Decompression Case Review

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.

Welcome, doctors, to today's episode of the Practice Builders Podcast. I'm Dr. Kyle Pankinen. And happy to be with you today. Doing a solo project today. Dr. Leone is on— he is on vacation in Hawaii enjoying himself, and he's a hardworking guy. He deserves it. So we'll fill in today by myself, and this is going to be a little different, a little bit different type of podcast than what you're used to. It's going to be a little heavy on the clinical, but there's going to be some Points that I'm gonna bring out when I share this episode that will help you from a business point of view as well, and being successful not only clinically but business-wise, especially in the area of spinal decompression. So we're gonna call this episode simply Decompression Case Review. So I'm gonna highlight a couple of recent decompression cases, share a little bit about their history, their exam findings, their outcome, but then just give some insights as to each case and how you want to think through some of these and approach these, not only from a clinical point of view, but also from a business point of view as well. And this is just going to help you to make you a better decompression doctor, and it's gonna help your bottom line as well. So I hope you find these 2 cases insightful. So without further ado, let's dig in. So case number 1 is a 40-year-old male. This is a patient of mine. He's been with me for several years. His wife actually used to work for me years ago. And, but he has a history of just recurrent episodes of fairly acute low back pain. And over the past 4 or 5 years, maybe 1 to 3 times a year, he'll come in and, ah, doc, it's flared up again. And so we do a quick course of just some chiropractic adjustments, some physiotherapy with them. Just routine chiropractic stuff, and usually within a few visits, he's I'm feeling better, Doc, and in essence, I'll see you when I need you. But more recently, well, this was on July 10th of 2025. He injured his lower back doing some heavy lifting, and the pain over a course of the next few days just gradually escalated from there. And he's— so he comes in, you know, several days later, and, you know, I update his exam. Nothing significant out of the ordinary, just some localized low back pain. There's no leg symptoms. It hurts to bend and to lift and to twist, and walking all kind of aggravate or worsen it. And if he's just resting and relaxing, It relieves it. He's doing some at-home, over-the-counter pain pills, some ice, some heat at times, you know, just your typical garden variety chiropractic case, right? Well, at least that's what I thought. I've treated him before for similar things. And— But this time I'm treating him and days go by and then weeks and then We're actually a few months into this and he's a little better, but not a whole lot. And so then I start, you know, as Morris, usually it was just chiropractic and some, sometimes that was it, just adjustments. Well, then I start adding in laser therapy. We get him going on some exercises and He's just not getting better. About 3 years prior to this, I had taken some x-rays on his low back because he would get these occasional bouts. I thought, let's dig in a little deeper. Showed some hypolordosis, some mild degenerative disc disease throughout the lumbar spine, but nothing earth-shattering, nothing that would give any red flags or anything like that. So finally it got to a point where he was thinking, ah, I need to get a second opinion on this back. And at this time I was certainly thinking this has got to be a disc-related injury. And so I encouraged him because he was already made up his mind he was going to see an orthopedist. His wife had told him this. And so I said, well, if you're going to go, You know, probably he's going to order MRI. I said, at this point, I would encourage you to get an MRI. Again, no leg symptoms, no neurological anything. And so he got that orthopedic appointment, he got his MRI, and it showed an L5-S1 moderate degenerative disc disease, Modic Type 1 endplate changes. And a large right central disc extrusion measuring 14 by 9 by 20 millimeters, compressing the thecal sac and extending caudally behind the S1 vertebral body. The herniation contacts the medial aspect of the right S1 nerve root And the dorsal aspect of the right S2 nerve root as it exits the thecal sac. Big disc. But he had interesting, like I said, no leg symptoms. So he gets a shot into his low back. That doesn't help at all. And so then we start talking about spinal decompression. Therapy. And we start the program and we do a disc-based protocol on the Hill DT table. We use what's called Program 4. We start them out at 25% of body weight. We do a 5-degree angle to try to target the L5-S1 disc. And we do 24 sessions. All trying to do our best to reduce this large disc. So, you know, a case that morphed from chiropractic into decompression. So one of the learning points from this case is, if you have those garden variety cases that you treat once a year, a few times a year, periodic episodes, A lot of those are disc cases, and it's gradually morphing and emerging into a more significant disc condition. And what started out as a chiropractic case now morphs into a decompression case. So one of the business take-homes is you need to be able to recognize Hey, when is this turning towards a decompression case? You and I all have patients like this in practice who used— they may have been a longtime chiropractic patient, and what used to work for them in a visit or 2 or 5 visits or 10 visits, and now it's no longer working anymore. All right, that's the one you want to start thinking about, decompression therapy. And these patients are already in your practice, they already know and trust you, so evolving them into a decompression program is a little bit easier sell. What about the size of this disc? This is what I see happen with a lot of doctors that I, that I Talk to or that I review cases with, they see a large disc on MRI and they're like, "Oh wow, that's too big. I'm gonna have to send that one to the surgeon." Uh uh. The latest research studies out. This is gonna blow some minds. Bigger discs respond better than smaller discs. An extrusion. A sequestration many times responds better than a bulge or a protrusion. In other words, it seems as if from research, the further out the disc goes from its origin, the more the body will mount an inflammatory/immune response and actually work to Reabsorb that disc material, and so the take-home message is: Do not be intimidated by the size of a disc, even if it's a big one. And a big one would be anything over ten millimeters. That's a big disc. As long as there's no progressive neurological deficits, no cauda equina syndrome. Treat those conservatively. Treat those conservatively. So the size of the disc doesn't seem to necessarily matter according to some of the latest research studies. What about the time to relief? Well, big discs like that, it's gonna get better. That's what the studies show, but it may take a little bit longer. This is not a case that you're maybe gonna see a great deal of change in a few weeks or a month or even 2. This is a 3 to 4 month process typically. And so when I treated this patient, at the end of the decompression program, the 3 months, he was 25% better. But he was— he could move better. He could do some of his daily activities better. His pain level had dropped, but he still was nowhere where he wanted to be. I said, give it one more month. And so we kept working with him once a week, had him keep doing his rehab at home. At the end of 4 months, he was 75% better. And we've since gone on to do monthly maintenance with him. And I just saw him actually today. He's doing pretty well. He's had a pretty extended period of time now where he's— this is the best I felt in a long time. So what is success? Well, in a case like this, big disc, he could have gone to surgery for it, I suppose. The shot didn't help. That would have been the next thing the surgeon would have recommended. A surgical success case Is that the person gets a 50% relief. So I always tell doctors, my decompression cases, the goal of treatment is to get the case to 50% or greater improvement without surgery, without surgery. That is a big— when you're doing the business side of trying to convert patients to decompression, Always compare your success rate with surgery. And that surgery has at best, what they're looking for improvement is 50% or more. Well, here you say to the patient, our goal of treatment is to get you 50% or more improvement without surgery.

Surgery.

Patients like that. That is a strong, I don't know if I wanna use the word selling point, but it is a strong point of emphasis that patient, when you're trying to convert a patient to a decompression care plan, always use the 50% relief rule and always talk about we're trying to avoid surgery. And that we can in many cases get the same, if not better, improvement or rate of success without surgery. I am going to talk about that a little bit more in my second case, what actually the percent success rates for surgery actually is. But I wanted to touch on that right now. Alternatives. Always talk to your patients about alternatives. Pills. What are the alternatives to for in medicine? It's pills, shots, ablations, and surgery. That's what they got. Either going to drug it, numb it, or cut it. I always tell patients that are considering, you know, I'll think about this decompression program, or it sounds good, doc, but I want to try pills, shots, or surgery.

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The studies on those— the latest study out on Chronic spine pain for injections, steroid injections or ablation. The latest study out says, don't do it. They are— the panel recommended, they advised against using them because the results are unimpressive. They are not much better than doing nothing. And there is significant potential for side effect. And so I tell patients these things about the latest studies on that. Pills, muscle relaxers are no better than placebo according to studies. Nonsteroidal anti-inflammatory drugs are slightly better than placebo, but they also come with side effects. Opioids, if they use them at the recommended dosages, in other words, a lower dosage that won't maybe cause dependency, addiction, they're not effective, no more effective than placebo at those dosages. And then if they have to use them at the higher dosages, they sometimes can help with pain, But then you run the risk of addiction and other side effects. So they're advising against the use of them for treating spine pain. What about gabapentin in Lyrica and some of these nerve-type drugs? Gabapentin has been shown in studies to be no better than placebo. It is important to know these things when you are educating patients about alternatives so that you can have good conversations and make good recommendations. And it helps the patients to see you as the expert, which you are. You are. So know the alternatives to what you do, which is pills, shots, and surgery. Drug it, numb it, cut it.

Okay.

And because patients are going to have questions about those types of things. All right. Now let's talk about the next case. This one won't be as long. This is a 57-year-old female, comes into me with low back pain, right thigh pain. It's only been there for 3 weeks, but she's had a history of low back surgery in 2010 at L4-5. She's seen another chiropractor. She's been to a massage therapist. She's been to an acupuncturist. She's been to her medical doctor and got pain medicine. And she's seen the orthopedist and has got little to no relief over these 3 weeks. So she's really been running to doctors. At first, their doctor, the regular doctor, ordered an MRI of her hip. 'Cause she had this pain down her thigh. That, of course, was normal 'cause he MRI'd the wrong area. The orthopedist then ordered an MRI of the lumbar spine, and the results were as follows. Multilevel Schmorl's nodes, which are— those are intradiscal, they're herniations. Okay. L3-4, though, this was the pain generator.

Right.

Foraminal disc extrusion results in moderate to severe neuroforaminal stenosis and impingement upon the right L3 nerve root. That is what was causing her thigh pain.

Okay.

This is a decompression case. It is not a chronic case, but there are multiple things there. We have the confirmed disc. We have had previous surgery. She's tried other interventions and the orthopedist told her to go to physical therapy and what? Get an injection. Okay. Well, she, she wanted to try something different. Her husband had seen some— an ad that we ran for decompression. And so she came in, we did the full decompression program on her, 24 visits. She just finished her program. She's 98% better. So a good success. Here's some talking points though. Number one, we know from studies that under age 50, like 90-some percent of disc herniations are L4-5 or L5-S1. However, once they get above age 50, that's when the upper lumbar herniations come into play. So here we have an L3-4. That would be uncommon under 50, but this woman is 57. Mid to upper lumbar herniations become much more prevalent at that age. So from a clinical point of view, you want to really be cognizant of that fact. This was a far lateral disc. This was a big disc too. Just like that case before and putting significant pressure on that nerve root. And again, don't let the size of the disc intimidate you. Do good doctoring, work these up neurologically, orthopedically. And as long as they're not progressively worsening neurologically, there's no cauda equina syndrome. Research studies show 96 to 98% of these will respond to conservative non-surgical treatment. We have way too many doctors out there that are sending patients for surgery way too soon and based upon imaging findings and not conditions on the ground. And that is a big mistake. So a lot of decomp— From a business point of view, A lot of decompression doctors are turning cases away, sending them to surgery, sending them to pain management specialists when they got the goods. They can help these cases with decompression. I used to work with a doctor, or I should say consult for a doctor that didn't do any exam, only relied on imaging findings to determine Whether a case was a decompression case or not. Big, big mistake, because imaging findings don't always tell the whole story. You have to correlate the imaging findings with your history and a world-class exam to see if those things match the imaging findings. If they do, yeah, that's a then you know exactly what's going on. You got a beautiful decompression case. But I've seen many cases over the years where the exam findings don't match the imaging findings and the exam points to another level or a facet or an SI joint being the primary pain generator. So you have to sort through those things and not rely just on imaging alone. Let's talk about, this is a business and a clinical thing, guidelines on surgery. So if they've had a past surgery, in most cases you can do decompression on those cases, doctors. You don't wanna turn those away. As long as they've, if it's a laminectomy or discectomy, as long as 3 months has gone by and they're pretty well healed from it, As far as I'm concerned, they're fair game. If they've had a fusion, you need at least 6 months of healing time to potentially consider decompression on those cases. If they've had more than one level— if they've had just one level of fusion, those can be treated with decompression. If they've had multiple levels, it's take it on a case-by-case basis. The answer is sometimes. Depending on other factors such as, are they overweight? Are they diabetic? What's their diet like? Are they a smoker? In other words, how's their overall health otherwise? If it's bad and they got multi-levels of fusion, probably not a good case selection. If they only have You know, if they have multiple levels of fusion, more than one, but, you know, they're not significantly overweight, they're not smoking, they got a halfway decent diet, they're not a diabetic, you get the idea. That might be a case where you do decompression on. So patient selection. Now, past surgery, this is the talking point though. When you have that patient who is, Contemplating, should I do decompression or surgery? Here's the statistics you wanna share with them. Number one, just like I shared before, a surgeon considers it a surgical success if the patient gets 50% or more better from the surgery. What do you and I consider success with decompression? Same thing. I always tell patients the goal is to get you 50% or more relief. That's success. Number 2, I always share with them if they're considering surgery, and again, there are some cases that are surgery if progressive neurological deficits, cauda equina, you know, they got red flags like tumor, fracture, infection. Those need to be sent out of the office. But that is only 2 to 4%. First-time spinal surgery, depending on the study you read, has anywhere from a 10 to a 46% failure rate. Somewhere in that range. I have seen as low as 10, but I have seen as high as 46 to— I actually saw one study that was 50. But it is probably somewhere in the middle. So let us take 10 to 46. Let us say it is In the middle, it is about 28%. Well, that is what you do. Your first-time surgery, there is about a 28% chance it is not going to work. A second time, a second surgery— Oh, I had surgery a few years ago, doc. It helped. I am going to go back. Now it is back again. I think I am going to go back and try another surgery. A second spinal surgery, boom, it is a flip of a coin. It is 50/50 whether it is going to do them any good at all. A 3rd spine surgery has a 70% failure rate and a 30% success rate. A 4th spine surgery has an 85% failure rate and a 15% success rate. And a 5th spine surgery has a 95% failure rate and a 5% success rate. That puts surgery into perspective for your potential decompression cases. So therefore, if you have a patient that's wrestling between the two, they got their medical doctor's advice sitting on one shoulder and your advice talking on their other shoulder and talking to each ear. Those types of statistics can sway their thinking, hopefully to your side of the ear in a sense. And that can make a big difference in educating patients to hopefully take what? Our route, the nonsurgical route. And if you have a great decompression protocol like we teach at Specialized Practice, And you have the clinical skills to do good histories, do world-class exams, work these patients upright, correlate with any extra MRI findings, and know and master patient selection, you're gonna get great results. And statistically, I can tell you about what you're gonna get, docs, 'cause I've been doing decompression for over a decade, and this is the truth.

I'm sorry.

I have tracked every single case that I've done over those 10 years. And the success rate of spinal decompression is 85 to 93%. It's always in that range. And year in and year out. And you gotta remember, these are the challenging cases. And what I mean by that is 85 to 93% of the cases that I've treated with the protocol that we use and teach at Specialized Practice, Wow. 85% will get a minimum of 50% or greater relief. Well, that's better than first-time surgery, right? By my math, if first-time surgery is a 10 to 46% failure rate, so let's just put it in between at 28%. Well, that's only a 72% success rate in getting them 50% or greater relief. We have a protocol that works 85 to 93% of the time to get them 50% or greater relief. When you can present things to patients in that manner, boy, that hits home to them. And that hope that— and that situates you as you're the spine expert. You're the non-drug, non-surgical expert for spine conditions, which is how you want to position yourself if you're in the world of decompression. And this will set you up as the expert in their eyes. And they, you know what they say? I'm going to follow your approach, doc. I'm going to try to stay away from surgery if at all possible. I am going to try to stay away from injections and ablations and pills because you have told them what the studies say. And it is the truth. It is backed up by peer-reviewed science. And so the data is on our side, docs. The data is on conservative, non-drug, non-surgical intervention. So I hope this resonates with you, mostly clinical, but there is some really good business pearls in there and communication strategies that I think can really move the needle in the right direction in increasing your conversion rate on your decompression cases. So if you like the episode, give us a like, tell a friend, tell a colleague about the Practice Builders Podcast. And we enjoy bringing this information to you. And speaking for Dr. Leone, I'm Dr. Kyle Pankinen, and we'll see you on our next Practice Builders Podcast.

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. 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.