Epidurals Back Surgery

SPINE: A COST-EFFECTIVE TREATMENT FOR LUMBOSACRAL

PAINC. Norman Shealy, MD, PhD, and Vera Borgmeyer, RN, MAAJPM 1997;7:63-65.C.Norman Shealy MD, PhD, is Director of The Shealy Institute for Comprehensive Health Care andClinical Research and Professor of Psychology at the Forest Institute of Professional Psychology. VeraBorgmeyer is Research Coordinator at the Shealy Institute for Comprehensive Health Care and ClinicalResearch. Address reprint requests to: Dr. C. Norman Shealy, The Shealy Institute for ComprehensiveHealth Care and Clinical Research, 1328 East Evergreen Street, Springfield, MO 65803.American Journal of Pain Management

INTRODUCTION

Pain in the lumbosacral spine is the most common of all pain complaints. It causes loss of work and is thesingle most common cause of disability in persons under 45 years of age (1). Back pain is the most dollarcostly industrial problem (2). Pain clinics originated over 30 years ago, in large part, because of thenumbers of chronic back pain patients. Interestingly, despite patients’ reporting good results using “upsidedown gravity boots,” and commenting on how good stretching made them feel, traction as a primarytreatment has been overlooked while very expensive and invasive treatments have dominated themanagement of low back pain. Managed care is now recognizing the lack of sufficient benefit-cost ratioassociated with these ineffective treatments to stop the continued need for pain-mitigating services. 

We feltthat by improving the “traction-like” method, pain relief would be achieved quickly and less costly.Although pelvic traction has been used to treat patients with low back pain for hundreds of years, mostneurosurgeons and orthopedists have not been enthusiastic about it secondary to concerns over inconsistentresults and cumbersome equipment. Indeed, simple traction itself has not been highly effective, therefore,almost no pain clinics even include traction as part of their approach. A few authors, however, havereported varying techniques which widen disc spaces, decompress the discs, unload the vertebrae, reducedisc protrusion, reduce muscle spasm, separate vertebrae, and/or lengthen and stabilize the spine (3-12).Over the past 25 years, we have treated thousands of chronic back pain patients who have not responded toconventional therapy. Our most successful approach has required treatment for 10- 15 days, 8 hours a day,involving physicians, physical therapists, nurses, psychologists, transcutaneous electrical nerve stimulator(TENS) specialists, and massage therapists in a multidisciplinary approach which has resulted in 70% ofthese patients improving 50- 100%. 

Our program has been recognized as one of the most cost-effectivepain programs in the US (13). The average cost of the successful pain treatment has been cited as less thanhalf the national average (13).Our protocol combined traditional, labor-intensive physical therapy techniques to produce mobilization ofthe spinal segments. This, combined with stabilization, helped promote healing. In addition we usedbiofeedback, TENS, and education to reinforce the healing processes. We wanted to produce a simpler andmore cost-effective protocol that could be consistently reproduced. The biofeedback and education couldbe easily replicated. The problem was producing spinal mobilization to the decree that we coulddecompress a herniated nucleus and relieve pain. Stabilization would come after pain relief.The DRS System was developed specifically to mobilize and distract isolated lumbar segments. Using, aspecific combination of lumbar positioning and varying the degree and intensity of force, we produceddistraction and decompression. With fluoroscopy, we documented a 7-mm distraction at 30 degrees to L5with several patients. In fact, we observed distraction at different spinal levels by altering, the position anddegree of force.

We set out to evaluate the DRS system with outpatient protocols compared to traditional therapy for bothruptured lumbar discs and chronic facet arthroses.Subjects. Thirty-nine patients were enrolled in this study. There were 27 men and 12 women, ranging, inage from 31 to 63. Twenty-three had ruptured discs diagnosed by MRI. Of these, all but four hadsignificant sciatic radiation, with mild to moderate L5 or S I hyperalgesic. All had symptoms of less thanone year.The facet arthrosis patients also underwent MRI evaluations to rule-out ruptured discs or other majorpathologies. They had experienced back pain from one to 20 years. Six had mild to moderate sciatic painwith significant limitations of mobility.

METHODOLOGY

Patients were blinded to treatment and were randomly assigned to traction or decompression tables.Traction patients were treated on a standard mechanical traction table with application of traction weightsaveraging- one-half body weight plus 10 pounds, with traction applied 60-seconds-on and 60-seconds off,for 30 minutes daily for 20 treatments. 

Following the traction, Polar Powder’ ice packs and electricstimulation were applied to the back for 30 minutes to relieve swelling and spasm, and patients were theninstructed in use of a standard TENS use to be employed at home continuously when not sleeping-. Aftertwo weeks, the patients received a total of three sessions with an exercise specialist for instruction in andsupervision of a limbering/strengthening exercise program. 

They were re-evaluated at five to eight weeksafter entering the program.Decompression patients received treatment on the DRS System-n, designed to accomplish optimaldecompression of the lumbar spine. Using the same 30 minute treatment interval, the patients were giventhe same force of one-half the body weight plus 10, but the decree of application was altered by up to 30degrees. The effect was to produce a direct distraction at the spinal segment with minimal discomfort to thepatient.Eighty-six percent of ruptured intervertebral disc (RID) patients achieved “good” (50-89% improvement)to “excellent” (90-100% improvement) results with decompression. 

Sciatica and back pain were relieved.Only 55% of the RID patients achieved “good” improvement with traction, and none excellent.”Of the facet arthrosis patients, 75% obtained “good” to excellent” results with decompression. Only 50% ofthese patients achieved “good” to “excellent” results with traction.

Table 1. 

Patient assessment of pain relief secondary to decompression and to traction.
RID Facet arthrosis
Decompression
Excellent 7 (50%) 2 (25%)
Good 5 (36%) 4 (50%)
Poor 2 (14%) 2 (25%)
Traction
Excellent 0 2 (25%)
Good 5 (55%) 2 (25%)
Poor 4 (45%) 4 (50%)
Excellent = 90 - 100% improved
Good = 50 - 89% improved
Poor = < 50% improved

DISCUSSION

Since both traction and decompression patients received similar treatment (except for the differences in thetraction table versus the decompression table) with similar weights, ice packs, and TENS, the results arequite enlightening. The decompression system is encouraging and supports the considerable evidencereported by other investigators stating that decompression, reduction, and stabilization of the lumbar spinerelieves back pain. The computerized DRS System appears to produce consistent, reproducible, andmeasurable non-surgical decompression, demonstrated by radiologyOf equal importance, the professional staff facilities required, as well as the time and cost, are allsignificantly reduced. Since the more complex treatment program of the last 25 years has already beenshown to cost 60% less than the average pain clinic, the cost of this simpler and more integrated treatmentprogram should be 80% less than that of most pain clinics-a most attractive solution to the most costly painproblem in the US. In addition, patients follow a 30-day protocol that produces pain relief yet allows themto continue daily activities and not lose workdays.

SUMMARY

We have compared the pain-relieving results of traditional mechanical traction (14 patients) with amore sophisticated device which decompresses the lumbar spine, unloading of the facets (25patients). The decompression system gave “good” to “excellent” relief in 86% of patients with RIDand 75 % of those with facet arthroses. The traction yielded no “excellent” results in RID and only 50%“good” to “excellent” results in those with facet arthroses. These results are preliminary in nature. Theprocedures described have not been subjected to the scrutiny of review nor scientific controls. Thesepatients will be followed for the next six months, at which time outcome-based data can be reported. Thesepreliminary findings are both enlightening and provocative. The DRS system is now being evaluated as aprimary intervention early in the onset of low back pain-especially in workers’ compensation injuries.

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13. Managed Care Organization Newsletter (American Academy of Pain Management). July 1996

What is the success rate of spinal decompression?

Most research has shown spinal decompression to be successful in 71% to 89% of patients. More than 10 different research studies have been conducted with all of them showing good results for patients treated with spinal decompression. Here is a summary of some of the research studies performed on spinal decompression.

At the 18th Annual Meeting American Academy of Pain Management, Tampa FL Sept. 5 2007, John Leslie of the Mayo Clinic found the following:

• Multi-center, phase II, non-randomized pilot study utilizing spinal decompression
• Designed to evaluate the effectiveness and safety of spinal decompression in the treatment of chronic lower back pain
• Patients enrolled — average of ten years of chronic back pain
• After two weeks of treatments of spinal decompression — 50% reduction in pain scores
• Upon completion of the entire six week protocol success rate of 88.9% was documented

Can spinal decompression really cause a decrease in a disc herniation or cause an Increase In Disc Height

True non-surgical Spinal Decompression Therapy was developed to provide a non-invasive option for low back and neck pain caused by herniated, bulging and degenerated discs.

Researchers of a case report published in Volume 2 Issue 1 of the European Musculoskeletal Review state, “Evidence based data that show the promising effects of spinal decompression on the safe and effective treatment of LBP continue to accumulate. The report titled Management of Low Back Pain with a Non-surgical Decompression System Case Report reveals the pre and post treatment MRI findings of a 69 year old male with low back pain. Prior to treatment the patient reported experiencing low back pain radiating into both legs. When asked to describe his pain intensity on a scale of 0-10 the patient rated his pain a 10. The patient underwent 22 treatments over a seven week period. Utilizing the same pain intensity scale the patient reported a pain level of 1 post treatment. Four month after the initial treatment a follow up MRI revealed decreased herniation size and increased disc height at multiple lumbar levels.”

American Journal of Pain Management studied the Long-term Effect Analysis of Spinal Decompression Therapy in Low Back Pain: It was A Retrospective Clinical Pilot Study done in July 2005 by C. Norman Shealy, MD, PhD; Nirman Koladia, MD and Merrill M. Wesemann, MD. They observed the following Outcome: Of 24 study participants, each reported consistent pain relief and continual improvement of symptoms one year later. Improvement in pain continued after the treatment sessions were completed.

In Practical Pain Management from Technology Review April 2005. Vol. 5, Issue 3. C. Norman Shealy, MD and PhD found that “spinal decompression treatment leads to satisfactory pain relief and improved quality of life in up to 88% of patients-many of whom have failed other “conventional” approaches. Based on the author’s review of recent study results, spinal decompression appears to be the current optimal recommendation for most lumbar pain syndromes.

In an article in the Journal of Neuroimaging entitled MRI Evidence of Nonsurgical, Mechanical Reduction, Rehydration and Repair of the Herniated Lumbar Disc from April 1998 Vol. 8, NO.2, Edward L. Eyerman, MD., found that spinal decompression resulted in the following: “ All but 3 of 20 patients reported significant pain relief and complete relief of weakness and immobility, when present. This study also shows a correlation between the improvement on the MRI and the reported improvement in pain.”

In an article from the Journal of Neurological Research entitled Vertebral Axial Decompression for Pain Association with Herniated or Degenerated Discs or Facet Syndrome from April 1998 Vol. 20, NO.3, E. Gose, PhD; W Naguszewski, MD; R. Naguszewski, MD., found the following from spinal decompression: “Pain, activity and mobility scores greatly improved for 71% of the 778 patients studied. The authors consider Z GRAV’” to be a primary modality for low back pain due to lumbar herniations, degenerative disc disease, and facet arthropathy. The authors concluded that post-surgical patients with persistent pain or “Failed Back Syndrome” should try Z GRAV before further surgery.

Does the success of spinal decompression treatments last or does the pain just come right back when a patient is done with treatments?

“Results have been reported in a small series of patients with chronic low back pain caused by disc herniations, bulges and degeneration who were treated with a spinal decompression device. 4 years after receiving spinal decompression treatments, of the 23 patients who responded, 52% had a pain level of zero and 91% were able to resume their normal daily activities. Over 80% showed 50% or Better Pain Reduction at the End of the 4 Year study. And greater than 50% Still Had a Pain Level of Zero. Thus pain relief not only improved but lasted.” ~ Decompression Reduces Chronic Back Pain: A four year Study; R. Odell M.D., D Boudreau D.O., Anesthesiology News March 2003