to give us better clinical indications is to break down the patients by diagnosis and treat only those who fit the criteria. that way the true success rate can be established.

In my own practice we are very meticulous in our selection process and patients are not accepted into any program unless we have been able to establish very specific clinical findings. That is why our success rate is so high, we only accept those we feel very strongly that we can help. Unlike many medical studies published apparently disproving individual treatments, where the study population is a mixed bag.

The truth is no one treatment has all the answers. In my experience the best treatment approach is one that addresses all of the various components of back and neck pain and treats them simultaneously, giving the patient the best possible chance of a successful outcome. That is what we strive for everyday at the Arizona Back Institute.

With the unemployment rate at record numbers more and more people are out of work and willing to do whatever they can to make money to support their families. With that said there is not a day that goes by that I don’t give thanks to my choice of careers and the impact that choice has on so many others.

Everyone wants to hear that they have done a good job, no matter what the vocation or job description. It gives you a sense of satisfaction and pride to know that others see your hard work and dedication. My job as a back pain doctor is no different. My acknowledgment of a job well done is a patient responding to my care, someone who has suffered, but now is pain free.

I have had this conversation many times with my employees when they comment on the complete 180 degree turnaround of a particular patient. Often we’ll see someone literally become a different person, they are cheerful, friendly and really happy in sharp contrast to the miserable, edgy, skeptical person they came in here as.

Just today Francesca my front office coordinator told me about a patient of ours who after 20+ years in pain turned around as he was leaving the office and said to her ” You guys have no idea how much you have changed my life”. This patient went through our manipulation under anesthesia program and I can’t tell you how satisfying it is to hear a patient say that. With the programs we offer, treatments like manipulation under anesthesia and spinal decompression we hear comments like that a lot. Our programs have helped those that everything else has failed. In fact our average patient has been in pain for 7.8 months and has tried no less than 3 other treatments and we get them better!

And that is why I love my job…

Research done by A. Vania Apkarian, PhD and colleagues showed that chronic back pain has a strong effect on the prefrontal cortex in humans. The newest research reveals that this connection is much more powerful then we once thought. Evidence shows that chronic pain alters the structure of the brain leading to destructive atrophy of regions involved in memory, rational thinking, and the processing of emotions. They’ve also showed that long term neurological changes associated with chronic low back pain may result in impairments in thinking and decision making.

So as you can see, back pain is much more debilitating then you may have thought. It affects not only function, but also emotional well-being, concentration and decision making. Dealing with the pain, needs to be done through restoring the structures of the spine, not masking the perception of pain with drugs. Also if pain has this type of effect on the brain, imagine what affect the surgical removal of tissues from spine or a fusion of the spinal segments has on the brain.

Just look at the example of a person losing a limb. That limb had a connection to the brain and information from that limb activated brain centers and wired the brain a certain way, depending on the skills that the person could perform with that limb (ie like playing the piano). Remove the limb and the brain immediately undergoes dramatic change, and at times the person may still get the perception that the limb is still there (phantom limb pain). The spinal joints and muscles are rich in receptors and have a large influence on brain function. Damage or alteration of these structures leads to more and more dysfunction as these studies have shown.

Treatments like neurologically based spinal rehabilitation, spinal decompression and MedX rehabilitation address chronic back pain from the structural perspective and allow functional restoration of the problem. This leads to changes ultimately at the brain level and an improvement in the deficits that the chronic pain may have caused. Drugs and invasive treatments don’t do this.

The above explanation is exactly why a recent study presented at the 2009 annual meeting of the International Society for the Study of the Lumbar Spine is very misleading. According to researchers from the Netherlands spinal decompression doesn’t work, and here is how they came to that conclusion. They took 60 patients that met the following criteria 1) they had low back pain of more than 3 months 2) they had radiographic evidence of a degenerative disc 3)or MRI evidence of a bulging disc. Every study subject was prescribed a course of physical exercise and then randomized into one of two groups: 1) 20 sessions on a machine marketed as a spinal decompression device and 2) sham spinal decompression which essentially was just static traction. The study subjects were blinded as to what treatment they received.

The researchers did find that the patients treated with the “spinal decompression” device in fact did have tremendous success. Their pain levels went from a 61 at baseline on a visual analog scale to 32 at the 14 week follow-up, there was also improvement in leg pain, Oswestry Disability Index Scores improved and there was a significant reduction in the use of pain medication. However, there was similar improvement in the sham group so the researchers came to the conclusion that spinal decompression doesn’t work. An interesting conclusion to say the least, now here’s my take on the study…

First, to be clear there was significant improvement in both groups. We all know the placebo effect is very powerful and if you recall from one of my previous blog posts there were similar results with vertebroplasty. A much more invasive and potentially dangerous treatment, but doctors wouldn’t accept the results. Why? Because they saw with their own eyes the clinical benefits in their offices on a daily basis. Another problem with this study is the machine used as the spinal decompression machine in my opinion isn’t spinal decompression, it was intermittent traction. And the only difference between both groups was that one was static (the sham group) and was was intermittent (meaning the table would pull on the spine with a relaxation in between). So essentially they were comparing traction to traction. My advice…have a third group utilizing either the VAX-D or the DRX9000 the only real spinal decompression devices on the market in my opinion.

So the bottom line, spinal decompression works and it works very well, especially on patients that have not responded to other treatments and are moving into a chronic situation. It’s safe and in my experience it is the best treatment for disc related low back and neck pain available today.

Several recent reports have shown that the use of opioids for back pain has led to a serious increase in the number of injuries and deaths. The benefits of opiods in the long-term treatment of chronic back pain haven’t been documented, but the risks related to this treatment approach are painfully apparent.

In fact the National Drug Intelligence Center (NDIC) recently issued a publication showing that “the number of deaths and treatment admissions involving controlled prescription drugs, particularly prescription opiods, has increased significantly. This problem is becoming so wide spread that the Centers for Disease Control and Prevention (CDC) has reported that the #1 cause of death in middle-aged adults is no longer auto accidents, but is now drug poisoning. During 2005-2006, 92% of poisoning deaths involved drugs!

This is all very shocking to say the least…things have to change, and my hope is that many of you will find relief from your back pain without the use of drugs. Non-surgical treatments like spinal decompression really work. This treatment approach provides a long lasting benefit by addressing the cause, not clouding your brain so you don’t realize how bad you are. So the next time you reach for that pill bottle, do yourself a favor and call my office instead.

As a back pain doctor I am always asked whether or not I believe smoking affects the spine, does it cause an increased likelihood of back pain? The short answer to that is yes, I do. But, medical studies on the subject just never could quite pin smoking down as a potential cause. It makes sense when you think of the physiology of the disc, the fact that it lacks a blood supply and relies on fluid exchange from the blood supply to the bones above and below. You would logically think that a lack of oxygen in the system would affect the tissues without a blood supply first, right?

Well, a Finnish study recently published in the American Journal of Medicine has come to the conclusion that smoking is “modestly” associated with the risk of low back pain and the effects may be “at least partly reversible.” The Finnish researchers identified and reviewed 81 studies from around the world involving smokers, former smokers, or never-smokers and low back pain conducted between 1966 and 2009. Of those, 40 studies involving more than 300,000 adults and adolescents met the standards for the analysis.

They found that “Current smokers (adolescents or adults) are at only 31% higher risk of low back pain compared with never smokers but this estimate is only for low back pain for one day or more during the past 12 months,”

The research does suggest “the effects of smoking may be at least partially reversible,” since former smokers were less likely to seek care for low back pain than current smokers. However, more research into former smokers will be needed to make a more definitive claim.

So there you have it, at least some evidence of a cause and effect relationship between smoking and lower back pain. I know it isn’t ground breaking research, but it’s all I have.