spinal surgery

Hip Pain And Corticosteroids & Chronic Pain After Spinal Surgery

CF 303: Hip Pain And Corticosteroids & Chronic Pain After Spinal Surgery Today we’re going to talk about Hip Pain And Corticosteroids & Chronic Pain After Spinal Surgery But first, here’s that sweet sweet bumper music

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  OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around.  We’re the fun kind of research. Not the stuffy, high-brow, look down your nose at people kind of research. We’re research talk over a couple of beers. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  I’m so glad you’re spending your time with us learning together.  Chiropractors – I’m hiring at my personal clinic. I need talent, ambition, drive, smart, and easy to get along with associates. If this is you and Amarillo, TX is your speed, send me an email at creekstonecare@gmail.com If you haven’t yet I have a few things you should do. 
  • Go to Amazon and check our my book called The Remarkable Truth About Chiropractic: A Unique Journey Into The Research. It’s excellent educational resource for you AND your patients. It saves you time putting talks together or just staying current on research. It’s categorized into sections so the information is easy to find and written in a way that is easy to understand for everyone. It’s on Amazon. That’s the Remarkable Truth About Chiropractic by Jeff Williams. 
  • Then go Like our Chiropractic Forward Facebook page, 
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  • Review our podcast on whatever platform you’re listening to 
  • Last thing real quick, we also have an evidence-based brochure and poster store at chiropracticforward.com
You have found yourself smack dab in the middle of Episode #303 Now if you missed last week’s episode , we talked about Spinal Manipulative Therapy And Bezodiazepines & Yanking Someone’s Head Off. Make sure you don’t miss that info. Keep up with the class.  On the personal end of things….. Back at it. You remember when I told you last week that I think we’re on a turnaround after having been out sick and then the next week having to spend half a week in Chicago for the Forensics conference? I think the trend is continuing.  I’m looking at 46 appointments today. That’s including 3 new patient exams, 2 PI intakes, and 3 re-exams. So it’s going to be a busy one today. I’ll be glad when the day wraps up at 6:00 pm this evening. Thursday is looking a little light but it’s 8:30 on a Monday morning right now. We have plenty of time to fill that day out in the next few days.  We had our first cold blast of the year and guess who’s not happy about it? This guy. This guy that love the Summer and green things and birds chirping and shiny happy people out running around and enjoying the warm weather. This guy.  In fact, cold weather and Winter basically piss me off a bit if I’m being honest. It’s terrible. Everything goes dormant, the clocks change so it’s dark before I even get off of work, the cold wind and wet rain and ice and snow…..I’m getting triggered just to talk about it honestly.  So, the point is, it’s a mental battle for me on some very low level. It’s in the background for sure but it’s a battle for me. I hate it and yet, I have to learn to live with it every year and just get through it. Maybe I’m dramatic about it. Sure. But don’t we have our challenges that work our mental state? We’re all different so I’m sure yours is likely different than mine in lots of cases.  Another thing that has been working my mental state is the lack of a good billing company. I tried to have in-house billing for years. I lost almost a million dollars over the course of 3 years because I trusted too much. She didn’t steal. She just didn’t re-submit when denied so once timely filing passes, you’re outta luck. Well, we were outta luck a bunch it seems and by the time I found it, it was pretty far gone.  A lot of beer will get you past something like that.  They don’t share these things with you when you’re going through school but there are some soul-sucking parts to being a clinic owner. What would it be like to just show up and go to work and go home without the worry and the fret of the HR part….the billing and collecting part? What would that all be like?? I don’t know but I’m moving down the path of finding that out. I’m working on a potential partial buyout in the next 6 months. And ya know what? I’m not even nervous about it. Because the business end of it isn’t my special skill. Not my special talent. It gives me loss of enjoyment.  So as I go down that path, I’ll be updating you. It may be something you’ll be interested in as well in the coming years. Especially if you’re 50-something and getting long in the tooth.  We shall see. To be continued.  Item #1 Our first one this week is called, “Rapidly Destructive Hip Disease Following Intra-Articular Corticosteroid Injection of the Hip” by Okie et. Al. and published in Journal of Bone Joint & Surgery on November 17, 2021.  Okike K, King RK, Merchant JC, Toney EA, Lee GY, Yoon HC. Rapidly Destructive Hip Disease Following Intra-Articular Corticosteroid Injection of the Hip. J Bone Joint Surg Am. 2021 Nov 17;103(22):2070-2079. doi: 10.2106/JBJS.20.02155. PMID: 34550909. Why They Did It While recent reports have suggested that hip corticosteroid injections can hasten joint degeneration, there are few published data on the topic. The purpose of the present study was to evaluate for an association between corticosteroid injection and rapidly destructive hip disease (RDHD) and to determine the rate of, and risk factors for, occurrence. How They Did It
  • This study was conducted in 2 parts. First, to assess for a potential association between hip corticosteroid injection and RDHD, a case-control analysis was performed. 
  • Patients who developed RDHD between 2013 and 2016 served as cases, whereas those who underwent total hip arthroplasty for diagnoses other than RDHD during the same period served as controls, and the exposure of interest was prior intra-articular hip corticosteroid injection. 
  • Second, in a retrospective cohort analysis, we analyzed all patients who received a fluoroscopically guided intra-articular hip corticosteroid injection at our institution from 2013 to 2016. 
  • The rate of post-injection RDHD was determined, and logistic regression was used to identify risk factors for occurrence.
What They Found
  • In the case-control analysis, hip corticosteroid injection was associated with the development of RDHD. 
  • There was evidence of a dose-response curve, with the risk of RDHD increasing with injection dosage as well as with the number of injections received. 
  • In the retrospective cohort analysis, the rate of post-injection RDHD was 5.4%. 
  • Cases of post-injection RDHD were diagnosed at an average of 5.1 months following injection and were characterized by rapidly progressive joint-space narrowing, osteolysis, and collapse of the femoral head.
Wrap It Up
  • This study documents an association between hip corticosteroid injection and RDHD. 
  • While the risk of RDHD following a single low-dose (≤40 mg) is low, the risk is higher following high-dose (≥80 mg) injection and multiple injections. 
  • These findings provide information that can be used to counsel patients about the risks associated with this common procedure. 
  • In addition, caution should be taken with intra-articular hip injections utilizing ≥80 mg of corticosteroid and multiple injections.
Before getting to the next one, Next thing, go to https://www.tecnobody.com/en/products That’s Tecnobody as in T-E-C-nobody. They literally have the most impressive clinical equipment I’ve ever seen. I own the ISO Free and am looking to add more to my office this year or next. The equipment you’re going to find over there can be marketed in your community like crazy because you’ll be the only one with something that damn cool in your office.  When you decide you can’t live without those products, send me an email and I’ll give you the hookup. They will 100% differentiate your clinic from your competitors. I have to tell you, Dr. Chris Howson, the inventor of the Drop Release tool re-activated the code! Use the code HOTSTUFF upon purchase at droprelease.com & get $50 off your purchase. Would you like to spend 5-10 minutes doing pin and stretch and all of that? Or would you rather use a drop release to get the same or similar results in just a handful of seconds. I love it, my patients love it, and I know yours will too. droprelease.com and the discount code is HOTSTUFF. Go do it. Item #2 Our last one this week is called, “Prevalence of Chronic Pain After Spinal Surgery: A Systematic Review and Meta-Analysis” by Alshammari et. Al. and published in Cureus on July 13, 2023 and Damnit that’s sizzlin’ hot! Why They Did It Degenerative disc disease and low back pain are common challenges that persist even after a discectomy. However, characterizations and quantifications of these illnesses from the patients’ perspective are insufficient. We aimed to perform a systematic review of the literature and meta-analysis to determine the frequency of chronic pain after spinal surgery.  How They Did It
  • They searched all of the common libraries of research to retrieve articles describing the frequency of persistent back pain, reoccurring disc herniation, and undergoing another operation following primary lumbar discectomy. 
  • They excluded articles that did not disclose the proportion of patients who experienced ongoing back or leg pain for over six months after the operation. 
  • They included 16 studies evaluating 85,643 patients. 
What They Found The pooled prevalence of persistent pain was 14.97%  Wrap It Up With all advancements in technology and operation techniques, many patients (14.97%) still have failed back surgery syndrome. Appropriate preoperative communication and multidisciplinary and coordinated treatment strategies yielded the best results. I would argue that it’s actually higher than that. In a book that I highly recommend called Back In Control by spinal surgeon Dr. David Hanscum, he cites research showing that when surgery is performed on a patient with chronic pain syndrome, that person is 60% more likely to develop chronic pain at the new site of injury….the site of surgery. That’s when everything goes perfectly.  I have a friend that is a neurosurgeon in our market and he regularly tells his patient that spinal surgery is about a 50/50 chance of success or failure. I haven’t asked him for research on that but I’m passing the info along as it was passed to me.  Take it or leave it.  Alright, that’s it. Keep on keepin’ on. Keep changing our profession from your corner of the world. The world needs evidence-based, patient-centered practitioners driving the bus. The profession needs us in the ACA and involved in leadership of state associations. So quit griping about the profession if you’re doing nothing to make it better. Get active, get involved, and make it happen. Let’s get to the message. Same as it is every week.  Store Remember the evidence-informed brochures and posters at chiropracticforward.com.   

Purchase Dr. Williams’s book, a perfect educational tool and chiropractic research reference for the daily practitioner, from the Amazon store TODAY!

Chiropractic evidence-based products

Integrating Chiropractors

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The Message I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health! Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic! Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference.  Connect We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. Website
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Social Media Links https://www.facebook.com/chiropracticforward/ Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/ Twitter YouTube https://www.youtube.com/channel/UCtc-IrhlK19hWlhaOGld76Q iTunes https://itunes.apple.com/us/podcast/chiropractic-forward-podcast-chiropractors-practicing/id1331554445?mt=2 Player FM Link https://player.fm/series/2291021 Stitcher: https://www.stitcher.com/podcast/the-chiropractic-forward-podcast-chiropractors-practicing-through TuneIn https://tunein.com/podcasts/Health–Wellness-Podcasts/The-Chiropractic-Forward-Podcast-Chiropractors-Pr-p1089415/ About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine (FIANM) and Board Certified Diplomate of the American Board of Forensic Professionals (DABFP) – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger  

The Failure Of Lumbar Fusion Surgery

CF 160: The Failure Of Lumbar Fusion Surgery

Today we’re going to be talking all about lumbar fusion surgery and my growing disdain for the procedure. 

But first, here’s that sweet sweet bumper music

 

OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around. 

We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers.

I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  

If you haven’t yet I have a few things you should do. 

  • Like our Facebook page, 
  • Join our private Facebook group and interact, and then 
  • go review our podcast on iTunes and other podcast platforms. 
  • We also have an evidence-based brochure and poster store at chiropracticforward.com
  • While you’re there, join our weekly email newsletter. 

You have found yourself smack dab in the middle of Episode #160

Now if you missed last week’s episode, we talked about setting yourself apart in the way you treat migraines. This was an excellent episode that has no choice but to make you better. Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

I watched an ESPN 30 For 30 the other night. It was on Jim Valvano and his North Carolina State Wolfpack that won the national championship in basketball in 1983 I believe. It was such an unlikely story and some of his techniques were a bit wonky. 

For example, he used to make the team practice cutting down the nets from the goals after winning the championship. Far before it was ever even in the realm of possibility. The players said that was more than a little weird at first but that they came to enjoy it and it was just a part of goal-setting and visualizing. 

Visualization is such a big part of a mental process we can, and should, partake in. I myself forget to think to do it. Even though I know how impactful visualization can be. 

I can give you a personal example where visualization came in handy for me. I was a mediocre discus and shot put thrower in high school. OK, probably above average to be honest but I don’t want to pump my own tires too much. 

I ended up my junior year at 150’. That throw might win district but won’t do a lot for a guy at a regional meet. 

When my senior year came around, in the early Spring, I began getting recruited by a lot of colleges. Mostly DII colleges. One of the coaches recruiting me knew about my discus and shot put throwing. He recommended a book. It was called Peak Performance: Mental Training Techniques Of The world’s Greatest Athletes by Charles A. Garfield. 

This book was about relaxation and visualization techniques of the top athletes in the world. It was like nothing I’d ever read. Now, this was back in 1990. They may have improved visualization and relaxation techniques since then but I’m telling you, this book punted me into a different stratosphere on this stuff. I’ll put a link to it on biblio.com in the show notes for this episode. Go check it out. 

https://www.biblio.com/book/peak-performance-mental-training-techniques-worlds/d/1362768092?aid=frg&currency_id=1&gclid=Cj0KCQiAlsv_BRDtARIsAHMGVSZ40_eKAIMbAHTRPRIUrdGXJN5c6n4SG74XgCEYiPpihaJGbuny2QgaAmgHEALw_wcB

Anyway, while I was throwing in the low 160s in the discus and low 50-foot range in the shot put, when I got this book it was toward the middle of the season so it was a bit rushed. But I dove in immediately. 

Within two weeks I was at 168’ and then at the end of the season, I won state in Texas (not an easy feat with a state of 25 million people)  with a personal meet best of 176’ 4 1/2 inches. I beat my best throw of my junior year by 26’. Not only that but I went to state in the shot put. Most definitely my weak event and threw my personal best there. It was my best throw by about a foot which is a huge jump in that event ending up at 55’. Just a couple of inches from our school record. Not an accomplishment that would have ever happened without this book. 

i apologize. I went out on a tangent a bit there but I’m talking about this book and this visualization topic because it’s real and I know it can make a difference in your life and your practice. 

Listeners of this podcast know I’m not a hippy-dippy kind of dude. This isn’t a hippy-dippy thing. It’s real and I’ve experienced it. This book is meant for business as well. I encourage you to check it out yourself. 

That 30 For 30 is my favorite. It’s very inspiring and he has some great quotes in the show. You can Google his quotes as well to save some time. But, in one part, he was quoting Ralph Waldo Emerson and the quote was, “Nothing great was ever achieved without enthusiasm.”

For many of us, 2020 and COVID stole our enthusiasm. If you take Emerson at his word here, then that would mean that 2020 and COVID also stole our greatness. 

I want to encourage the listeners of the Chiropractic Forward Podcast to get your enthusiasm back. Get your greatness back. Do it right now. Make it a priority. Make it a foundation of your practice this month and let’s see what happens. 

Pass it down to your staff. Keep them pumped up. Even when or if numbers are down. My numbers are down. I’ve made no secret about that. But around here, we’re going to make enthusiasm a key ingredient of our values. Along with honesty, integrity, ethics, love, fun, and being evidence-based and patient-centered. When we add enthusiasm into that mix, I think we have a winning concoction. 

This discussion portion was meant to only deal with enthusiasm but I got to talking about Jimmy V and his visualization efforts and like an ADD guy, I saw a squirrel and just went that direction. Thank you for indulging me. I hope you found something helpful in it all. 

 em today. I first want to say that I am not against surgery for the right person and the right issue. If it’s needed and the last resort, well why the hell not? But a stat I came across a year or so ago said that out of the 56 million back pain sufferers in our country, only about 5% of them actually, truly, clinically need surgery. 

Then, as you’ll see, when you have something as invasive and impactful on life as lumbar fusion being performed so often with no improved overall outcomes on the back end of it all….well, don’t you have to be responsible and step back and take another look at that and ask yourself, what are we as surgeons doing this for, and should we continue?

Item #1

This first one today is called “Is Lumbar Fusion Necessary for Chronic Low Back Pain Associated with Degenerative Disk Disease? A Meta-Analysis” by Xu et. al. (Xu W 2020) and published in World Neurosurgery on November 27, 2020. 

Hot potato, hot potato, get ‘em while they’re good and hot!

Why They Did It

The authors wanted to evaluate the efficacy and safety of lumbar fusion versus nonoperative care for the treatment of chronic low back pain associated with degenerative disk disease.

Remember this is a meta-analysis. It’s right up there at the top of the research pyramid with systematic reviews. Meaning….it’s good stuff.

How They Did It

  • They did a comprehensive duplicate electronic database search that included PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure. 
  • They took studies published up to June 30, 2020
  • The main outcomes including clinical results, complications, and all-cause additional surgeries were presented in the form of short and long-term follow-up results. 
  • Six prospective studies involving 159 patients for short-term follow-up and 675 for long-term follow-up were included.

What They Found

  • The 2 interventions exhibited little difference in regard to short- and long-term Oswestry Disability Index and visual analog scale scores for back and leg pain, 
  • Lumbar fusion might bring about lower additional surgery rate 
  • Lumbar fusion might bring about a higher complication rate in the long term.

Wrap It Up

“The present meta-analysis determined that fusion surgery was no better than nonoperative treatment in terms of the pain and disability outcomes at either short- or long-term follow-up. It is necessary for clinicians to weigh the risk of complications associated with fusion surgery against additional surgeries after nonoperative treatment. Considering lax patient inclusion criteria in the existing randomized clinical trials, the result needs to be further confirmed by high-quality research with stricter selection criteria in the future.”

So, since we know systematic reviews and meta-analyses are like computers, then we know that they are only as good as the data you put into it. What you put into it determines what you get out of it. If they haven’t done a lot of quality research on low back fusions, well then they won’t have a lot of good quality information to assemble a meta-analysis. Right? 

When we look at 6 studies with 159 patients for the short-term part and we have 675 patients for the long-term…..I’m not a researcher but, to me, that sure doesn’t seem like a huge sample size. Certainly not when you consider the number of lumbar fusions happening around the world every single day. For such an expensive and invasive surgery, you’d sure think there’d be more to go on out there for a project like this. Is it just me?

CHIROUP ADVERTISEMENT

Item #1 was a new paper. Now I want to re-visit a couple of papers we have covered on the podcast before. One in episode 144 and one all the way back in Episode 54. 

Item #2

Item #2 is titled “Lumbar Spine Fusion: What Is The Evidence?” by Harris et. al(Harris I 2018). and published in the Journal of Internal Medicine in 2018. 

Basically, in this paper, they say that lumbar spinal fusion is common and associated with the high cost and a risk of serious adverse events. They state that they aim to summarize systematic reviews on the effectiveness of lumbar spine fusion for most diagnoses. 

Of important note is where they say that they found NO high-quality systematic reviews and the risk of bias of the randomized controlled trials they found was generally high. For something as serious as lumbar fusion surgery. Where they cut into the body, take two vertebrae that usually aren’t unstable on each other, and then drive screws into them and affix hardware to fuse them together forever and ever amen. 

No high-quality systematic reviews for lumbar fusion surgery and the RCTs out there generally carry a high risk of bias. 

Doesn’t that just give you a warm fuzzy feeling inside when a surgery like lumbar fusion doesn’t have a lot backing it?

They go on to say that the available evidence doesn’t support a clinical benefit from lumbar fusion surgery compared to non-operative treatment or stabilization without fusion for thoracolumbar burst fractures. 

They say that surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome. That was based on a single trial. 

Item #3

This one we covered in episode 144 is called, “Surgery for chronic musculoskeletal pain: the question of evidence” authored by Harris et. al(Harris IA 2020). and published in Pain Journal in September of 2020.

Why They Did It 

They say that globally, the most common reasons surgery is performed relate to the musculoskeletal system, and outside of injury, the most common reasons pertain to arthritis and back or neck pain. AKA – chronic pain. Chronic pain has become a special interest of mine after going through the orthopedic diplomat last year. It’s fascinating. 

They say, “Although the surgical treatment of chronic pain generally relies on attributing pain to objective, often visible changes on imaging studies, the causes of chronic pain are more complex and are strongly influenced by psychosocial factors.” 

Things like Yellow Flags. Go look up yellow flags and Annie O’Connor’s book called World Of Pain please and thank you.  Annie will be speaking at the Texas Chiropractic Association’s Winter Conference on March 5-6. I encourage you to be watching out on www.chirotexas.org for more info because you’ll be able to take this seminar from anywhere in the world. And I recommend you do because my hero, Dr. Anthony Nicholson from Australia will be one of the presenters. Dr. Carlo Amendolia, I will be a speaker at this thing, Dr. Brandon Steele, and Dr. Jay Greenstein as well. This is quite the conference getting put together, folks. So make your plans. 

They say that surgeries like debridement of degenerative joints and things of that nature ignore the complexity of chronic pain. They look at surgery as purely mechanistic in nature with little to no involvement otherwise and the procedures often rely on observational evidence only, rather than rigorous, comparative trials.  

In addition, they say that when the trials have actually been performed for these surgeries have been mostly subjective and measurements are usually not blinded to reduce the bias of the outcomes.  

Who really wants to go under the knife for anything other than having a mole cut off when the procedures have not been thoroughly investigated, researched, and tested? 

Uh hell no. No thank you. 

This paper was written to demonstrate that observational evidence is not adequate when you consider the costs and risks of surgical intervention. They advocate that surgical procedures should undergo randomized controlled trials with blinding and showing statistical and clinically important symptomatic improvement when compared to no surgery at all.  

Well no duh. Who on Earth would put something into widespread use….surgically that is…..without doing their due diligence through research? Well…..evidently everyone in the medical profession from this.  

Ultimately in this paper, the goal here was to quantify what kind of support exists in the literature for some common procedures.  

How They Did It

  • The first thing to do was to identify the common procedures performed for chronic pain
  • Secondly, they had to identify the number of published RCTs comparing each procedure to a control group treated without that procedure
  • They did a search of the Cochrane Central Register of Controlled Trials
  • Each paper was reviewed by two independent authors

What They Found

  • A very low proportion of the RCTs on the selected procedures compared the procedure to not performing the procedure. 64 from the more than 6,735 studies. Less than 1% if you’re keeping track. Is that not stunning? And infuriating?
  • Of those 64, only 9 were favorable to surgery. 
  • When considering individual surgical procedures, the majority of comparative trials did not favor surgery 
  • None of the studies using patient blinding for any procedure found it to be significantly better than not having the surgery at all. 

Wrap It Up We conclude that many common surgical procedures performed for musculoskeletal conditions causing chronic pain have not been subjected to randomized trials comparing them to not performing the procedure. 

Based on the observation that when such studies have been performed, only 14% (on average) showed a statistically significant and clinically important benefit to surgery; there is a need to produce such high-quality evidence to determine the effectiveness of many common surgical procedures.  

Furthermore, the production of high-quality evidence should be a requirement before widespread implementation, funding or professional acceptance of such procedures, rather than the current practice of either performing trials after procedures have become commonplace, or not performing comparative trials at all.” 

Wouldn’t you like to know that your mom’s spinal surgery procedure was fully vetted? It was researched against not doing it at all? They haven’t done that? 

Make memes and/or infographics from the sound bites I’ve given you here. You can use all of this stuff if you have a little imagination. 

Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it.

Let’s get to the message. Same as it is every week. 

Store

Remember the evidence-informed brochures and posters at chiropracticforward.com. 

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The Message

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots.

When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few.

It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient.

And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!

Key Point:

At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints….

That’s Chiropractic!

Contact

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes. 

Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms. 

We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference. 

Connect

We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

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About the Author & Host

Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

 

 

Bibliography

  • Harris I, T. A., Stanford R, (2018). “Lumbar spine fusion: what is the evidence?” Internal Med J.
  • Harris IA, S. V., Mittal R, Adie S, (2020). “Surgery for chronic musculoskeletal pain: the questions of evidence.” Pain 161(9): S95-S103.
  • Xu W, R. B., Luo W, Li Z, Gu R, (2020). “Is Lumbar Fusion Necessary for Chronic Low Back Pain Associated with Degenerative Disk Disease? A Meta-Analysis.” World Neurosurg 146: 298-306.

CF 054: Lumbar Fusion Surgery and Its Evidence Or Lack Of

CF 054: Lumbar Fusion Surgery and Its Evidence Or Lack Of

Today we’re going to talk about a great new paper coming to us from Internal Medicine Journal on Lumbar fusion surgery and it’s evidence or lack of. What’s the word on lumbar fusion surgery? We’ll tell you.

But first, here’s that silky smooth Chiropractic Forward bumper music

Integrating Chiropractors

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  

You have glided all fast and furiously into Episode #54 and we’re happy to have you here smokin tires and all. Kill the engine and take a chill pill, won’t you?

DACO

Let’s talk a bit about the Diplomate of the Academy of Chiropractic Orthopedics program quickly. I’m sitting at around 76 of my online hours and I have to get 250 of those. Yes, if you were wondering, it is going by slowly here lately but I’m going to have a little time this week and weekend to put the pedal to the metal and get after it. 

Some classes from this past week were migraines, migraines in children, thoracolumbar junction difficulties, and chronically injured hamstrings. 

Spelling Issues

These courses come from a group in Australia and they really take the long road when it comes to spelling. Did you guys know that? The first thing that’s crazy about the Aussies is that they use esses instead of z’s. For example, recognize is spelled with an s rather than a “z”.

When you see the word orthopedic spelled orthopaedic, it’s because of them and the English. We take the shortcuts and say, hey, recognize has a z sound in it so let’s spell it with a z. Hey, orthopedic has an e sound in the middle of it so let’s drop the dumb a since we don’t need it and let’s just spell it orthopedic. 

Here’s another one. Behavior. These goofy people spell it behaviour. They snuck in au right there at the very end of the word like they thought they were going to get away with it or something. Uh uh. Nope. We Americans don’t need the u at the end so we just end it in or. Because we’re cool and ain’t nobody got time for that crap. 

The most annoying one is probably edema or estrogen. They start both of those words with an O. Who the hell would ever spell estrogen Oestrogen? Or edema spelled oedema? That’s absolutely uncalled for and I’d appreciate them re-evaluating their use of the English language in this manner. 

Absolute ridiculosity. 

I am currently designing some really cool stuff all based in research and current evidence that I think you will all be interested in. At least I hope you are because, from what I’ve seen in researching, it’s like nothing else out there. 

Go to chiropracticforward.com right now while you’re thinking about it, just under this week’s episode, you’ll see an area where you can sign up for the newsletter. It’s only once a week and it’ll help us tell you about what we’re working on when we get it ready to go live!!

Now, let’s get to the reason for the season here. 

The is titled “Lumbar Spine Fusion: What Is The Evidence(Harris I 2018)?” and it was written by Ian Harris, Adrian Traeger, Ralph Stanford, Christopher Maher, and Rachelle Buchbinder. I recognize at least two of these names from the low back pain series published in The Lancet earlier this year. 

If you have not been through those papers, please listen to episodes #16, 17, and 18 of this Chiropractic Forward podcast for all the info you need on that. 

Basically, in this paper, they say that lumbar spinal fusion is common and associated with high cost and a risk of serious adverse events. They state that they aim to summarize systematic reviews on the effectiveness of lumbar spine fusion for most diagnoses. 

Of important note is where they say that they found NO high-quality systematic reviews and the risk of bias of the randomized controlled trials they found was generally high. For something as serious as lumbar fusion surgery. Where they cut into the body, take two vertebrae that usually aren’t unstable on each other, and then drive screws into them and affix hardware to fuse them together forever and ever amen. 

No high-quality systematic reviews for lumbar fusion surgery and the RCTs out there generally carry a high risk of bias. Great. Duly noted. Awesome. Lumbar fusion surgery

They go on to say that the available evidence doesn’t support a clinical benefit from lumbar fusion surgery compared to non-operative treatment or stabilization without fusion for thoracolumbar burst fractures. 

They say that surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome. That was based on a single trial. 

That was the high points of the abstract but let’s move in a little more and get on the micro level of this thing. 

This study takes info from Australia and, in the land down under, lumbar spine fusion is the fourth most costly surgical procedure, behind knee replacement, hip replacement, and C-sections. For a procedure with no high-quality systemic reviews. The first word that comes to mind for me here is, “Damn.”

The most common reasons used for lumbar spine fusion procedures would be intervertebral disc disease (which nearly everyone beyond 50-60yrs old has), degenerative scoliosis, and spinal canal stenosis. 

The main purpose here was to compare lumbar spinal fusion to non-operative means. Not to compare it to other surgical procedures. 

Conclusion

As part of the conclusion, the authors say, “The available evidence does not support the hypothesis that lumbar fusion surgery confers a clinical benefit compared to non‐operative alternatives for low back pain associated with degeneration. Similarly, the available evidence does not support the hypothesis that spine fusion confers a clinical benefit compared to non‐operative treatment or stabilization without fusion for thoracolumbar burst fractures. 

Benefits of lumbar fusion surgery compared to non‐operative treatment for isthmic spondylolisthesis are unclear (one trial at high risk of bias). Surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome (based on a single trial).

Ideally, lumbar fusion surgery for spondylolisthesis, burst fractures, back pain or degenerative conditions (degenerative scoliosis, spinal stenosis, recurrent disc herniation or instability), should only be performed in the context of high-quality clinical trials until the true value for each of these conditions is established. 

Until better quality evidence is available, treatment will continue to be guided by expert clinical opinion based on evidence at high risk of bias. Patients contemplating lumbar fusion surgery should be fully informed about the evidence base for their particular problem, including the relative potential benefits and harms of fusion compared with non‐operative treatments.

When Surgery Is OK

Let’s transition from that to an excellent guideline called When Surgery is OK and this comes from the legendary Dr. Stu McGill. 

To keep this episode from getting too long and out of hand, let’s hit the highlights. This is a 3-page document so we’ll shorten it to the extent that makes sense while still squeezing the good stuff out of it. Use these thoughts and ideas when deciding if surgery is indicated. 

Stu says to try the virtual surgery game and consider surgery only when it fails. Meaning pretend you had surgery today and tomorrow is the first day of recovery. It is characterized by gentle movements and activities but mostly a forced day of rest. The days following a typical post-surgical progression involves restricted activity. If this helps, no surgery at this time. 

Consider surgery when neurological issues are substantial, such as loss of bowel and bladder control. Note: that does not include radiating symptoms like sciatica, peripheral numbness, atrophy, etc….

Consider surgery in cases of trauma. When structures are unstable and need to be stabilized. 

Consider surgery only when the pain has been unrelenting and severe for a substantial period of time. Pain can be a terrible and misleading reason to get surgery. 

Select the surgeon. Dr. McGill says everyone likes to state that they had the best surgeon. He has found that asking the nurses and physical therapists at the hospital which surgeon has the best results is a wise way to go. 

Discuss the pain with the surgeon. Ask what the pain generator is and if they can cut it out. IF there are several tissues involved, chances of success are getting worse. Also if there is damage at several levels. 

Clarify what the success rate is. What does success even mean in your case? Does that mean you survived or does it mean you did OK for a bit before relapsing into pain? You want long-term success to any and all other options available. 

Beware of new treatments. That one should really go without any further discussion. Don’t be a pioneer on the patient side of surgical procedures. 

Beware of disc replacement – Dr. McGill states in this paper that he has not seen a successful case as of the writing of the article. 

Always exhaust the conservative options – He says you may believe that since you tried physical therapy and it didn’t help that only surgery remains. It just may be that the exact therapy tried was not the right one for your specific condition. 

FREE MRI Review

Beware of institutes that offer to view medical images and, with no other information, advise patients on surgery. Pictures are not linked to pain. He argues that a thorough clinical assessment is absolutely essential. I want to butt in on this one. The laser institute and orthopedic surgeons are all over the commercials on TV with this one. 

I will take this time to admit because they’re doing these free MRI reviews, I’m offering the same in my region but here’s why. It’s evidently enticing or they would not offer it and I KNOW for a fact they have a higher-paid marketing department that has decided it is indeed effective. 

That’s one of the reasons I’m doing it but the real reason is because I know that the majority of these people, if they get a free MRI review at the osteopath or the laser spine institute, they’re very likely to be lined up for surgery whereas I, after a thorough exam, will be lining them up for conservative, non-invasive therapy and I can usually keep these people from surgery and useless shots. 

There’s a difference. My free MRI review is to prevent them from surgery. Their free MRI review, in my opinion, is to QUALIFY them for surgery. 

Wrap Up

In wrapping this article or paper up, Dr. McGill says the following, “Tissues in the back become irritated with repeated loading. Consider accidentally stuffing a toe or biting the lip repeatedly – eventually, the slightest touch causes pain. This is symptom magnification because the tissues are hypersensitized. Reduction of the hypersensitivity in the toe or lip only occurs following a substantial amount of time after the accidental stub or bite has stopped.”

Dr. McGill goes on to say, “For example, people with flexion bending intolerance of the spine may replicate this every time they rise from a chair. Correcting this movement fault, metaphorically taking the hits away, results in less sensitized tissues, an increased repertoire of pain-free tasks, and a return of motion. Motion returns once the pain goes away.”

Boom. Snap. Pow. Shazam. KaBAM!! Superhero abilities via the chiropractor and ZERO surgery. How clever. 

Opinion

I don’t care what your chiropractic practice looks like. OK….I lie. As long as it doesn’t make mine look hokey or bad, then I don’t care what your practice looks like. Some are geared toward getting people out of pain. Some are geared to some wellness protocol. Some are floundering because they don’t know where they belong or exactly what they’re trying to accomplish. 

I’ll admit that, at one point in time, I was one of them. 

But, one common thread through all sorts of practices is this, we keep people from surgery. Maybe not 100% of the time but we do a hell of a job with the tools we’ve been given and I love the direction that opioids and lumbar fusion surgery failures are pushing our profession. 

Sometimes even in spite of ourselves. 

Integrating Chiropractors

The Message

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment instead of chemical treatments like pills and shots.

When compared to the traditional medical model, research and clinical experience show that many patients get good or excellent results through chiropractic for headaches, neck pain, back pain, joint pain, to name just a few.

Chiropractic care is safe and cost-effective. It can decrease instances of surgery & disability. Chiropractors normally do this through conservative, non-surgical means with minimal time requirements or hassle to the patient.

And, if the patient develops a “preventative” mindset going forward from initial recovery, chiropractors can likely keep it that way while raising the general, overall level of health of the patient!

Key Point:

Patients should have the guarantee of having the best treatment offering the least harm.

That’s Chiropractic!

Contact

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

Help us get to the top of podcasts in our industry. That’s how we get the message out.

Connect

We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

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About the Author & Host

Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

 

Bibliography

Harris I, T. A., Stanford R, (2018). “Lumbar spine fusion: what is the evidence?” Internal Med J.

 

 

CF 024: They Laughed When I Said I Could Still Help After Back Surgery

CF 020: Chiropractic Evolution or Extinction?