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Debunking the Myth of Discogenic Pain
and Lumbar Fusion |
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In the MedFak Orthopaedic Journal, March 22,
2004 Professor Klaus-Peter Schulitz, Orthopaedic
Department, Heinrich-Heine-University, Düsseldorf, Germany pointed out in an
editorial that
the continued use of
pedicle screw fixation for the treatment of degenerative disc
disease had to be questioned: |
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Multi-level complex spinal fusion as a treatment for axial
back
pain has become the single most controversial subject
in the U.S. health care system.
Carragee has pointed out that, at best, only 50% of such patients
have a high quality outcome (The Role of Surgery
in Low Back Pain, Current Orthopaedics, 2007). Deyo has
stated
that the small advantage of instrumentation in promoting solid
bony fusion is of little advantage in promoting pain relief or
functional recovery but also is associated with a higher
complication rate (Back Surgery-Who Needs It?, N
Engl J Med, 2007). Researchers at the Dartmouth
Medical School have noted that thousands of Americans have opted
for these types of fusions "when the evidence for surgical
success is virtually nonexistent."
The August, 2010 issue of the BackLetter reports on a survey of
Orthopedic Surgeons attending the Annual Meeting of the American
Orthopedic Association in Boca Raton Florida which indicated
that of 100 respondents only one indicated that they would
undergo fusion to treat their axial low back pain.
How then do unsuspecting patients get talked into this?
The answer has to do with their being told that their pain is
"discogenic" in nature and that fusion will give them a 70-80%
chance of pain relief
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80% of the American population experience at least one
episode of disabling back pain during their lifetime and nearly
25% of Americans suffer from chronic back pain. If they
are non-smokers the great majority of these patients will
self-heal with non-surgical conservative therapy.
Illustrated below is one, of
many, case examples in point: |
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This 64 year old retired widow
was seen by a spine surgeon for the treatment of low
back pain of three years duration. At the time
of her first examination, on the basis of reviewing her MRI
study he recommended, and then performed, a 4 level 360
degree instrumented
pedicle rod and screw fusion. Relief of back
pain lasted only 9 months and when seen 2 years
following surgery this patient was significantly
more disabled by back pain and had developed
additional problems related to transmitted stress . |
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What would motivate a surgeon to make such a recommendation not in the patient's benefit? Clearly there are
strong financial incentives for spine surgeons as indicated by
the exuberant growth of specialty spine clinics in association
with hospitals and now well-documented conflicts of interest
among well compensated spine professional surgeons. There is also evidence
that some "Fellowship Training" Programs promote this
practice. This is well illustrated by the following letter
of inquiry received from a hospital Credentialing Committee in the State
of Washington: |
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There exists today a plethora of cases similar to the one
presented above. Some believe that this problem has now
reached the proportions of a true
public health overuse
epidemic. The term "overuse" is defined as
providing a treatment whose risk of harm to a patient exceeds
it's potential benefit.Most certainly the great numbers of
such patients now being seen in spine care practice have created
a new category of "failed back surgery" cases which may now
eclipse lateral spinal stenosis
as the most common cause of spine surgery failure. These
cases have also allowed Chronic Pain Rehabilitation Programs to
become big business because of the increasing need for such.
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Discogenic Pain and Discography |
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Shown to the left is a needle
being placed in a disc prior to the injection of dye
or other substances The procedure is referred
to as a "discogram."
Although this test is used to evaluate internal disc disruption
it has
been frequently used as a excuse for recommending
fusion as a treatment for low back pain. |
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Evidence-based medicine has clearly
documented
that discography can cannot reliably differentiate
an asymptomatic degenerated disc and that the
procure itself can cause permanent disc damage. The diagnosis of "discogenic pain",
often used to justify spinal fusion, has come under ever
increasing scrutiny as not even being a major cause of low back
pain when compared to other musculo-ligamentous and facet
related issues.
In
2009 the American Pain Society indicated that there was no
evidence that discography was even a valid diagnostic test. The
overly aggressive marketing of discography as an objective means
of justifying spinal fusion has created a significant backlash.
In the state of Washington, at the present time, discography is
not a covered service.
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While multi-level spine fusions
may be reasonable treatment for patients incapacitated by back
pain from trauma, spinal instability, deformity or tumors there can not be, in our opinion, any
justification for performing multi-level rigid instrumented
fusions as primary treatment for axial low back pain due to
degenerated discs. Hopefully,
in the not-too-distant future, all such back pain patients will
be managed by promoting non-smoking,
good nutrition, non-opioid medications, physical and
manipulative therapies, regular exercise, and minimally invasive restorative spine
procedures performed by qualified interventional specialists.
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