I want to tell a little story of a patient I had about a year ago. He came to me with right sided sciatica and his right buttocks was completely numb. He had mild weakness but no foot drop in this extremity. The MRI results (see attached) 
showed a very large disc bulge at L5/S1 level and I felt the patient would need surgery. He was adamant about avoiding surgery and wanted to try everything else possible before “going under the knife”. I sent him to a neurologist for and EMG (nerve study) that came back with only minor nerve damage so we went ahead and began a series of spinal/core strengthening exercises and physical therapy modalities. We went for 2 weeks with no or little improvement. At this time he made the decision to begin IDD therapy (non-surgical spinal decompression). The therapy is typically 20 to 25 treatments and also incorporates myofacial release (soft tissue mobilization, physical therapy modalities, neuromuscular re-education, and spinal stabilization exercises (all of which were attempted prior to the IDD therapy and failed to bring about results alone). The patient’s care was tracked with an Oswestry Low Back Pain Disability Questionnaire and after 8 sessions the patient was 47% improved (see attached). After 25 treatments over about 2 months the patient was 100% recovered according to the Oswestry Questionnaire results (idd-patient-oswestry.doc). He was trilled and to be truthful we were both a little surprised with the results. My point to this story is that the insurance industry, and quite frankly, many physicians feel that this therapy is experimental and without merit. The studies are available and promising though not as extensive as some other therapies currently used to treat the same conditions. In my clinic I have only had one patient who did not improve at least 75% after completing the IDD protocols. About half of the treatment is covered with insurance but the IDD itself is not. The question is “Why”? The cost of this therapy is between $90 and $110 per treatment, which compared to the $35,000 to $50,000 for a surgical procedure is astronomical savings. Why aren’t therapies that show promise covered by insurance? Even with the $2000 to $4500 people may need to pay out of pocket for the therapy it is still cheaper than most people co-insurance responsibility for the surgery (anywhere from 10% to 20% depending on the individuals coverage). This is just one therapy in many that are not covered and cause the patient more out of pocket expense. Don’t we pay enough for our insurance coverage already. I think my family premium is approximately $1000 a month and I maybe see the doctor once a month. It just doesn’t seem like good business sense for the insurance companies not to pay for such therapies. They could even go to a program that demands that the “experimental therapy” provide at least a certain level of improvement or they would only pay a portion etc. There are ways to make it work for everyone: insurance companies, patients, and physicians. Just a thought…
The British Medical Journal (BMJ) put out a publication that investigates the effectiveness of different treatments for Lumbar herniated disc injuries, based upon the current research. The authors then catagorize the treatments as “likely to be effective”, “likely to be ineffective”, ”unknown effectiveness”, etc. I makes for interesting reading because one of the most prescibed treatments, over-the-counter NSAIDs, is found ”unlikely to be beneficial” according to the research uncovered by the authors. Check out the other findings by this group by following the link to the article titled,
I have posted articles recently that discuss the disturbing rise in spine surgery rates over the last few years. I would like to express that I am not anti-surgery but I do feel that it is always a last resort. I feel that too often surgeons are influenced by economic reasons and this is at the expense of the patient who has put his or her trust in that doctor. I have found that I vast majority of patient will respond to conservative care. Many of these patients, once treated conservatively, can go on to manage their symptoms on their own by continuing to exercise, keep their weight down, and living healthier lifestyles. Conservative care encompasses many different forms, from chiropractic care, physical therapy, acupuncture, exercise, massage, etc. If one form of conservative care doesn’t work try another and another. Don’t prevent relief of your pain because of preconceived notions or prejudices. Remember the surgeons knife will still be there if nothing else works but after surgery many times you have complicated you potential recovery if the surgery is unsuccessful. Food for thought.
Did the Influx of Specialty Spine Clinics Lead to an Increase in Spinal Fusions?
Proponents of physician-owned spine hospitals and clinics suggest they can provide more effective and cost-effective care of back pain and spinal problems than traditional hospitals. Specialization may lead to seamless, efficient care; economies of scale; lower production costs; improved outcomes; and higher levels of patient satisfaction. Detractors of physician-owned specialty hospitals suggest that they lead to the over utilization of poorly documented spinal procedures, particularly profitable invasive procedures. And that they create conflicts of interest for physician-investors who treat their own patients at these facilities. Economist Jean Mitchell, PhD, of Georgetown University recently examined trends in spine treatment utilization rates after the entry of physician-owned specialty clinics into two urban areas of Oklahoma . (See Mitchell, 2007.) Using claims data from the largest workers’ compensation insurance provider in Oklahoma , she studied the impact of specialty hospitals on spinal fusion rates involving workers’ compensation claimants from 1999 to 2004. The study found an increase in complex spinal fusions (e.g. instrumented circumferential fusions) but not in cheaper simple spinal fusions. Prior to the influx of specialty hospitals, the market area utilization rate for complex spinal fusion was 1.93 per 1000 back/spine cases under treatment. By 2004, this rate rose to 49 per 1000 back/spine cases under treatment. “This represents close to a 2439% increase in the market area utilization rate for complex spinal surgery for the study population,” according to Mitchell. The market area utilization rate for simple spinal fusions fell over the same time period. “For injured workers with back problems, physician-owned hospitals appear to have increased the use of complex spinal fusion surgery [i.e. instrumented circumferential fusions], the more lucrative procedure, in lieu of the less profitable simple spinal fusion surgeries,” according to Mitchell. Unfortunately, it was impossible to come up with a control group because there were no hospital market areas in Oklahoma that did not include physician-owned specialty hospitals.
Study of Fusion Among Medicare Beneficiaries
So instead, Mitchell performed a parallel investigation of trends in the utilization of fusion procedures among Medicare beneficiaries from 2000 through 2004. She compared rates of spinal fusion in four states with physician-owned specialty spine hospitals with several New England states where these types of hospitals don’t exist. The Georgetown economist found precipitous increases in profitable complex spinal fusion rates in the states with the specialty hospitals, but smaller increases in the New England area. “The utilization rate for complex spinal fusion in Oklahoma increased from 0.52 per 10,000 beneficiaries in 2000 to 4.05 in 2004, an increase of 679%,” Mitchell reported. There was almost a 300% increase in complex spinal fusion rates in South Dakota , a 637% increase in Arizona , and a 1395% increase in Kansas . By comparison there was a 194% increase in the New England states over the same time period. It is unlikely that these differences in fusion rates are solely related to the presence of physician-owned specialty hospitals. There are a variety of potentially confounding factors that might have contributed to these discrepancies, including rising spine surgery rates nationwide, geographic variations in surgery rates, changes in coding, varying patient populations, etc. However, Mitchell believes that the rise of specialty hospitals is the most likely explanation for these changes in utilization patterns. “Again, we considered other possible explanations for the dramatic differences in utilization that exist between the northeast and states with physician-owned specialty hospitals, but none could account for these stark differences,” she concluded. It is important to note that this type of study isn’t capable of making inferences about the benefits and risks of complex spinal fusions among workers’ compensation claimants or Medicare beneficiaries. However, recent studies of the results of spinal fusion surgery among workers’ compensation claimants are not reassuring. The overall success rates of spinal fusion among Medicare patients is something of a mystery, as they haven’t been studied in detail.
Reference:
Mitchell J, Utilization changes following market entry by physician-owned specialty hospitals, Medical Care Research and Review, 2007; 64:395–415.
Taken from “The Back Letter” Volume 22, Number 11, 2007
Recent studies have revealed that 90% of the population will suffer from lower back pain at some point during their life and 39-79% of those people will have some sort of recurrence. It is the second leading cause of visits to the doctor for patients aged 22 to 49 and the third leading cause for patients aged 50 to 64.
What causes lower back pain? Well that’s the sixty four thousand dollar question because lower back pain is often a mystery. But, some of the most debilitating and painful conditions are related to compressive disorders of the lumbar spine’s discs. Discs can be injured in many ways which cause them to bulge, herniate, extrude, and even fragment resulting in irritation to the disc and surrounding tissues, including the nerve roots. In addition, the discs of the lower back begin to lose some of their hydration from about the age of thirty and with injuries these discs will degenerate at an accelerated rate causing compression of nerve roots and joint structures. Treatment for lower back pain varies greatly from over-the-counter and prescription pain and anti-inflammatory medication, conservative care (chiropractic and physical therapy), to more invasive therapies such at epidural and nerve block injections and surgery. Over the last decade spinal fusions have increased by 500% in the Medicare population and a new Spine Patient Outcomes Research Trail (SPORT) study that compares surgical repair to conservative care found that both the surgery and non-operative groups improved substantially over a 2-year period. So what does this information leave for patients who have tried one or several of therapies with limited or no results? A relatively new technology has shown improvement rates that range from 70 to 94% after only two months of treatment. The preliminary studies show that even a year later the improvement is still approximately 76%. This therapy is “intervertebral differential dynamics” or IDD therapy and is an effective treatment for patients with back pain caused by disc bulges, protrusions, extrusions, facet syndrome, and degenerative disc disease. This therapy helps to decompress the spinal structures, reduce the size of disc bulges, and potentially improve the hydration and health of injured discs. IDD therapy is a new, computer directed, and specialized type of cyclical traction that allows for negative pressure, or vacuum, to occur inside of injured discs. The pumping nature of the 25 to 30 minute treatments promotes reduction of bulging material and increases blood flow and oxygenation to the injured area. The angle of pull is adjusted to concentrate forces specifically at the injured spinal level. In addition, the cyclical nature of the therapy applied to the lumbar spine allows higher quantities of force to be used without stimulating reactive muscle spasms that are commonplace with traditional mechanical traction. Further studies are needed but anecdotal results reported by practitioners are supporting the findings of these early studies.
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