320- Surgery or Conservative Care After a Lumbar Disc Herniation

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. Today's episode we're we have a fantastic piece of research. If you are into surgery versus not surgery, lumbar disc herniations and return to play in elite athletes. This episode is for you. We're gonna talk about a brand new study that came out and it is titled Return to Play after Symptomatic Lumbar Disc Herniation in Elite Athletes. A systematic review and meta analysis of operative versus non operative treatment. This is a study that has a lot of take home messages, a lot of great stats to be able to pull out of your back pocket, a lot of great table talk, one liners. This one has it all. It is going to be a great episode, so stay tuned. Before we get started, I want to say a few words about the smart chiropractor. The smart chiropractor powers your patient journey to provide you with more qualified leads, more new patients, better patient retention, consistent reactivations, all without spending any money on advertising. Yes, that is what we do day in and day out. We actually had a new doc come on board, the smart chiropractor a few days ago who ironically was somebody I went to high school with who also became a chiropractor practice practices up in Massachusetts. He got our success blast email sequence going out and had a full schedule of reactivations coming back into his practice. So if you are interested in marketing your practice without spending money on advertising, check out the smart chiropractor. But on today's episode we're talking research. And this is again a study that came out in September, October 2021, so not too terribly long ago. And it is all about return to play for elite athletes that struggle or suffer from a lumbar disc herniation. Now get this. The prevalence of symptomatic lumbar disc herniation in athletes is estimated to be as high as 75%. I found that absolutely shocking. Now here's the good news. Most cases of lumbar disc herniation can be treated successfully with non operative treatment. We all know that. I think inherently as chiropractors, but I can tell you most of the general public doesn't if they think they have a disc herniation, quote unquote, air quotes Going on over here. They think it's too far gone for chiropractic and it's just not true. One study suggested that it was unnecessary to obtain imaging results for the first four to six weeks. Why? Not because they didn't like imaging, but because almost 70% of patients will improve over this time period with non operative care. So there's a 70% chance over the first four to six weeks that with non operative care, patients are gonna find improvement. Now the four to six weeks is interesting because depending upon how that's judged, and I could say this also from somebody who used to work within a few multidisciplinary clinics, depending upon that timer, when that timer starts for four to six weeks, that's when the surgeons start to get, let's say, anxious about getting in there and quote, unquote, correcting the problem. We're gonna have a lot of air quotes today. And most of the time, overwhelming majority of the time, it's just not necessary. The spine patient outcomes research trial by Weinstein, it was a randomized clinical trial, reported actually minimal differences between open disectomy and non surgical care over a two year follow up. I love that study. We've talked about it before. Two years after having a disc herniation that's symptomatic, whether you had a dissectomy or whether you had non surgical care, you were about the same. There's no advantage to having it cut out. And there was another study that showed that there was no significant differences between microdiscectomy and non surgical treatment in terms of quality of life after each intervention. So there's now, there's just not a reason unless there's really red flags or, or a truly failed conservative care plan. That doesn't mean, you know, taking a Tylenol for four weeks and trying physical therapy three times, it really, really needs to be exhausted. This is an area that I am passionate about. You're gonna probably hear it come out a few times on today's episode. So the interesting thing that I thought about this study to begin with was the prevalence of symptomatic disc degeneration in elite athletes is actually significantly higher than a non athlete. So estimated 75% compared to 31%. So when you're putting your body toil through that tax, through that physical aspect of being an elite athlete, it can take its toll. There is positive benefits to it as well, but many, quite often, it comes with also really a lot of stress and strain over a significant amount of time. And that can add up and of course, as you're seeing here, lead to advanced disc degeneration at a higher prevalence and likelihood. And while surgery has been proposed to increase the rate of return to play and reduce that time, it's been increasingly suggested that non operative treatment might result on similar outcomes as we saw in those previous two studies. And that's part of the sell, quite frankly, of surgery. Well, you could do conservative care, but it might take you a long time to get back. You don't know if it's gonna work. One wrong move and now if we go in there, you got this big disc pressing out. We get in there and cut that out. For somebody who doesn't understand the body, that seems logical. You take that disc out of the way of the nerve and it's going to get better. And that's true, but it doesn't have to be cut out to have the same benefits. So this study, again was a meta analysis, it went pretty deep. And 20 studies were determined to be eligible and there were over 1100 patients. And that's really the study archetype, so to speak. The age was 28.3 years. The range was 14 to 49, but 28.3 years old and 98% men, which is interesting. Most frequently played sports. If you're saying elite athletes, what kind of athletes? We're talking about individuals who played football, basketball, baseball, hockey. Those were the primary. And then there were other participants in soccer, volleyball, bicycle, rugby and tennis. But the primaries were football, American football. I should specify basketball, baseball and hockey probably. Especially if you're practicing in us, Canada, uk. That's going to be where you're seeing most commonly one way or the other. So There were about 800 patients, 799 in the surgical group, 308 patients in the non operative group. And here's the good news, 663 of those returned to play successfully. So 83% returned. That was in the operative group versus 251 in the non operative group, which was 81%. So it literally was neck and neck. It was about the same if you were going to return to play. The return to play time for a lumbar discectomy was a little bit over five months and the group treated non operatively was four months. So you're actually able to get back and return to play faster with non operative care than with operative care. And your likelihood of return to play was within 1% of being the same. So very, very powerful return to play after lumbar disectomy in elite athletes. Ranges, they're estimating from about 80% to 90%. And despite the success of operative intervention, 83 success, they say non operative care was equally effective in regard to return to play rate at that 81.5% clip. So these are very, very powerful numbers. We know that spine surgery, it has all the risks. We're talking wound complications, infections, potential paralysis, and as they cite in the study, rarely blindness from ocular pressure in the prone position during surgical intervention. I've actually seen that once or twice myself, so it's not as rare as it might sound. So all of these risks can be avoided with non operative management while achieving similar outcomes. And this is a big deal. When we see athletes time and time again, I'm not going to say being pushed into surgical intervention, but maybe being given a portion of the story, not the whole story. And I could tell you this is happening in your town if you're listening to this on Monday morning. These conversations are happening in your town today, they're going to happen tomorrow, they're going to happen the next day. I don't like to say that, but it's the truth and I know it from being in working and practicing. On the other side, there are a lot of patients, I'm going to say, an overwhelming majority of individuals that go through with elective spine surgeries that have not, in my opinion, truly exhausted conservative care. So this is where we go back and we say, well, what are all of us doing to change that? Yes, we see guidelines changing, yes, we see some things changing at the highest levels. But the trickle down to that could be 10 to 20 years away if it ever happens. And we need to take the bull by the horns. This is why I've been so passionate within the evidence based chiropractor of saying get out there and build these relationships. There are people in your community getting bad information or not the complete story each and every day, the more that you are able to sort of insert yourself into that referral channel, even if it's for one person a year, isn't that worth it? I think it absolutely is. So this review identified elite athletes who were treated 2.5 times more often surgically than non operatively. That really says it all right there. They're two and a half times more likely to have surgery than to be treated non operatively for a lumbar disc herniation. And again, I trace this back to I have a slide in some of the presentations I give. I call it the journey of professional indifference. And this is what a lot of Medical providers are doing. Patient comes in with, you know, radiculopathy, they're given a medication. The medication either works for a short time or doesn't work at all because they have a mechanical problem. And it still. It still is there. After the. After they're sensitized to the medication, then an MRI is ordered. The MRI showcases there's a disc herniation, which was clear if the. If the physician would have done a proper evaluation to begin with. But the images showcase it. Oh, my gosh, John, you have a disc herniation. Let's get you over to see, you know, surgeon xyz. And that's the journey. And that happens day in and day out. Well, what'd you do for conservative care? Well, you know what? I went to see my primary care doctor. You know, he prescribed, you know, certainly he prescribed some NSAIDs. I took those. It didn't work. How long you take those? Four weeks. Well, you meet the minimum threshold of conservative care at best. There might be some. Some physical therapy thrown in there, but we've seen and explored on this podcast specifically time and time again, the benefits of what we do with our adjustments, the benefits of what we do potentially with flexion, distraction, the benefits of what we can provide that many, not all, but many physical therapists don't have the technique, the skill set or the offering for. And believe me, they have their place and they have a significant benefit. And they've helped plenty of individuals with lumbar disc herniations as well. But I just. I have this. I might be biased, but I have a sneaking suspicion, and I see it in the research that comes out time and time again, that there's a lot of people dealing with these low back issues, specifically lumbar disc herniation. Elite athletes, weekend warriors, and never athletes. And many of them are ending up with medications. Many of them are ending up with surgical intervention, and it's just not necessary. So seven out of the 20 studies, 35% reported complications that occurred in their patients, all of them related to surgical intervention. So we wanna talk about risk, the risk of adjusting. Somebody that has a lumbar disc herniation, to me, is nearly zilch. In the absence of red flags, the most common complication was. Drumroll. The recurrence of the lumbar disc herniation at the same level of operation. This is the bizarro world that we live in, where people are afraid to go in to see a chiropractor with a disc herniation because they're afraid it's Going to get worse. Yet the most common complication of surgery is for the same problem to come back, AKA the surgery didn't work. How many people are scared of that or admit it? Very, very few. So what was the conclusion on this study? Conclusion was, quote, there is no significant difference in return to play rate between elite athletes treated with operative or non operative management of lumbar disc herniations. Nor did the operative management have a faster time of return to play. Despite this, lumbar disc herniations in the athletic population are treated surgically with a dissectomy 2.5 times more often than non operatively. Do I think it's time for us to get out there, tell our story and those numbers to change? Absolutely. Do I think it'd be better? Number one for the patient, 100%, you reduce the risk even if the outcome is exactly the same. I got a feeling we'd edge that outcome long term. But even if the outcome is exactly the same, do no harm. It is about reducing risk. It is about providing maximum benefit. It's about being patient centric and patient first. And you know, getting out there, telling our story, showcasing the benefits. You bet that this is going to be in the pipeline of what we use for our MD marketing research briefs within the evidence based chiropractor. So our docs on the evidence based chiropractor program are definitely going to be using this getting out in their community. Not to put anybody down by the way, but really to showcase who they are and what they do to showcase there is another way because before you get 100 referrals, you have to get one. And there will be people, there will be patients, there will be individuals that don't want to have surgery at nearly any cost. And now that primary care doctor saying, well, I don't know where to send you, well, let's be that option. Let's showcase the great results that we get. Now we start really moving the needle in our community, we start improving the health of people in our community and we start really doing what we should, which is be those primary individuals that people in our community look towards when they have a neuromusculoskeletal complaint. So it takes time, it's not easy. But research like this continues to ignite my fire. I hope it ignites your fire as well because it just showcases the breadth and depth of what we can do as chiropractors and these. There was not a chiropractor by what I could see on this study. So this was really independently done outside of chiropractic outside of anything conservative. And I think it showcases very, very well what can be done. Now to be super clear, this study did not focus specifically on spinal manipulation or adjustments. Non operative care was more movement based, more exercise based. I would love to see this study redone with the specificity around flexion distraction or specificity around spinal adjusting, but we will keep our eyes peeled for that. So before we go, if you had a great 2021 as you come into 2022, you're probably looking to grow and expand your team. If you are looking to hire an associate doctor or hire a chiropractic assistant, please head over to chiromatchmakers.com we use personality assessments, team assessments to literally match make it's not about having a warm body in your practice, doc. We've all gone through staff turnover. We've all gone through maybe associate relationships that didn't turn out as planned. How do you mitigate that? You mitigate that through agreements and expectations and you mitigate that by doing full assessments prior to hiring. That is what we do at Chiro Matchmaker. So if you're looking to bring on a new associate doctor to grow and expand your team or looking to have a new chiropractic assistant come into your practice, visit chiromatchmakers.com we would be happy to help you. And other than that, I hope that you have a fantastic week in practice and I will talk to you soon.

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