10 Common Decompression Mistakes

Hey there, and welcome back. I'm Dr. Vince Leone, executive producer and co-host of the Practice Builders Podcast. With my partner in crime, Dr. Kyle Pankinen, we deliver proven strategies to help you grow fast, specialize with confidence, and build profitable staff-run practices. Let's go ahead and dive into today's episode now.

Well, all right, docs, welcome to today's episode of the Practice Builders Podcast. I'm your host today, Dr. Kyle Pankinen, and I'm going to bring to you a topic today that is what I would call 10 of the most common mistakes that I see decompression doctors make both clinically and professionally as far as business decision-making. So 10 common decompression mistakes, let's just call it that. And this is, this is an episode, if you, if you take some of these mistakes, truths, whatever to heart that I'm going to cover here, these will help you to avoid some pitfalls and to help you to increase your decompression case acceptance and help you with patient selection so that you're getting the right people on the table. For the right reasons. And so I think you're gonna like this list. And so we're gonna go through 10 different things. I'm not gonna dwell on any one for a long time. We're just gonna go through them and see if you identify with any of these. And if you do, you know, pick out one or two and make some necessary adjustments. And I think you'll like what happens. So Common mistake number 1, a lot of doctors rely exclusively on imaging findings to determine if someone is a decompression candidate. That is, that is not a good clinical way to approach cases because you can have MRI findings that look pretty bad, but— Those findings may or may not be the true pain generator. So you have to correlate history, world-class exam, which we teach at Specialized Practice, world-class cervical, world-class lumbar exam. If you're a decompression doc, you gotta take your exam to the next level to set you apart as the expert. And you have to correlate, so history, exam, and imaging findings together. So I have talked to doctors over the years that I have done consulting with and they say, oh, I just review their MRI findings and then I let them know if they are a candidate or not. That is not a wise way to do this, docs, because You can— we'll talk about some of the things later with MRI in this, but you can be fooled by MRI into thinking somebody isn't a candidate and being intimidated by MRI findings and turning people away that could very well have been helped. Conversely, you might be getting people converted to decompression that you're not even identifying what the real pain generator is. And you are treating an area of the spine that maybe is not actually the root cause of the problem. So do not rely exclusively on imaging findings. History, exam, x-ray, and sometimes MRI are necessary, but do not rely on just one thing. Number 2, overpromising and underdelivering. What do I mean by that? Sometimes we as doctors in our zeal to want to increase case acceptance and to get people on the table, we make statements that are overpromising. In other words, we don't use words like fix or cure or heal or—

Cure.

100% better, things like that. Okay? Or you don't want to give the person the impression that you're going to fix their problem and— or tell them, well, we should be able to get rid of 90% or 100% of this pain.

All right.

And then, so say you have a person that gets 50% or 60% better. But they were thinking this was going to be the answer to their condition. In other words, in their mind, this was the cure, the fix, if you will. And then they get 50 or 60% better. In their mind, they are disappointed. Why? I thought I would do a lot better than this, doc. From the outset, doctors, set realistic expectations. Use the 50% rule as I have taught Many times, but 50%, always, always tell the patient the goal of treatment is to reduce your problem or improve it by 50% or more. So that way, when they get 60 or 70% better, ah, you know, Doc, we were in the beginning talking, we wanted to get at least 50% better. I am at least 70% better. Boy, this has been a— I am glad I did this, doc. This was a good, worthwhile treatment regimen for me, and I am pleased with my results. You see that they got the same. Both of those patients got 50%, 60%, 70% better. One is disappointed and one is happy with their results. And before you poo-poo that, A 50% improvement for some of the conditions that we treat with spinal decompression is an excellent clinical outcome, docs. 50% relief for a lot of cases, that's life-changing for many people. I've had people say to me, doc, if I could get rid of half of this pain, boy, that would make a big difference in my life. I could sleep better or, Stand longer or walk further or enjoy my grandkids more, things of that nature. So do not underestimate the power of using 50% as a benchmark where we determine success in a case or not. Keep in mind that meaningful clinical improvement determination In other words, the least amount of improvement that patients deem as it was worthwhile for me to go through this treatment, according to research studies, is 30% improvement. So some people might be happy with, I am not as good as I would like to be, doc, but you know, I am 30, I am 40% better than I was. I'm glad I did this treatment. It's moved me in the right direction. So don't oversell, don't overpromise and then underdeliver. Underpromise and then overdeliver is what you want to do. Okay? Number 3, always needing to have an MRI to proceed with decompression. If you have a good history, A world-class exam and a good set of x-rays, in not all, but most cases, you have enough information to proceed with a course of decompression. Now, if there's progressive neurological deficits, if there's motor weakness on your exam, if the person is definitely Moving in the wrong direction, not the right. Well, yeah, okay. Maybe we get an MRI right from the outset. There are cases where that is very much a good idea, but I don't think it's necessary that every person that we put on the decompression table has to have an MRI before we can proceed. It's nice, and thankfully a lot of them come in to us with an MRI that they've already had, Because now they are looking for another method or route to deal with their disc or spine condition. But it is not essential for every case. If you have a case where the exam points towards an L5-S1 disc, they have S1 dermatomal pattern, it can be reproduced with straight leg raise, All your exam points to L5-S1. Their history matches that as well. You take an x-ray and you see, oh, there's moderately degenerated disc at L5-S1. What more do you really need would be my thinking on that case. So I think we sometimes, you know, we get enamored that the MRI is going to tell us that this is a decompression case or not. And In most instances, I find it's nice to have it, but it's not necessary. Now, I'm not afraid to order MRI when it's needed, but I would say the majority of cases, at least starting out, do not need an MRI. Okay? Number 4, this touches a little bit what we mentioned already, but not identifying the true Pain generator. What do I mean by that? So this will be again the doctor that relies on the imaging more so than the exam to determine qualification for decompression. And so I'll just give an example or two. I've had many patients— we have another doctor in our area about an hour, a little over an hour from us that does decompression. And good doctor, but I've seen his treatment notes and his exams. His— let's just say his exams are quite lacking. And so I recently had a patient that came into me for a second opinion, and we went through his history. I examined him, and everything pointed to Sacroiliac joint. You know, Yeoman's test and Hibb's test and palpation tenderness, location of pain, referral pattern into the upper leg. And he had some X-ray findings and even an MRI of his lumbar spine. It wasn't pretty. I'm not saying he had a beautiful low back. But his exam clearly pointed there was no reproduction of any symptoms coming from his lumbar spine on on the exam. But yet this doctor recommended a big course of decompression, five six thousand dollar plan, and and while this patient came into me for a second opinion and. I could have said, yep, you need decompression. My plan's a little bit cheaper. Let's get you going. I said, you know, you do have some issues in your lumbar spine, but this joint here is the pain generator. Let's take a different approach. So we did a program of chiropractic adjustments and shockwave therapy and custom orthotics. And in 3 visits, his pain was gone.

Wow.

Well, could he have gone through a decompression program and potentially not gotten any relief? Yeah, that's possible because you would be treating the wrong area, not the true pain generator, because why? The exam was lacking. You can also have cases where the main pain generator is not the disc, maybe it's the facet joints. Now those can be decompression candidates, but you might be looking at an MRI and the problem is at L4-5, that's the disc, but the facet problem might be at L2-3 or L5-S1. You might not be targeting as specifically as you could be the exact level because you haven't identified the true pain generator by the exam. So that's a common mistake I see. Number 5, being intimidated by the size of the disc. I've heard this one many times. So doctors will send me MRI reports. What do you think, Doc? Should I refer them to the surgeon? Do you think this is even a decompression case? And what they're saying is, this is a big disc. Got an extrusion here, a 10 millimeter disc extrusion. We have a large free fragment, those types of things. And they're like, whoa, look at that on MRI, or look at what this report says. I don't know, Doc. Interestingly, and I'll be presenting this at the summit this fall, the Decompression Summit, recent research shows that Most large discs will actually, in some instances, respond better than smaller disc bulges or disc protrusions will. What we're finding from research is that the further out the disc extends from its origin, the more the body creates an inflammatory immunological response to it. And it actually works to reabsorb that herniated material or phagocytose that sequestered segment, free fragment. And so don't let the size of the disc intimidate you.

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Go by what are conditions on the ground. Now, in other words, what are the symptoms? Are there any significant neurological deficits? But are those neurologic— if they do have them, are they stable? Are they staying the same or improving, or are they Getting worse. As long as you are monitoring them neurologically and they are not regressing and going in the wrong direction, most of these large discs, even though they take time, they might take a few more visits, but many times these larger discs will respond just as good, if not better, than what you and I would say, oh, that is a— Sometimes we look at the MRI, oh yeah, you got a little disc bulge there. Oh, there is a little contact with the nerve there. Yep, you are a great candidate. This, in your mind, you think this should be a pretty easy case, slam dunk, right? Sometimes those are harder because that small disc bulge is sometimes not as easy to reduce and the body is not producing as much of a response to it as those bigger ones. So the moral of the story is do not make the mistake of getting intimidated by the size of a disc lesion. Okay, number 6, referring out for pills, shots, or surgery too soon or too often. I covered this extensively at the summit last fall, but there's a few things to keep in mind. Number 1, research shows only about 2 to 4% of all spine cases ever truly require surgery. So that's last resort. That's only for, you know, cauda equina, very progressive neurological deficits, failure to respond to, to the types of things that we do. There's a, there's a small, narrow subset of patients that do require surgery, and you need to know when to refer for that. But I see a lot of doctors, though, that They work with a local pain management clinic or an orthopedist or a neurosurgeon where they send them for shots or ablations or— and things like that. The latest study out that's less than a year old for chronic axial non-cancer spine pain, all the latest guidelines and recommendations recommend against— The use of epidural steroid injections and radiofrequency ablations. They are, I want to say worthless, but they are close to worthless and they can carry with it a significant risk of side effect. So I do not refer for ablations or for epidural steroid injections. The only time I refer to a neurosurgeon is if I think This patient, I think, needs surgery, or I am not quite certain if this is a surgical candidate or not. In other words, this is a person, they have progressive neurological deficits, or they are just— I have put them through a whole decompression program and they just have not responded. Well, maybe that is their only good remaining option. But injections and ablations, those— the only time that an injection may be worthwhile is in an acute stage when they are really in dire straits and hurting, and you just use it to just calm things down a little bit so that you can get them on the decompression table. But I find if you just use laser, maybe it is not going to work as fast as an epidural, but over a few weeks it will produce very good results to really calm those really hot discs down. So just use those things wisely, docs. We're chiropractors. We don't wanna be referring for pills and shots and surgery if we can absolutely avoid it. In most cases, it's unnecessary, okay? Number 7, not being aggressive enough with inflammation. A lot of research coming out that When you see on MRI Modic type 1 endplate changes, that's inflammatory in nature. There's research coming out that shows that some of these discs are inflamed.

They—

some of them actually, they think might have a low-grade infection in them that comes through the endplate, in through maybe an annular fissure, and infect the disc. And the disc is inflamed. Or you see on MRI a high-intensity zone, an annular fissure, that's a disc that is inflamed. You see a patient that has back and sciatic pain, but they don't have any obvious neural compression. In other words, a herniation or bulge that's actually putting direct pressure on the disc. Many of those, it's chemical radiculitis. And that's— it's inflammatory. We need to make sure in our protocols that we're utilizing our lasers, getting them on the supplement NutraDisc, and encouraging them to use an anti-inflammatory diet. So when you have a case that's not responding, maybe you need to address inflammation a little bit more aggressively.

Okay.

Mistake number 8, pulling more than is necessary. So I've talked about this before. Research— a lot of doctors think more is better, but the research does not point that out. The research actually points out, I think, the opposite. So they've done head-to-head studies with 10% of body weight versus 50% of body weight pull for the lumbar spine. And over 2 weeks, the 50% does better, but over 4 weeks and beyond, 10% did better. Now that does not mean 10% is the ideal pull. I think it is probably somewhere in between that, but a lot of doctors pull hard and in some instances they are flaring patients up needlessly. I say start lower and then gradually work your way on up higher only if you need to. But I find in most instances, I usually use 20 to 25% of body weight for the lumbar spine and rarely exceed 33% of body weight. I know some doctors that are pulling 50 and 60% of body weight. That— I'm not saying you can't get results with that. What I'm saying is— The research doesn't seem to indicate it's necessary to pull that hard. And why take a chance on flaring something up when you can start lighter? It's more comfortable for the patient. They're probably gonna get good results with a lighter pull, and you can always go up. But it's hard to pull hard and then come back down once they've had an exacerbation or flare. Final thing on that cervical spine study, they use 5% of body weight, 10% of body weight, 15% of body weight, 20% of body weight, and they found 20% of body weight for cervical spine produced iatrogenesis. In other words, they had headaches, dizziness, increased neck pain. 5% wasn't impressive. 10% and 15% of body weight produced good results. But 10% did just as good as 15%. So I always usually start my cervical cases at around 5% of body weight, and I might work up to about 10% of body weight, and that works quite well. Don't pull more than necessary. Number 9, always trying to hit a home run with every case. In other words, every back case, every neck case that walks through the door, this is all we want. We're going to work towards getting them a full-blown decompression program. If they clinically need it, always recommend it. But I see too many doctors that are scaring people away by recommending a 24-visit protocol for a milder back or neck condition. And the patient's like, this is overkill. There is a case to be made for hitting an occasional single or a double and home runs. You need to know how to categorize patients. A single might be a 6 to 10 visit program. A double might be a 12 visit program. And of course, your home run is your 24. Never be afraid to recommend the 24 if they clinically need it. But what might a double look like? It might look like somebody has mild to moderate chronic back pain, but it is not severe. They have some general disc degeneration. They do not have leg symptoms or anything like that. They just think they wake up stiff and sore. And after a couple hours, they feel better. That might be a really good candidate for half of a program.

Okay.

When might you use a single? Maybe on more of just an acute injury where you just, you know, we just need a short-term focused, you know, 2, 3 week program, maybe a month where we're just going to treat it, you know, 6 to 10 times. There's a 24-visit program might be overkill for that. And but you're, you're scaring people away That could be good patients. They just don't need the full meal deal. So don't— just because the decompression protocol is a 24-visit protocol doesn't mean every patient fits into that category. So you need to learn to compartmentalize people, and by your history and exam and imaging findings, where they fit. In that, and then make the appropriate recommendations. Finally, number 10, thinking decompression is only for disc cases. What about facet syndrome, synovial cysts that can put compression on nerves, cases of spondylolisthesis, spinal stenosis? You can have degenerative spondylolisthesis and facet arthropathy.

Mm-hmm.

And that leads to stenosis, but there's really no significant bulged or herniated disc putting direct pressure on a nerve. And you're looking— so you look at their MRI saying, well, the discs don't look that bad. Those can still be good decompression candidates though, docs, because decompression is going to open up and mobilize those facet joints. And decompression can increase— there might be a degenerated disc and decompression can increase the height of the disc. And maybe they don't have leg pain because they don't maybe have a bulged or herniated disc putting pressure on nerve. Maybe again, some of these cases might be a double depending on how chronic or how bad their pain is and what their exam findings are.

Mm-hmm.

But many of them could be a home run, a 24-visit protocol. But sometimes we get pigeonholed into thinking, oh, decompression is only for my disc pain patients. I think almost all back pain and neck pain patients could be potential decompression candidates, provided you give them the correct dosage recommendations for what their condition dictates. So start thinking, how can I incorporate and use my decompression table more than just for disc cases? So that's 10 common mistakes that I see people make, and they're not egregious mistakes, but they're just things that I see that if we're to shift our thinking in those areas and approach some of these things a little bit differently, We're going to have more case acceptance, better clinical outcomes. We're going to get the right selection of patients on the table, and we're going to just enhance our decompression practices, help more people, help our bottom line. That's a win-win for all of us. And so hope you liked today's episode of the Practice Builders Podcast. If you do, give us a like, share us. Tell a colleague about us, and we're going to keep bringing, bringing the good information to you docs. And so appreciate y'all. Thank you. Have a wonderful day, and we'll be back real soon with our next episode.

Hey, it's Dr. Vince again, and hope you enjoyed that episode. And if you're ready to grow your practice fast with high-value decompression patients, then the Decompression Accelerator could be a phenomenal option for you. For you. This is our 90-day sprint to help you scale with proven systems, staff-driven protocols, and full marketing support, and it's all guaranteed. Spots are limited. Head to www.decompressionaccelerator.com to learn more.