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Steroid shots (epidurals)

Steroid Shots for Back Pain Don't Work

Professional Group Advises Against Epidural Steroid Shots for Chronic Back Pain
By Miranda Hitti
WebMD Health News
Reviewed by Louise Chang, MD

March 5, 2007 -- When it comes to treating chronic back pain with sciatica, epidural steroid injections may only bring small, short-term relief, according to a group of neurology professionals.

Sciatica is pain running down the back of the leg, where the sciatic nerve is located. It often accompanies back pain.

In reaching its conclusion, the American Academy of Neurology's Therapeutics and Technology Assessment Subcommittee reviewed four studies on epidural steroid injections for back pain with sciatica.

Based on the findings, epidural steroid shots are not recommended for long-term back pain relief, improving back function, or preventing back surgery, write neurology professor and subcommittee member Carmel Armon, MD, MHS, and colleagues.

Armon works at Tufts University's medical school and Baystate Medical Center in Springfield, Mass.

Taken together, the four studies show that patients who got epidural steroid shots had a slight drop in pain two to six weeks after the injection, compared with patients who got epidural shots containing no medicine (placebo injections).

However, the epidural steroids didn't relieve back pain more than the placebo at 24 hours, three months, or six months after administration, the review shows.

The epidural steroid shots also didn't appear to improve the patients' average back function or help patients avoid back surgery.

"While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful," Armon says in an American Academy of Neurology news release.

Armon's team didn't have enough data to evaluate the use of epidural steroid shots for neck pain.

With few high-quality studies to review, the researchers call for further studies on epidural steroid injections for neck and back pain.

EPIDURAL INJECTION (More Research)

Epidural injections ("injection within the epidural space of the spinal cord") with corticosteroids, lidocaine or opioids have no proven benefit in treating neck or upper back symptoms. In the instances that people find improvement, the effects are often temporary and require repeat injections, and several per year are not uncommon. There is also an increase in risk in contracting a spinal infection that can lead to meningitis. In fact, the results of a randomized, double-blind trial, published in the June 2003 issue of the Annals of Rheumatic Diseases indicated that an epidural steroid injection was no better than an epidural saline ("salt water") Injection (i.e. placebo) for sciatica. These findings are consistent with those of another definitive trial presented at the last American College of Rheumatology meeting.

Given that there have been advances in spinal surgery, the outcomes can still be very unpredictable. In failed back surgery, post-operative pain syndrome is a very disabling and troubling reality of surgical intervention. According to the 2002 Johns Hopkins White Paper on "Low Back Pain and Osteoporosis "* by John P. Kostulk, M.D. and Simeon Margolis, M.D., PhD., surgery "is not the treatment of choice for most people with back pain." The report goes on to say "fewer than 5% of people with back pain are good candidates for surgery". "Surgery ought to be used when all other measures have been explored, and only if it appears that there is a strong probability that it will improve the condition." An article in Spine reviewed the outcomes and complication rates for surgical intervention in degenerative disc disease. Complication rates were as high as 55% and included: hematoma, neurologic adjacent segment degeneration, infection and hardware/instrument-related issues. Another study determined the effects of single-level (2 vertebrae) and 2-level (3-4 vertebrae) spinal fusion success rates reported 53% with "good" and "fair" results with single- level fusion and no "good" results with 2-level fusions.

Having read about the possible side effects relating to these "traditional" treatments, you might want to consider the drugless, non-surgical approach that Non-Surgical Spinal Decompression has to offer.

  • Wolfe, Michael MD et al. Gastrointestinal Toxicity of Non-Steroidal Anti-inflammatory Drugs. N Engl J Med. 1999 June 17; 340(24): 1888-1899.
  • Singh, G. Recent considerations in nonsteroidal anti-inflammatory drug gastropathy. Am J Med. 1998 Jul 27; 105(1B):31S-38S.
  • Soloman SD, McMurray JJ et. all. Cardiovascular risk associated with celecoxib in a clinical trial for colorectal adenoma prevention. N Engl J Med. 2005 Mar 17;352(17): 1071-80.
  • Kostulk, John P. M.D., Margolis, Simeon M.D., PhD Johns HopkinsWhite Paper on Low Back Pain and Osteoporosis 2002.
  • Glass, Lee MD. Occupational Medicine Practice Guidelines: American College of Occupational & Environmental Medicine. 2nd ed., OEM press.
  • Bono, Christopher MD, Lee, Casey MD. The Influence of Subdiagnosis on Radiographic and Clinical Outcomes After Lumbar Fusion for Degenerative Disc Disorders: An Analysis of the Literature From Two Decades. Spine. 30(2):227-234, 2005.
  • Knox BD, Chapman TM. Anterior Lumbar Interbody Fusion for Discogram Concordant Pain. J Spinal Disord 1993;6:242-244.

Back Surgery: Too Many, Too Costly, Too Ineffective.

Here is a very informative story.  We here at www.plantationdecompression.com are here to provide you with the most educational and informative information available so that you the reader can make educated decisions about your healthcare.  I find it interesting that many surgeons I have spoken with state that surgery is only required about 10% of the time.  However….. due to lack of education and the refusal to take care of ones self, or participate in rehabilitation programs, individuals are looking for a "magic bullet" that does not exist.  Now approximately 6/10, that's 60% with back pain try surgery first…(this information comes from local surgeons)  This is alarming, because once surgery is performed, your options are significantly limited with regard to the available treatments out there. Please read below...

-Dr. Cooper

Back Surgery: Too Many, Too Costly, Too Ineffective.

By J.C. Smith, MA, DC

David Spodick, MD, professor of medicine at the University of Massachusetts, has stated: "Surgery is the sacred cow of our health-care system and surgeons are the sacred cowboys who milk it."33 Indeed, spine surgery has become the cash cow in the medical world and will only grow larger unless sensibility prevails over profiteering.

In reality, doctors and hospitals are making huge profits off the backs of unsuspecting patients who are not told there may be better and cheaper ways to solve their back pain with chiropractic care or other non-invasive methods. The costs of back surgeries are among the most expensive, and these costs do not include hospitalization, imaging, drugs or medications:34

  • Anterior cervical fusion: $44,000
  • Cervical fusion: $19,850
  • Decompression back surgery: $24,000
  • Lumbar laminectomy: $18,000
  • Lumbar spinal fusion: $34,500

Deyo found that the mean hospital costs alone for surgical decompression and complex fusions ranged from $23,724 for the former to $80,888 for the latter.35 When combined with surgical costs, medications, MRIs, rehab, and disability, every spine surgery case approaches $100,000 or more. The direct costs are astronomical and may reach as high as $169,000 for a lumbar fusion, and for a cervical fusion as high as $112,480.36

operating room Research suggests that of the 500,000-plus disk surgeries performed annually, as many as 90 percent are unnecessary and ineffective.37 This is unsustainable, and yet growing at incredible rates. Deyo noted, "It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just six years," and he mentioned one strong motivation included "financial incentives involving both surgeons and hospitals."38

In the current era of evidence-based medicine, it is difficult to understand the huge increase in spine fusions considering their high costs, poor outcomes and increased disability costs. Indeed, it certainly appears we have now entered into the era of economic-based medicine instead of evidence-based. Despite the huge increase in numbers and costs for spine surgery, the evidence shows this has been a waste.

In 2010, researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers' Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in the hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.39

After two years, only 26 percent of those who had surgery returned to work compared to 67 percent of patients who did not have surgery. Of the lumbar fusion subjects, 36 percent had complications and the reoperation rate was 27 percent for surgical patients. Permanent disability rates were 11 percent for cases and 2 percent for nonoperative controls. In what might be the most troubling finding, researchers determined that there was a 41 percent increase in the use of painkillers, with 76 percent of cases continuing opioid use after surgery. Seventeen surgical patients died by the end of the study.40

The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs do not work, according to the study's lead author, Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine. His study concluded: "Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a Workers' Compensation setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor return to work status."41

Commenting on spine surgery, Nguyen said, "The outcomes of this procedure for degenerative disc disease and disc herniation make it an unfortunate treatment choice."42 According to the editors of The Back Letter, a newsletter from the Department of Orthopedic Surgery at Georgetown Medical Center in Washington, D.C., "This form of surgery in workers' compensation subjects appears to be a gamble at best."

Deyo admitted to The New York Times that the spine profession is ignoring the call for restraint on drugs, shots and back surgery. "People say, 'I'm not going to put up with it,' and we in the medical profession have turned to ever more aggressive medication, narcotic medication, and more invasive surgery."43

In his 2009 article, "Overtreating Chronic Back Pain: Time to Back Off?" Dr. Deyo speaks of the shortcomings of the medical spine treatments in the U.S.:44

"Jumps in imaging, opioid prescriptions, injections, and fusion surgery might be justified if there were substantial improvements in patient outcomes. Even in successful trials of these treatments, though, most patients continue to experience some pain and dysfunction.

"Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain. We must rethink chronic back pain at fundamental levels."

Dr. Deyo is not alone in his call for reform in spine care. The editors of The Back Letter agreed with his frustration with the medical approach:45-46

The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate … There is growing frustration over the lack of progress in the surgical treatment of degenerative disc disease. Despite a steady stream of technological innovations over the past 15 years - from pedical screws to fusion cages to artificial discs - there is little evidence that patient outcomes have improved … Many would like to see an entirely new research effort in this area, to see whether degenerative disc disease and/or discogenic pain are actually diagnosable and treatable conditions. (Emphasis added)

Another study conducted by Deyo and Cherkin in 1994 compared international rates of back surgeries and found the startling fact that the rate of American surgery is unusually excessive and directly attributed to the supply of spine surgeons:47

"The rate of back surgery in the United States was at least 40% higher than any other country and was more than five-times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopedic and neurosurgeons in that country."

"While many surgeons are careful about which patients they recommend for spine operations, some are not so discriminating," says Dr. Doris K. Cope, professor and vice chair for pain medicine at the University of Pittsburgh School of Medicine. "It's a case of, if you have a hammer, everything looks like a nail."48

And be certain that spine surgeons have been nailing patients for decades. Not only have spine surgeries skyrocketed, so have emerging treatments that have also not proven effective, although very profitable - the increased use of opioids and epidural steroid injections.

The recent growth in "pain management" clinics featuring epidural steroid injections (ESI) has received troubling criticism from medical experts like Robert J. Barth, a neuropsychologist, who believes these ESI treatments "reliably fail, the treatments seems to lead to a progressive worsening of the claimant's presentation, the ineffective treatment never ends, and the original treating doctors refer the claimants into pain management simple as a means of escaping from or 'dumping' a problematic patient."49

Barth believes "pain management does not accomplish anything but getting the patient addicted." He concludes that the "pain management situation in the U.S. is, indeed, horrific."50 Nonetheless, it is among the fastest growing segments in medicine today.

A similar review of pain management via ESI was regarded as "goofy" by R. Norman Harden, MD, in the American Pain Society Bulletin:51

"We practice at a time when unproven experimental, invasive, and expensive procedures are often compensated without question. Many of the surgical and interventional techniques have never been subjected to evidence based inquiry. Oddly, the FDA approves devices and procedures relatively easily … in this context, there has been a proliferation of extremely goofy therapies, which are expensive at best, and downright dangerous at worst."

Another criticism of ESI appeared in the American Pain Society Bulletin by Steven H. Sanders, PhD, who revealed nerve blocks for back pain are not supported by scientific research: "From the current review, we must conclude injections and nerve blocks produce a large amount of money with very little science to support their application."52

Not only have epidural injections come under criticism; so has the widespread use of opioids in the long-term treatment of back pain. "There is increasing recognition that this massive treatment movement may have been a mistake," opined the editors of The Back Letter. "The proven benefits of opioids do not extend to the long-term treatment of chronic pain … Editorials and commentaries in medical journals are starting to pose the question, 'How could this have happened?'"53

A new study on opioid use from Denmark reveals more disturbing news. Although proponents of opioid drugs speculate they provide significant pain relief, improve function, and enhance quality of life over the long term, a new study by Per Sjogren, MD, and colleagues refutes this claim. They found the use of opioids was associated with inadequate pain relief, poor quality of life, long-term unemployment, and high levels of medical care-seeking.54

"Furthermore, the results indicated that individuals with chronic pain using strong opioids had a higher risk of death than individuals without chronic pain," according to Sjogren."55

Chiropractic: The Best Buy

Not only can most medical spine treatments be avoided, but they also must be reigned in if America hopes to reduce its health-care spending crisis. This problem has become more apparent after research found that the Fortune 500 companies spent over $500 million a year on avoidable back surgeries for their workers and lost as much as $1.5 billion in indirect costs associated with these procedures in the form of missed work and lost productivity, according to a two-year study by Consumer's Medical Resource (CMR).56

This CMR study, "Back Surgery: A Costly Fortune 500 Burden," found one out of three workers recommended for back surgery said they avoided an unnecessary procedure after being given independent, high-quality medical research on their diagnosed condition and treatment options. In addition, those patients who refused surgery and opted for alternative and less invasive procedures to treat their back pain reported healthier and more personally satisfying outcomes.

As the TRICARE study found, patients are more satisfied with chiropractic care than medical care treatments for low back pain. T.W. Meade, MD, of the Wolfson Institute of Preventive Medicine, London, England, surveyed patients three years after treatment and found that "significantly more of those patients who were treated by chiropractic expressed satisfaction with their outcome at three years than those treated in hospitals - 84.7 percent vs. 65.5 percent."57

A recent comparative study of back pain treatments by Antonio P. Legorreta, MD, MPH, et al., "found cost savings relating to chiropractic treatment of common complaints such as neck and back pain. Focusing on low back pain diagnoses that were selected specifically for comparability between medical and chiropractic practice, our analysis found that patients with chiropractic coverage had significantly lower rates of use of resource-intensive technologies, such as x-ray examinations, MR image, and surgery, and lower use of more expensive patient care settings, such as inpatient care. This is reflected in the significantly lower cost, at both the episode level and the patient level, of providing care for back pain."58

Another study by Niteesh Choudhry, MD, PhD, from Harvard Medical School and Arnold Milstein, MD, from Mercer Health and Benefits consulting firm, also found, in terms of clinical and cost effectiveness, that "chiropractic physician care for low back and neck pain is highly cost-effective, represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds."59

Not only is manual therapy more clinically effective, another large study shows it is also less costly than medical care. A study published in 2010 revealed data over a two-year span from 85,000 Blue Cross Blue Shield beneficiaries with low back pain in Tennessee. The patients had open access to MDs and DCs through self-referral, and there were no limits applied to the number of visits allowed and no differences in co-pays. Results show that paid costs for episodes of care initiated by a chiropractor were almost 40 percent less than care initiated through an MD. They estimated that allowing DC-initiated episodes of care would have led to an annual cost savings of $2.3 million for BCBS of Tennessee.60

Not only are these spine surgeries very expensive and in many cases unnecessary; the latest research has shown that chiropractic care is more effective and less expensive. However, the medical profession has ignored this call for restraint and in many cases, continues its boycott of chiropractic care despite the evidence. Indeed, it appears to be a case of "don't confuse us with the facts."

The truth is now emerging. There is now broad agreement internationally that surgery should not generally be considered until there has been a trial of conservative nonsurgical care.83-85

Pran Manga conducted two studies in the 1990s and noted, "There should be a shift in policy now to encourage the utilization of chiropractic services for the management of low back pain, given the impressive body of evidence on the effectiveness and comparative cost-effectiveness of these services, and on the high levels of patient satisfaction."86 As well, an editorial in the Annals of Internal Medicine published jointly by the American College of Physicians and the American Society of Internal Medicine (1998) noted that "spinal manipulation is the treatment of choice":

"The Agency for Health Care Policy and Research (AHCPR) recently made history when it concluded that spinal manipulative therapy is the most effective and cost-effective treatment for acute low back pain87 ... Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement. One might conclude that for acute low back pain not caused by fracture, tumor, infection, or the cauda equina syndrome, spinal manipulation is the treatment of choice."88

Treatment of Choice

More spine experts are emerging from the medical closet to express their support for chiropractors, although most remain cautious with the fear of reprisal from their surgical peers who profit greatly from spine surgery.

William Lauerman, MD, chief of spine surgery, professor of orthopedic surgery at Georgetown University Hospital, has stated: "I'm an orthopedic spine surgeon, so I treat all sorts of back problems, and I'm a big believer in chiropractic."89

Richard Deyo, MD, MPH, has mentioned chiropractic as a solution: "Chiropractic is the most common choice, and evidence accumulates that spinal manipulation may indeed be an effective pain remedy for patients with back problems."90

Gordon Waddell, MD, also has suggested chiropractic care as a solution: "There is now considerable evidence that manipulation can be an effective method of providing symptomatic relief for some patients with low back pain."91

Jo Jordan, PhD, wrote that spinal manipulation may be the "lone ray of light" for back pain treatment.92

The Back Letter editorial staff also noticed the stubbornness of physicians to implement the new guidelines for low back pain, which includes the use of spinal manipulation as a first route of treatment before surgery.93

Although most MDs and many in the public remain convinced that a disc problem requires surgery, most guidelines now recommend nonsurgical care before surgery. The North American Spine Society (NASS), the same organization that attacked the AHCPR findings in 1994, has now published online a Public Education Series that includes "Spinal Fusion." Remarkably, this explanation proved to be very accurate, including the opinion that "[f]usion under these conditions is usually viewed as a last resort and should be considered only after other conservative (nonsurgical) measures have failed."94

The admission by NASS that fusion should be a last resort is a huge warning that has been unheard by the public. More surprisingly, NASS again admitted that spinal manipulation should be considered before surgery in the October 2010 edition of The Spine Journal:

"Several RCTs (random controlled trials) have been conducted to assess the efficacy of SMT (spinal manipulative therapy) for acute LBP (low back pain) using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone."95

Indeed, it is past time for every physician to follow this advice and stop prescribing pain pills, muscle relaxers, epidural steroid injections and MRI scans that lead to unnecessary spine surgeries. It is time for all primary care MDs to refer patients to chiropractors for their hands-on care before any drugs, shots or surgery is suggested. It is past time for physicians to follow the Hippocratic Oath to do no harm, and the current medical practice for back pain is doing great harm to many patients.

Dr. Rick McMichael, president of the American Chiropractic Association, recently spoke on this important issue with regard to reducing costs for health care:

"America cannot expect to significantly change its health care outcomes and the costs of health care unless we are willing to make some significant changes in how we deliver health care services. We must reduce the excessive use of pain meds and unnecessary surgeries. Positioning doctors of chiropractic as first-contact, portal-of-entry, primary care providers for a larger segment of the nation's patient population holds great promise as one very important change that could significantly impact health care outcomes and reduce health care costs.

"We must press forward for full implementation of Section 2706 of the Patient Protection and Affordable Care Act to stop the discrimination against DCs and other licensed health care providers. Full implementation of this new law will change our health care system dramatically, offer patients a real choice of health care and provider type, improve patient outcomes and satisfaction levels, and reduce overall health care costs. This change is long past due!"96

Resolving Back Pain Without Surgery: Get the Message Out

Chiropractors, once the forbidden fruit of the medical world, today have become the fiscal darlings in the medical world who can reduce the huge expense as well as save thousands of patients from unnecessary spine surgery. Of course, the medical profession has no interest in seeing this evidence-based approach cut into its billion-dollar spine surgery business, especially by chiropractors.

The AHCPR battle with NASS on Capitol Hill was evidence of the medical resistance to evidence-based research. Indeed, American medicine is renowned for its intransigence considering it takes 17 years for a new method to be incorporated into the mainstream while it takes 44 years for an ineffective method to be removed.97

Indeed, this begs the question: Will it take 44 years before the tsunami of back surgeries ends and people finally learn that chiropractic care is the preferred choice of treatment for the majority of back pain cases?

It is our duty to bring this message to the public. The facts are clear that drugs, shots and spine surgery have not stopped the rising tide in the tsunami of back pain, and reliance upon these treatments may actually be worsening the problem; indeed, medical spine care today is a shot in the dark with suspect treatments, unreliable outcomes and at great expense.

On the other hand, there are ethical orthopedists who are well-aware of the misfortune of back surgery. Jens Ivar Brox, MD, lead investigator of the Norway Spine Study, reported that he and his colleagues "no longer perform spinal fusion specifically for 'degenerative disc disease' because they do not regard it as a clearly diagnosable entity."98

Dr. Brox admitted some of the orthopaedic surgeons in his department have recurrent back pain and disc degeneration, but these surgeons refuse to have fusion surgery or recommend fusion surgery for their family members. "So the question is: Why should we recommend these procedures for our patients?" Finally, an honest surgeon speaks.

Every American spine surgeon should ask themselves the same question: will they be so quick to do surgery on their own family members (or have it done on oneself) as they do on their patients?

If this evidence-based health care reform movement seriously wants to lower costs and improve outcomes in the epidemic of back pain, the chiropractic profession stands as fiscal and health care conservatives to help solve this huge issue. Of course, this back pain issue has not discussed other ways chiropractors can help, such as with wellness care, neurogenic illnesses, pediatric, geriatric, sport injuries or the many issues that fall under our scope of practice - all important issues the public needs to learn.

Until the day finally arrives that chiropractic care escapes the fog of skepticism, "buyer beware" is the best advice for patients until they understand that chiropractic, as Dr. Rosner mentioned, "at least for back pain, appears to have vaulted from last to first place as a treatment option."99

References

83. Weber H. The natural history of disc herniation and the influence of intervention. Spine, 1994;19:2234-2238.

84. Saal J. Natural history and nonoperative treatment of lumbar disc herniation. Spine, 1996;21:2S-9S.

85. Postacchini F. Results of surgery compared with conservative management for lumbar disc herniations. Spine, 1996;21:1383-1387.

86. Manga P, et al. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Ontario Ministry of Health, 1993.

87. Bigos SJ, et al. Acute Low Back Pain Problems in Adults: Clinical Practice Guideline No. 14. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1992. AHCPR publication no. 95-0642.

88. Micozz MS. Complementary care: when is it appropriate? Who will provide it? Annals of Internal Medicine, July 1998;129(1):65-66.

89. McClain B. "Mainstream Makes Adjustment." The Washington Post, July 17, 2007.

90. Deyo RA. "Low -Back Pain." Scientific American, August 1998:49-53.

91. Waddell G, Allan OB. A Historical perspective on low back pain and disability. Acta Orthop Scand, 1989;60(suppl 234).

92. Jordan J, et al. Herniated lumbar disc. Study in BMJ Clinical Evidence, quoted in The Back Letter, July 2010;25(7):76-77

93. "Evidence-Based Care That Includes Chiropractic Manipulation More Effective Than Usual Medical Care." The Back Letter, 2008;23(1):3.

94. Spinal Fusion. North American Spine Society Public Education Series. www.spine.org/documents/fusion

95. Freeman MD, Mayer JM. NASS contemporary concepts in spine care: spinal manipulation therapy for acute low back pain. The Spine Journal, October 2010:918-940

96. Rick McMichael, DC, President, American Chiropractic Association, via private communication Jan. 28, 2011.

97. "Refuting Ineffective Treatments Takes Years." The Back Letter, 2008.

98. Brox JJ, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine, 2003;28:1913-1921.

99. Testimony before the Institute of Medicine Committee on Use of CAM by the American Public, Feb. 27, 2003.


References

35. "New Study Demonstrates a Three-Fold Increase in Life-Threatening Complications With Complex Surgery." The Back Letter, June 2010;25(6):66.

36. Schlapia A, Eland J. "Multiple Back Surgeries and People Still Hurt." April 22, 2003.

37. Finneson BF. A lumbar disk surgery predictive score card: a retrospective evaluation." Spine, 1979:141-144.

38. Ibid.

39. Carroll L. "Back Surgery May Backfire on Patients in Pain." MSNBC.com, Oct. 14, 2010.

40. Nguyen TH, Randolph, DC, et al. Long-term outcomes of lumbar fusion among workers' compensation subjects: an historical cohort study. Spine, Feb. 15, 2011;36(4):320-331.

41. Ibid.

42. "Dismal Results for Spinal Fusion Among Patients With Workers' Compensation Claims." The Back Letter, November 2010;25(11):121.

43. Kolata J. "With Costs Rising, Treating Back Pain Often Seems Futile." New York Times, Feb. 9, 2004.

44. Deyo RA, et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med, 2009;22(1):62-68.

45. The Back Letter, July 2994;12(7):79.

46. The BACKPage Editorial. The Back Letter, March 2005;20(7):84.

47. Cherkin DC, et al. An international comparison of back surgery rates. Spine, June 2004;19(11):1201-1206.

48. Carroll L, Op Cit.

49. Barth RJ. "Saying No!-Unjustified Surgeries, Pain Management and Tests." For the Defense, March 2006;48(3):33-39. Washington & Lee Law School Current Law Journal Content.

50. Ibid.

51. Harden RN. "Chronic Opioid Therapy: Another Reappraisal." APS Bulletin, January/February 2002;12(1). Pain and Public Policy, Corey D. Fox, PhD, Department Editor

52. Sanders SH, Vicente P. Medicare and Medicaid financing for pain management: the wrong message at the right time. The Journal of Pain, September 2000;1(3):197-198.

53. "How Could This Have Happened?" The Back Letter, 2011;26(1):7.

54. Per Sjogren, et al. A population-based cohort study on chronic pain: the role of opioids. Clinical Journal of Pain, 2010;26(9):332-9.

55. "Long-Term Opioid Therapy for Chronic Pain: Dismal Results in Real-World Settings?" The Back Letter, 2011;26(1):1.

56. "FORTUNE 500s Waste Over $500 Million a Year on Unnecessary Back Surgeries for Workers." Consumer's Medical Resource, July 21, 2008.

57. Mead TW. Letter to the Editor, British Medical Journal, July 3, 1999.

58. Legorreta AP, et al. Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs. Arch Intern Med, 2004;164:1985-1992.

59. Milstein A, Choudhry N. "Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans? An Evidence Based Assessment of Incremental Impact on Population Health and Total Healthcare Spending." Funded by the Foundation for Chiropractic Progress.

60. Liliedahl, RL, Axene DV, Goertz CM. Cost of care for common back pain conditions initiated with chiropractic doctor vs. medical doctor / doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer. JMPT, December 2010.


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