Red Flags That Tell You a Patient Is Not a Good Candidate for Spinal Decompression

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.

All right, docs, welcome to today's episode of the Practice Builders Podcast. I am your host, Dr. Kyle Penkinen. I am super thrilled to be with you today doing a solo project today. My partner in crime, Dr. Leone, is— I think he's going to record his own separate episode. And I kind of like to focus sometimes a little more on the clinical aspects. So sometimes when I do my solo ones, it's a little bit more slanted clinically. And Dr. Leone is the mastermind when it comes to business and And he, don't get me wrong, he's a great clinician. And, but at Specialized Practice in our group, I'm the clinical director. And so I'm gonna bring you a podcast today that I think will resonate with a lot of you doctors. And this is gonna be called Red Flags That Tell You a Patient Is Not a Good Candidate for Spinal Decompression. I'm just like you. I want to get everybody that I can on the spinal decompression One, it is good for most of them and it is good for our bottom line. But there are some cases and some patients that just simply are not good candidates. And it will save you a lot of headaches and it will save you also on that patient that if they should not have been on the table in the first place.

Right.

What are they? They're the ones that go tell their friends and family and neighbors and so forth, ah, that decompression stuff, that didn't work for me. So it's a lot of times we fail not in converting decompression cases, we fail in the sense that our selection is sometimes poor. We're not here to make— not everybody is a decompression candidate. That's the bottom line. And so we're not here to— if you have 100 patients walk through the door, yeah, all of them could potentially benefit, but there's probably a few of them that are like, no, I don't wanna take that case for a variety of reasons. And so I wanna go through some of those reasons today.

Okay.

And also some of the things I've seen clinically Where maybe other doctors had done decompression or recommended decompression that I examined in my own clinic and found this really isn't a case for decompression anyways. And I'm gonna give a couple of recent examples in my own clinic of new patients of mine that when I first read their history and saw their imaging findings, I thought, ooh, this is a decompression case.

Mm-hmm.

But when I examined them, I realized they were not. So let's go through those, some of these. So the first red flag, red flag number 1, the patient's MRI doesn't match their symptoms. So for instance, you could have a large herniation on an MRI, but it's not the pain generator. And I want to go through a recent case that I had. So I had a gal that came into me as a new patient just a week or two ago, and she had chronic right low back pain. And it was, it was around the SI joint area. But she came to me, she already had an MRI done. She had had injections into her low back. And she had significant lumbar spine involvement. She had spondy at a level or two. She had some stenosis going on. She had some degenerated bulging disc. But there was no mention on the MRI of any type of nerve root compression or, you know, really anything that would say, oh, there's definitely Compression nerve. There was no annular tears. This is an older lady. No annular tears to suggest, well, maybe there's some chemical radiculopathy going on, or, or, you know, chemical irritation of the nerve root. Nothing like that. Just wear and tear, degeneration, which can be a pain generator. But so, but she didn't get any relief from any of the injections. She's had some chiropractic treatment elsewhere. And it would give her some temporary relief, mostly instrument-based adjusting that had been done. So we did a detailed history and then I did a detailed set of orthopedic tests on her and tests like Yeomans were positive, HIBs were positive, and her pain, I could palpate right over her SI joint. And all of her exam findings pointed to SI problems. She had had joint replacements. She had both of her hips replaced and one knee. And she also had images of that and the hips looked good. So I asked her a question. I asked her, have you ever had an X-ray of your low back or hips when you were standing? Well, come to think of it, Doc, no, they were— I was lying down. And so that started tipping me off in my mind that joint replacements, I've seen many cases over the years where they ended up with leg length inequality. So I said, we need to get a new set of x-rays of you, but when you're standing. So I x-rayed her when she was standing and found she had an 18-millimeter short leg on the left. So a very significant leg length inequality. That was the root cause of the problem. That was a case you could decompress the lumbar spine until the cows come home. And I'm not saying it wouldn't have done any good, but that wasn't where her pain was coming from, from the lumbar spine. It was coming from the leg length inequality. And the sacroiliac joint. And so we got her some foot levelers, we put her in a heel lift, we did some shockwave therapy right over the sacroiliac joint, did some gentle drop piece adjusting, and within 2 visits, significant relief of her pain. She had the wrong diagnosis. So that is an example. So you can't rely just on your imaging findings To determine if somebody is a decompression case or not, you have to correlate with history, detailed exam, which we teach what's called the world-class cervical and the world-class lumbar exam at Specialized Practice. If you're relying on the MRI, you're headed for trouble because the disc isn't always the pain generator. And you can have disc bulges and disc herniations, and they might be just incidental findings. And so that's why you have to work up. So the MRI doesn't match their symptoms. That is red flag number one. And that is a recipe for having a failure and also a case that maybe didn't really need decompression in the first place. So that is number 1. Red flag number 2, severe central canal stenosis. So I always teach doctors that if there is central stenosis and it's at one level only, you got a realistic shot of decompression to help in that, especially if there's, you know, there's usually loss of disc height. If there is a posterior or central disc bulge or herniation, Mm-hmm. And you can reduce it with the decompression. You create more room for that central canal. Also, but a lot of them, it's posterior. It's facet arthropathy. It's ligamentum flavum hypertrophy. Some people have epidural lipomatosis in the posterior canal. And so those are things that the decompression may not have as much effect on.

Okay.

But here's the kicker with spinal decompression. If it's severe at one level, you got a pretty good chance. But if it's severe at 2 or 3 or 4 levels, docs, that is going to be a recipe for probably not a high likelihood of a high outcome in that case. Now, I'm not saying you can't offer them any help. I'm just saying That you're not gonna have a case that's gonna get 70 and 80 and 90% better. And so these are cases that you need to really set realistic expectations. And oh, well, I'm gonna talk about that a little bit later on, what realistic expectations are. So, but if they have severe central stenosis and it's at multiple levels, Those are cases that might not be the best patient for spinal decompression. Third one is if they have significant psychological barriers. You and I all have patients like this. They exhibit fear, avoiding behaviors. Oh, I can't do that, doc. I don't do certain activities anymore because it could hurt me.

All right.

They are very afraid of their pain. They are afraid of living a normal life, doing normal activities and things because it could hurt my back, even though in many instances they could be doing that. Or there is your classic disability mindset where there is some potential secondary gain. Well, these disability patients, If they get better, guess what? Well, they gotta work. They can't collect disability. So if you have somebody that's applying for disability or they're already on disability, but they've heard about this wonderful spinal decompression—

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My experience tells me these are people that likely, no matter what you do, they're not going to get better. And interestingly, a lot of these, when they start to feel better, they self-sabotage because it scares them, because they think to themselves, well, I actually am feeling better. Now I don't have an excuse not to do X, Y, or Z. And they, they think about the things they might actually lose if they were to get better, how that would change their life, and it scares them. And so they drop out of care, or they, or they say, oh, this isn't working, doc, for me. I'm just gonna I'm just going to skip the rest of the program. We're just going to stop at visit 8 or 10 or 12. And so if there are these significant psychological barriers, disability, fear avoidance behaviors going on, or somebody that maybe has severe anxiety, depression, some of those just are not good candidates. You're better off— To avoid putting them on the decompression table. Red flag number 4, the patient wants a miracle. Doc, you're my last hope, and I'm putting all my confidence in you. And my friend or my neighbor, they said they got rid of their pain, or my friend said this will cure me. Or you get the idea. They're oversensationalized. They're overhyping the expectations. And in other words, they have unrealistic expectations. Here's how you keep yourselves out of trouble, doctors. And you— I tell all of my decompression cases, and actually anybody that has any kind of chronic pain, whether I'm doing decompression or something else, Always say the goal of treatment is to reduce your pain by 50% at a minimum or more. And then set as your secondary goal whatever it is their pain is taking away from them in their life, whether it's their sleep, their love life, their, their work, playing with grandkids, going on walks, golfing, fishing, whatever. That is the secondary goal, is to make inroads into getting that back or improving that aspect or area of their life. And so, if you set realistic expectations upfront, it saves you from that painful conversation later. Well, doctor, you kind of made it seem like this was going to fix my problem. Or that I would be able to live my normal life completely again, or that this would take care of it. Never use the word fix. Never use the word cure. Always use words like improve, function better, 50% or more improvement. That is the types of language that you want to use, docs. So you gotta set realistic expectations so that that patient, once they get to a point where they're 60% better, whoa, hey doc, we were talking about 50% as the minimum goal. I've already achieved that and more. They're happy with 60% improvement versus the patient who is expecting to get 100% better or 98% better, and then they are at 60% and they are disappointed. So you got to be careful of those patients that want a miracle. Okay. Red flag number 5 is a poor compliance history. You all know these patients that they do not follow recommendations. They miss their appointments. They don't complete or do their home exercises. Those aren't— if you have a history with a patient where, you know, they don't keep their appointments, they're late all the time, they— no matter what I tell them to do, they rarely do it, they don't seem to value their care. What are the odds that you're going to get them to comply with a 24-visit, 3-month Decompression program? The answer is probably next door to nothing. Okay, that's, that's not a good candidate for a decompression program. And you need to remind people in decompression that it's a process. It's not just a single treatment. And so, which brings me to another point. The latest research on decompression shows that the average Patient can expect to see relief in 3 to 6 weeks. Okay? So all new decompression patients, I always tell them the goal is 50% or more relief. Whatever that goal is, we're going to try to get you sleeping through the night again, or getting back to work, or playing golf again, and that we expect to see Some type of meaningful change in somewhere in that 3 to 6 week range so that they do not get in their head that, oh, I have done 2 visits, I do not feel any better, doc, what is going on here? Or I have been at this for 2 weeks, or whatever. You get the idea. It sets realistic expectations from the get-go. Red flag number 6 is Ignoring the bigger picture. So you might have a patient that has chronic low back, leg pain, and, you know, they got some MRI findings, their exam findings match their imaging findings, and it's like, okay, this is a good case. However, they're a smoker, they're significantly overweight. They're really weak core. They they eat an inflammatory diet. They're in a job that they sit all day, or they're in a job that's you know a lot of manual labor and lifting. In other words, there's a lot of other factors that go into this case that might be like you know. Even though it looks like it could be a decompression case, but they have all these other comorbidities and other factors that are going to limit their ability to be able to respond to decompression. Those are cases that you might want to pass the buck on or say, you know what? You are a potential decompression candidate, but I do not think our odds of helping you are that high because you are smoking, you are significantly overweight, you are really weak, you have a job that keeps aggravating your condition. Maybe we need to address some of those issues for a few months first before we get you on the decompression table. And so, It may be decompression is just a part of an overall larger treatment strategies. So as we kind of start to wind this down, this segment, the successful decompression doctors, they'll ask a couple questions. One, can this patient improve with decompression? And secondly, Should this patient be accepted into my decompression program? So when you're examining, or you say you're doing a history on a patient, and maybe they're coming in, you know that, okay, maybe through an ad or referral or word of mouth, they're interested in decompression. One of the things I a lot of times say is, Mrs. Jones, we're going to do a detailed history. We're going to do a world-class exam. And we're going to see if you are a candidate for decompression. And that kind of changes the mindset of the patient coming in, that to realize that, well, maybe not everybody is a candidate. And it puts a little bit more control in a sense back in you, the doctor. So the highest performing decompression practices, they don't necessarily treat more patients, they select better patients. If you go through the process of selecting good candidates, weeding out those that are likely failures, then you're gonna have a higher success rate. And those successful cases then will morph into what? More referrals, more word of mouth, and, uh, it's— and then fewer headaches for you. So I know we all want to get as many people on our tables as we can. I'm right there with you, docs. But there is a time and a place to say, you know what, This is not a good candidate for decompression, not only clinically, but it's a good business move for you as well. As hard as it is sometimes when we're trying to grow decompression, to turn a case or 2 or 3 away here and there is a really good practice to do. So what I would encourage you to do is look at your last Number of any case recently in the last, say, 3 months, 6 months, a year where it was a failure. And what's a failure? If they get less than 50% better, to me, that's a failure. 50% is if a patient has spine surgery and they get 50% better, that's considered a successful spine surgery. So We're treating with decompression many of the same cases that would potentially end up in spine surgery. So to me, with decompression, non-surgery, if they get 50% better without surgery, that's a successful case. That's a good clinical outcome. And anything above 50%, I consider that to be— A clinical bonus. So review any failures you've had over the last year and see if you can pick out any of these red flags that I went through today and realize, oh, that's why that patient didn't get better. It probably falls into one of those 6 categories that I listed. And then learn from those failures. That's what we do, right? We learn. We do that through our whole life. We learn from our failure. So you identify which red flag was present, and then you learn from it. And then that often you'll turn that into a blueprint for success down the road where you'll become a master of patient selection. And you'll figure out which cases are likely to respond, which are not, and then you're off to the races because you're going to help so many of those cases. And, and the best advertising— what? It's a happy, successful patient case that refers their friends, their family, their neighbors, and word of mouth. I mean, I do a lot of external marketing, but still At the end of the day, the word-of-mouth referrals is the best marketing on the planet, and it doesn't cost as much. I like that too. So I hope this episode resonates with you. Tell a friend or a colleague about the Practice Builders Podcast. Give us a 5-star review. And I know I get a lot of feedback from doctors that say, I listen to every one. They listen to it when they're in the shower or they're driving down the road or whatever the case might be. So we appreciate all you docs and thank you for listening to today's episode of the Practice Builders Podcast. Dr. Kyle Pankinen signing off.

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.