367- Avoiding Lumbar Discectomy with Chiropractor

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.

How hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. This week we're talking research, a BMJ Open article, lots of clinical pearls, highly relevant if you're listening to this podcast. It came out just this year and it is all about the association between chiropractic spinal manipulation and lumbar discectomy in adults with lumbar disc herniation and radiculopathy. This is a retrospective cohort study utilizing United States data. And that is the title. We dropped it down below if you wanna check out this study. But over the next 15 minutes we'll break down some of the key aspects, highlight what you need to know to have great conversations with your patients and great conversations with other healthcare providers in your community. Before we get started, if you have not checked out Patient Pilot, now is the time to do so. Head on over. Schedule a demo. We'll give you preferred pricing. Patient Pilot is all about automated email marketing. This works in every practice. We work with over 300 docs. We send over a million emails per month. We drive people back when we're talking reactivations. We help them stay throughout their active care plans with retention. And yes, we can help with new patient acquisition by getting a new patient pop up. All of it's automated. All of it's personalized. If you're listening to this podcast, head over to the smart chiropractor dot com. Check out Patient Pilot. Schedule a demo. That's what's going to give you best pricing. We'll also hook you up with some bonuses. This is something you need to do in your practice in 2023 and beyond. But if you're not utilizing automated email marketing, you are missing out. And everything else in your practice is quite frankly sub optimized. This is a foundational component Patient Pilot. Check it out now atthe smart chiropractor.com but as I said at the top on today's episode, we're talking about the association between chiropractic spinal manipulation and lumbar disectomy. So let's first talk lumbar disc herniation. Set the stage. Then we'll get into all of the details as we drive through this study on today's episode. A lumbar disc herniation, as we all know, is A focal displacement of intervertebral disc material beyond the normal limits of the disc margin. Now, this sometimes, depending upon where it happens, is it posterior, Is it posterior? Lateral, Is it more lateral? Is it anterior? If it's in the right spot, it can compress a nerve root, causing radiculopathy. Of course, radiculopathy, we're talking about lower extremity pain, sensory disturbances, weakness, muscle strength differences, all of those things can happen. And lumbar disc herniation is a common reason for patients to receive chiropractic care or to undergo surgery to remove that material in a procedure, as highlighted in the title of this study, called a diagram disectomy. So that is really what's setting the stage. Now, prior studies, earlier studies have documented the benefits of chiropractic spinal manipulative therapy. I'm going to call chiropractic adjustments for the ease of this podcast for lumbar disc herniation and radiculopathy, including what we always like to see, randomized prospective studies. So in meta analysis, spinal manipulation was found to be one of the most effective treatments for discogenic radiculopathy. Let me repeat that again. Spinal manipulation has been found to be one of the most effective treatments for discogenic radiculopathy. That is in the research. That is not just my guesswork. And US and international clinical practice guidelines, as we've talked about many times on this podcast, have recommended spinal manipulations for the care and treatment of low back pain as well as radiculopathy. Now, now, that doesn't mean it's happening as often as it should, quite frankly, by the nature of what we see with medications, with surgery being dramatically overdone. But I'll save that for later on in this podcast. So what are the factors? If that's the case, why would anybody undergo a dissectomy? Right. So there's a couple different reasons, and some of it is, quite frankly, I'm gonna say pressure and lack of knowledge. But let's look at the research. Why does somebody undergo, and there's a couple different reasons why. One is totally legitimate. Severe or red flag neurogenic deficits, cauda equina syndrome. These are real reasons, and they should be addressed as quickly and quite frankly, probably as aggressively as possible. But there are people that have continued pain despite conservative treatment, and that affects quality of life. That's a real thing. My question always is, have they really undergone true conservative treatment, or did they go to see somebody a couple times, take a couple Advil, and have they undergone the gamut because not everything works for everybody. That includes what we do as chiropractors. So have they undergone everything on the conservative care, not just one thing and hope for the best? And I think quite often the answer to that is no, they haven't. Which is why we see surgery being overperformed, in my opinion, so much. So for patients without red flags or cauda equina, early dissectomy in the research has proven to provide short term benefits. However, the long term outcomes are similar at one to two years of those receiving conservative care. This gets down to some of the irony of surgery as well. Well, I'm gonna go get a surgical consult cause I want the problem fixed. Well, that's completely contraindicative to what we see in the research where the fixing happens through movement, the fixing happens through time, the fixing happens through healing, the fixing doesn't happen through cutting. When long term outcomes at one to two years are similar, whether somebody underwent surgery which is ridiculously risky and expensive and permanently changes biomechanics and whether they went through conservative care. And that's conservative care like just in general. So imagine if you do a really great job and really fine tune it for a patient. I got a feeling you're gonna beat surgery all day, every day. So this is about, this is why patient education matters so much. Because there's such an abundant amount of misinformation out there, surgery's gonna fix the problem. It's a big disc herniation. That means I need surgery. No way. As a matter of fact, those are typically reasons to not have surgery unless there's red flags. So this study was ridiculously huge. They used 101 million patient records within this TriNetX US research network. Now, that doesn't mean that all of those were included in the study, but that was the pool to start pulling from and in January 2022. So I guess just about a year ago, there were 10 healthcare organizations within the TRI NetX network that had providers administering chiropractic spinal manipulative therapy, as they call it here. And although this study examined only a fraction of U.S. chiropractic providers, integration of chiropractors into hospitals they identify as a growing trend, with 5% of US chiropractors reporting a hospital affiliation in 2019. I think back, and if you heard me talk on podcasts when I joined an orthopedic group, oh gosh, the first one I joined was maybe 15, 16 years ago. I estimate that I was probably one of 20 to 25 chiropractors working in an actual orthopedic integrative setting. Now it's up to 5% of US chiropractors. So that is, that's probably, I don't know, a lot, hundreds, if not a thousand. So that is, that's a big deal and that's a big evolution of the profession. Not everybody needs to go that way. It's not for everybody. There are benefits and detriments, but it's great to have additional opportunities. Integrated chiropractors are most often employed within physical medicine, rehab or physical therapy settings. And on average, this is the bad news for the young docs here, on average have 21 years experience in practice. So not every job has that as a necessity. And clearly when I joined with the PE group, I was probably only five years into practice. But that landscape is competitive, you need to be aware of it. So when they looked at these patients in this study, the age bracket was 18 to 49 years old. And we know lumbar disc herniation of course is common, most common in patients, you know, 30 ish to 50 ish years, as they say. They ultimately ended up identifying, you know, 5,785 patients in the spinal manipulative therapy cohort and about a half million in the other cohort. So these are what their comparing to. And they kind of whittled them down to make sure they were evenly distributed. So what did they find? They found a few key things. Disectomy was less frequent in the chiropractic cohort throughout one and two year follow up windows before and after matching these patients. So after matching 1.5% of patients who received chiropractic and 2.2% of people, patients who received other stuff Underwent dissectomy at one year follow up at two years, 1.9% of chiropractic patients, 2.4% of patients who received other care had dissectomy. So that's a big, big deal. Let's talk about that. That's almost, you know, it almost cuts your odds in half. I mean especially at the two year marker it just about is. So that's a big deal. I mean, let's even play it conservatively and say 50% because maybe I'm exaggerating a little bit there. It's not a double in terms of the numbers, but you have 50% red. That is a big deal. I mean a 20% reduction is a big deal. But when you think about the fact of being able to, if you're exposed to chiropractic, you're going to decrease odds of opioids by 50%, as we've seen in the literature. Decrease odds of surgical intervention 25%, 50%. And those things are always still options for you later if absolutely necessary. This is just what blows my mind. I take a step back and look at the puzzle pieces on the table here and I'm like, surgery permanently changes things. Opioids should nearly never be prescribed except in extreme situations. Why aren't they the last things on the totem pole? And in my opinion, there's a lot of lip service to the fact of again, surgeons saying, oh well, we checked the box of conservative care. That's literally what they're doing most of the time. Is checking the box of conservative care the most minimum amount of conservative care necessary for them to get paid for the surgery? Let's be very clear about that. That is the way it normally goes. Of course, there are rare exceptions to that. So why isn't chiropractic it's guideline concordant. It's recommended everywhere. You can always have the surgery if it doesn't work and you didn't burn bridges with surgery, you burn bridges physiologically and biomechanically and don't have all of the side effects and ramifications of medication. So why would those things ever be done in a single case that's not a dramatic red flag before a chiropractic evaluation? I don't know the answer to that, but I know that that's something that we talk about all the time and of course something that we're working on to change as much as we can to help people just live better lives. That's what this ultimately comes down to. So there is a prior study which examined about two and a half million patients, adults in the US with low back pain or extremity pain and no red flag diagnosis, and found that about 1.2% of patients underwent surgery over a one year follow up. And smaller studies have reported a frequency of disectomy of 5% or greater. So there's some latitude there. Like how often are these surgeries being done? I can tell you, I look at every graph of the aggregate number of surgeries being performed, elective spine surgeries, that is every year. And it's just like, you know, it's like the business you want to be in because the line just goes up, right? You know, just like more and more and more and more even as things become more stringent. So I look at the health of the population, I say is, are people living better lives? Again, if you ask 8 out of 10 people, if you ask 8 out of 10 people,. If you ask 10 people, are you happy you had surgery? After having a surgery, I'd be hard pressed to believe that eight are gonna say, yeah, I'm so happy I did it, eight. And quite frankly, look at chiropractic, I get a feeling it's more likely than not that eight are going to say, I'm so glad I went there, I wasn't going to go there. I didn't believe in chiropractic. Then they experience it, they experience the benefits and they're happy they did. On the surgery side, it's literally the complete opposite, which is why you look at studies like this and I'm glad they're producing them. But how this is applied in practice is so different than what the research is showing. And the knowledge base of the consumer is so wildly different. That's the challenge and opportunity for us. And that's the good and the bad news. The good part about that is you have the opportunity to really make an impact and set the table in your community. And that is something that we shouldn't take for granted. It's something that we should lean into and quadruple down on. Which is quite frankly why we produce the tools we do at the evidence based chiropractor and the smart chiropractors to help you do exactly that. So the conclusion of this study said these findings suggest that patients receiving chiropractic spinal manipulative therapy for newly diagnosed lumbar disc herniation and or radiculopathy without serious pathology, spinal deformity or absolute indications for surgery have significantly important word reduced odds of discectomy through two year follow up after index diagnosis compared with those receiving other care. That is the take home message. I think that's an important take home message. It's as important as any take home message we can have, which is when people are exposed to chiropractic care, it ultimately diverts their care in a positive way. They undergo less advanced intervention, they receive better, you know, same or better results in the short term and the long term. And it's how the body actually works. I've said it before, I'll say it again. Movement based care is how the body works. You have to have as optimal as you can and optimal is different for everybody. Segmental, regional, whole body motion, that's how you're gonna function and feel at the highest level. And it's not about cutting things out, it's about working what you got until or if you Hit a red flag state which is such a slender is the beautiful part of it. It's a slender amount of people that undergo these challenges. That doesn't mean it's gonna be not be frustrating if you're in abject pain. It doesn't mean it's not gonna be frustrating if the progress is slow. But again that speaks to the communication you have with your patients is critical for them to understand the process, the progress in how things can go and the benefit detriment of care and treatment. So hopefully there was some take home messages for you there. We'll drop that link down below. Before we wrap up, I wanna say a couple words about World Spinecare as well as Power Step. If you have not picked up a free sample pair of Power Step orthotics, what are you doing? I'll drop the link down below. They're willing to hook you up. They support this podcast. I'm gonna ask you to support them. Pro.powerstep.com sample pro.powerstep.com sample use the code EBC evidence based chiropractor. They will hook you up with a free sample pair of orthotics. Check it out, see what they have going on. World Spine Care the question is, do you want to see a world where everyone has access to evidence based chiropractic? There's over a billion people worldwide that experience low back and neck pain and most of them don't have access to quality spine care that we take for granted and see and do every day. But you can be part of that solution through World Spine care. With over 50 chiropractors volunteering in international clinics, World Spine Care has the expertise to help reduce this leading cause of disability worldwide. You can be part of the solution and make a tax deductible charitable donation today@worldspinecare.org EBCPodcast WorldSpineCare.org EBCPodcast this is the season of giving. If you wanna hop over there. This is an organization that does incredible work day in and day out in underserved populations around the world. I practically can't think of any anything more important in speaking with their team over there. And Nathan, it's incredible the work that they do on the budget they have. So if you can head over and literally $5, $10 more is great, but everything counts. WorldSpineCare.org EBCPodcast Give to those organizations doing awesome work out there and part of the awesome work is not only what World Spine Care does, but what you do in practice each and every day. Thank you for being a chiropractor. Thank you for tuning into this podcast as we head into the New Year. If you have not left us rating or review that awesome, that helps us reach more and more docs. Have an awesome week in practice and I will talk to you soon.

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