ArizonaBackInstitute

By Randall Pruitt, DC, DACNB, FACFN, DAAPM, MUAC, CES-NASM

In my practice I am often asked my opinion on a number of pain procedures. One that I have been asked about time and again is facet injections. In a recent editorial in the Back Letter the evidence or lack of evidence for facet injections was discussed. Even though the scientific literature has shown that they don’t work there has been a 543% increase in their use over the past several years. What is interesting to me is that many doctors will be quick to bash a treatment like spinal decompression, because they say there is lack of evidence at this point and time. However, when the evidence clearly shows that a procedure like facet injections doesn’t work they discount it and try to somehow justify it’s utilization. It isn’t too hard to see why the Medicare system is failing, for example the cost to Medicare for facet injections was 229 million dollars in 2002 and as recently as 2006 it had gone to 511 million. Can you imagine what it is today? Probably close to a Billion.

This is the type of issue that drives me crazy when it comes to the treatment of back and neck pain. There is so much waste out there and so many procedures that are expensive and unnecessary and most of them don’t offer a long term solution to low back pain or neck pain. A program designed to actually treat the underlying cause and restore function is really what is needed and there are protocols like that, including the program at the Arizona Back Institute.

So if your doctor wants to do facet injections or some other procedure that you’re not sure about, make sure to ask him or her about the evidence, the long term ramifications and the treatment goals before you agree.

Two randomized controlled trials on vertebroplasty published in the New England Journal of medicine in August of 2009 came to some unexpected conclusions.The first study performed in the United States by David Kallmes, MD of the Mayo Clinic compared the vertebroplasty procedure to a sham procedure in 131 patients in 11 centers. The second study performed by Dr. Rachel Buchbinder of Monash University in Australia compared vertebroplasty to a sham procedure in 78 patients in 4 centers. Neither study found any advantage for the vertebroplasty procedure compared with the dummy procedure.

With the above findings from two independent studies in different countries you would think that there would be a significant decrease in the number of vertebroplasty procedures done in this country, right? Well not exactly, you see the doctors who perform vertebroplasty swear by it, no matter what the research says. Why would they do this? Because they have seen it work time and time again. In fact an article in the Boston Globe in response to these studies suggested that “these findings are unlikely to change the practice of many specialists, who said they don’t jibe with their years of experience”, which is what brings me to my point. Medical research is there as an aide to help doctors do the right thing, to do the best we can for our patients and offer those under our care treatments that are proven effective. Does this mean we don’t do anything that the research has yet to prove? I don’t think so.

Take into consideration spinal decompression, a treatment that has become more and more popular over the past several years. There are studies showing very good results and a high success rate, but opponents of the treatment claim that the research isn’t of high enough quality and there are no RCT (randomized clinical trials) proving it’s effectiveness. Does that mean it doesn’t work? Absolutely not, in fact I have seen it work on thousands of patients like clockwork. Over and over again, patients respond to spinal decompression, and in my program always after other treatments have failed. Now what if a study came out showing that it didn’t work, would I stop offering it? Not on your life!

I bring up this point because clinical experience in my opinion trumps medical research. An effective treatment for any condition is an effective treatment with or without peer reviewed journal articles. Most doctors who don’t have a vested interest appear to be scientifically minded and impartial until you start messing with their livelihood. In reality many aspects of medicine are not as scientifically grounded as you may think. Many of the routine procedures for back pain have not been proven or in some cases have been proven not work. Yet, they are still performed day in and day out.

Now am I saying we don’t need research? Absolutely not, I love research. I look forward to my monthly journals with anticipation. The good news is that a lot of the most recent studies on back pain and disc physiology are helping to support what I have seen in my practice over the years. That is a very satisfying feeling and one that hope helps a lot of back pain sufferers through the years.

By Randall C Pruitt, DC, DACNB, DAAPM, FACFN, MUAC, CES-NASM

I recently came across a study in the medical journal Spine that looked at the evidence surrounding invasive treatments for back pain. Guess what they found? Not a lot, and when I come across research like this it makes me mad…why? Because these treatments cost a lot of money and I see in my practice everyday people that have gone through them all and are no better and often worse. Some of the treatments and diagnostic protocols they review included discography, facet injections, epidural steroid injections, spinal cord stimulators and of course surgery of various kinds including disc replacement.

What is interesting is that none of these treatments really cut the mustard in efficacy. There is an interesting phenomenon in health care that when you challenge someones belief system or way of doing things they get a little angry about it so in the conclusions of this study phrases like “clinicians should employ a shared decision-making approach to x or y treatment” was included. I guess this phraseology takes a little of the sting out, but at least to their credit they would go on to say what the discussion should include. For example in the case of spinal cord stimulators they recommended that the discussion include the fact that the panel in this study could not find any sufficient evidence to recommend spinal cord stimulation for failed back surgery syndrome. And in the use of facet injections, prolotherapy and intradiscal steroid injections the panel again couldn’t find any compelling evidence that these treatments work, and they included IDET, medial branch blocks and radio-frequency ablation.

My point to all of this, is that in the world of back pain treatments you really should be informed about what options are available. I have seen thousands of what I would call “failed traditional” cases in the many years I have been practicing. In my opinion spinal decompression really is the most effective treatment I have ever seen in the treatment of chronic neck and back pain. Not to mention it’s safe and actually leaves your spine healthier, unlike most of the invasive treatments mentioned in the study. I see too often the results of long term mismanagement of these cases and it only makes it more difficult to treat. Many patients are left without a lot of options. So before you undergo an invasive procedure look into alternatives like spinal decompression. You’ll be glad you did.