Our job as doctors is to provide the best care possible and educate the public on ways to get better while avoiding the risks of drugs and surgery. The fact remains that back pain treatment is a microcosm of everything wrong with the healthcare system today. Back trouble, in all its permutations, is estimated to cost the United States roughly $100 billion a year, more than is spent annually to treat cancer, coronary artery disease, and AIDS combined. On a per-capita basis, other nations — chief among them, the United Kingdom, Australia, Canada, Germany, Sweden, Denmark, the Netherlands, China, and South Korea — also pay hefty bills.
However, annually I watch how chiropractic reimbursements decline. I watch how Medicare would rather pay a PT than a DC. I watch how insurance companies pay for epidurals, even though they are utilized off-label and not approved by FDA for back pain.
So why is nonsurgical spinal decompression considered experimental? Failed back surgery syndrome has now received a name of epidemic proportions. However, today spine surgeons’ go-to procedure is still lumbar spinal fusion.
Ricard Deyo, M.D. states, “Back pain is among the most frustrating medical complaints for patients and doctors alike. Both expect the usual medical paradigm of diagnosis and treatment to work as it usually does. That is, we doctors take a medical history, examine the patient, order tests, and figure out exactly what’s wrong with the patient — exactly what anatomical structure or physiological disruption is causing the pain. Then we provide the best treatment designed specifically for that problem, and voila! The patient gets better. Sadly, this paradigm routinely fails us when it comes to back pain. The pain sometimes goes on well beyond the time it takes tissues to heal from injuries. Patients often don’t improve when the doctor thinks they should. Doctors often don’t prescribe tests or treatments that patients think they should.”
The key to his statement is that it takes time for tissue to heal, but primary care doctors have possibly launched a prescription opioid epidemic. I’ve read and watched how interventional pain physicians —those who perform epidural spinal injections — are faced with evidence that their shots didn’t work. Blatantly in the news, Federal prosecutors punish device manufacturers for selling spinal instrumentation that was inadequately tested. Wrongful screws and hardware are being used. Painkiller manufacturers and the U.S. Food and Drug Administration could possibly be in bed with each other. It’s time for chiropractors to stand up and stop the insanity.
Growth of spinal fusion surgery has soared in this country over the past two decades. According to government statistics, surgeons performed almost 61,000 fusion operations in 1993. In 2011, they performed 465,000 operations, which is a relative increase of 660%. Over those years, the U.S. population increased by just 20%. The average hospital charge for a spinal fusion in 2011 was $100,785. The “national bill” for those operations in 2011 was almost $47 billion. That made spinal fusion surgery, in aggregate, the costliest type of in-hospital surgery in the United States.
National data suggest that a herniated disc is the most common and most rapidly increasing reason for fusion operations. We’ve already noted that rates of fusion surgery vary widely around the country. We’ve also seen that success rates seem to run between 40-50%. Dr. Norman Shealy, a renowned neurosurgeon, stated that he knew after performing his first back surgery that back surgery wasn’t the answer.
In today’s world, greed is evident in the back pain industry, and it’s our job to stop the epidemic of failed back surgery and opioid addiction. Aside from kickbacks, consulting fees, and royalties, payment levels favor spinal fusion surgery over simpler operations. In the Medicare population, a surgeon might be paid a few thousand dollars for a decompression operation, but a complex fusion operation, involving multiple spinal levels, might pay 10 times more. Hospitals often benefit financially too, and the device makers certainly do. The Wall Street Journal reported that pedicle screws cost less than $100 each to make but sell for $1,000 to $ 2,000 each.
Is there really unnecessary spinal surgery? Many surgeons believe neurosurgeon Edward Benzel thought that only half the fusions performed in the United States were appropriate. When comparing the United States with other developed countries, some authors found that the U.S. rate of back surgery is about twice the rate of Canada, Australia, New Zealand, and most European countries. It’s roughly five times the rate of England. My research shows that fusion operations in the United States are increasing and that the complexity of the procedures is increasing. That means more discs involved, more extensive involvement of the vertebrae, and more metal implants.
Dr. Charles Rosen, a noted orthopedic surgeon at the University of California at Irvine, leads the Association for Medical Ethics. His observations reinforce the concern about the use of unnecessary surgical implants and surgery. Consistent with the kickback lawsuits, Rosen told a Senate committee that surgeons often receive huge consulting fees from companies in return for using their products. He also noted that the agreements encouraged promoting specific devices at medical meetings.
Rosen testified, “Patients usually don’t know of this conflict, which leads frequently to unnecessary implants and surgery. You can easily put $30,000 worth of hardware in a person during a fusion surgery. More complex surgery is linked to higher complication rates. It appears to increase the need for repeat surgery as well. Yet any benefits in greater pain relief or easier daily activities remain unclear. A randomized trial comparing three types of fusion operations found that more complex operations didn’t produce better pain relief or daily functioning. But the most complex surgery had the highest complication rate and the highest likelihood of ending in yet another operation.”
If failed back surgery is now of epidemic proportions, our job is to educate the patient that there is an alternative to drugs and surgical treatment for back pain, a solution without surgery. Our job is to educate the patient that healing takes time, and that we are not just in the one-visit miracle business.
If you break a leg, you’ll wear a cast. People will sign it. How long do you wear it? Healing takes time. If you have any kind of surgery, people will visit you in the hospital. They’ll look at your scar, ask for weeks how you’re doing, and understand why you’re a little slower than usual. But if you have back pain, look out! Nobody can see it. You won’t have a cast or a scar. If you’re limping, people may assume you’re exaggerating. And if you’re a little slower than usual, don’t expect much sympathy or understanding. It’s an invisible pain.
Actually, I’ve had knee surgery, gall bladder surgery, hernia surgery, and shoulder surgery, and I promise you nothing was more painful than my herniated disc. At first, I was stunned and embarrassed. How could I have a herniated disc? Thanks to my son, Dr. Jason Kaplan, and nonsurgical spinal decompression, I have avoided back surgery. Based on its success record, that’s a good thing.
Over the years, I’ve occasionally found people with back pain may feel pushed into more aggressive therapy than they need by doctors who are just trying to do their jobs. Many back pain sufferers are pushed by family members, employers, and often even attorneys looking for a higher settlement. Back pain is often an invisible pain to most doctors, which is why an MRI is so important to your diagnosis and treatment utilizing NSSD. Patients often feel pressure to seek out opioids, injections, or even surgery as a means of demonstrating their commitment to getting better.
Many may find it hard to imagine that they could get better without surgery, but that is where you step in. My partner, Dr. Bard, and I travel the country teaching doctors to be better doctors. It is why we continue to do the national certification program for NSSD. It is important that we educate the patient about the failures of drugs and back surgery and the success of nonsurgical spinal decompression.
In the past, many thought pain was a purely physical phenomenon; a tissue injury stimulated a nerve that sent impulses to the spinal cord and then to a spot in the brain, and we perceived pain. That is the concept of Rene Descartes, the French philosopher and mathematician. It was insightful for the 1600s, but the concept is now 400 years out of date. A corollary of this centuries-old model is that, when tissue healed, the pain stopped. So if you continue to have back pain, it means there’s still tissue damage. That, in turn, might mean you shouldn’t move too much and shouldn’t exercise your back. It would need rest to heal.
Well, we know this is simply not true. Pain is often part of the healing process, so don’t let your patients’ complaints of pain scare you. Healing takes time; just review the study by Dr. Leslie of Mayo Clinic that shows a sixweek healing process.
In my last book, Awaken the Wellness Within, I discuss that the brain and the spinal cord turn out to be constantly changing. They regularly make new cells. The cells constantly rearrange their connections with other cells. Inside the cells, genes that were turned off are turned on and vice versa. That means new proteins are made and cell behavior can change.
Scientists coined the term “neuroplasticity” to describe this ability of the brain and spinal cord to change. An implication of this is that pain impulses from the back aren’t just transmitted through a nerve to the spinal cord to be perceived at one place in the brain. Not only does the brain perceive pain, but it also can modify or “modulate” pain. Pain impulses can be amplified or tamped down along the way by other parts of the nervous system. That is where the chiropractic adjustment fits. Today, doctors of chiropractic can deal with bones, nerves, and muscles and treat pain nonsurgically. It’s time doctors stand up and stop the insanity.
During 32 years as business partners, Dr. Eric Kaplan and Dr. Perry Bard have developed Disc Centers of America, Concierge Coaches, and the first national certification program for nonsurgical spinal decompression.
Dr. Jason Kaplan is a Parker University graduate practicing in Wellington, Florida with his wife, Dr. Stephanie Kaplan. Jason also is an Instructor for Disc Centers of America and teaches technique for the National Certification Program at Life University. To learn more, call 888-990-9660 visit thechiroevent.com or decompressioncertified.org.
