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November 16, 2004

BehindTheMedspeak: Back pain - and the dirty little secret doctors would rather you not know


The latest "breakthrough" in the treatment of back pain has just been unveiled: it's the Charité (memo to Johnson & Johnson: lose the accent mark - such fancy-pants product names don't go over real well with the American public) artificial spinal disc.

This implant is the first such product to be approved in the U.S.

Said Scott Hensley in the November 2 Wall Street Journal, "The ability to replace disks could open up a new era in back treatment."

Translation: it could mean your orthopedic surgeon or neurosurgeon can finally afford that Maybach he's been eying.

Continued Hensley, "With the approval of the Charité disk last week... many chronic back-pain sufferers who have been holding off on surgery are reconsidering."

Big mistake.

Because here's that dirty little secret I alluded to in the headline of this post: back pain has nothing to do with what shows up on x-rays, CT scans, or MRI's.

In other words: many people with terrible back pain have completely normal radiographic studies; many people with terrible studies have no back pain.

The New England Journal of Medicine published a landmark study years ago demonstrating the lack of correlation between pain and disk degeneration, along with an editorial pointing out the uselessness of surgery in most patients with chronic back pain.

Nevertheless, surgeons continue to run patients in and out of the OR for this tremendously complex and potentially dangerous surgery.

All you get for sure when you have back surgery is the likelihood of a repeat operation.

And then another, and another.

Here's the article.


Artificial Spinal Disc May Open New Era In Treating Back Pain

But Worries Linger Regarding Implants' Long-Term Durability

There is a new solution for debilitating lower-back pain: replacing a spinal disc, just as worn-out hips and knees are swapped out for new ones.

Last week, the Food and Drug Administration approved the first artificial disc, an implant that surgeons can put in place of the spongy cushions between the bones of the lower spine, relieving pain and preserving flexibility.

The ability to replace discs could open up a new era in back treatment. When natural discs degenerate, they can cause excruciating pain in the back and legs.

The traditional treatment for recalcitrant back pain from degenerated discs is surgery that removes the damaged pad and fusion of the bones on either side of it.

That approach limits normal motion and flexibility, often transferring stress to other parts of the back, which can act up in later years.

With the U.S. approval of the Charité disc from Johnson & Johnson last week, after decades in development, many chronic back-pain sufferers who have been holding off on surgery are reconsidering.

Three more discs, with slightly different designs, are expected to become available in the next few years.

"It seems like it's time to have something done," says Mark Hall, a 38-year-old finance manager for Sprint in Kansas City.

Despite therapy and drugs, including frequent shots of cortisone into his spine, Mr. Hall says his back pain is so intense that it has kept him from sleeping and enjoying life.

A magnetic resonance imaging scan last year showed that a disc in the lumbar part of the spine appears to be the culprit.

After hearing about the Charité disc, Mr. Hall has been looking for a doctor qualified to take his case.

Many questions remain about the device, including concern about how long the implants will last.

"Just because you have back pain doesn't mean you should have disc replacement," says Geoffrey Blatt, a neurosurgeon with Midwest Neurosurgery Associates in Kansas City.

Disc disease, while painful, isn't fatal, he says, while disc replacement "is clearly dangerous surgery."

Nerve damage, infection and inadequate pain relief are possible.

For those who are considering whether to be the first on their block to get a new disc, there are some difficult questions to ponder.

First of all, the long-term durability of the Charité disc remains to be proven.

The same pressure that led the natural disc to fail could wear on the plastic in the replacement, though laboratory tests and the experience of patients in Europe who have had it implanted since the 1980s are reassuring to many doctors.

Also, the implantation is tricky and should be performed only by the "top echelon of spine surgeons," says Fred Geisler, a neurosurgeon at the Illinois Neuro-Spine Center, Rush-Copley Medical Center, Aurora, Illinois.

Dr. Geisler has implanted about 100 of the discs in a complex procedure that involves making an incision near the belly button and then moving the organs, blood vessels and nerves aside to reach the damaged disk.

He says it takes 20 to 30 cases for doctors to become comfortable with the procedure, which is far more difficult than a fusion.

"If you put this in crooked, it's like putting a knee in crooked," he says.

Just a few dozen surgeons in the U.S. are qualified to implant the Charité disc, though Johnson & Johnson has plans to train about 2,500 surgeons during the next year.

Many back specialists should be able to offer more information about the procedure.

At the moment, insurance coverage may be tough to come by, too.

The surgical procedure and the implant cost between $35,000 and $45,000.

Suzanne Roy, a project manager at Allmerica Financial in Worcester, Massachusetts, had the disc implanted during an extension of the clinical trial only after her human-resources department took up the battle for her.

The recuperation time from the disc implant is about half as long as that from spinal fusion, doctors say.

Many patients aren't candidates for the replacement.

Osteoporosis can weaken the spine, making a tight fit of the implant impossible.

Patients whose spinal joints are severely damaged also may be ineligible.

Also, the implant works only for people whose pain is caused by a single degenerated disc.

Besides MRI and CT scans, doctors poke the suspicious disc with a needle to see if it hurts.

Another poke with the needle in a good disc serves to make sure the pain isn't psychological.

For those who do qualify, the promise of lasting pain relief and the restoration of normal function is obvious.

About seven years ago, Kyle Spooner, a computer specialist in Weatherford, Texas, hurt his back lifting a concrete fountain. He tried physical therapy, acupuncture and massage treatments without finding relief.

"I was on a pretty steady diet of muscle relaxers and pain pills," says Mr. Spooner, 35 years old.

After three years of chronic pain in his back and legs transformed him from an active golfer and outdoorsman to an antisocial shut-in, he concluded reluctantly he would need spinal fusion.

Mr. Spooner received the disc in a clinical test in early 2000.

The surgery was painful, he recalls, but the constant ache he had felt in his legs was gone.

He was on his feet later that day and back to work in three weeks.

"Within a month and a half, I was swinging a sand wedge," he says.

Other doctors are optimistic about the treatment's potential.

"Everything we've been able to do up to now is get the pressure off the nerve or reduce inflammation by injections or oral medications," says Gerard Varlotta, director of Sports Rehabilitation at New York University Medical Center's Rusk Institute of Rehabilitation Medicine/Hospital for Joint Disease.

"We now have the means for changing the natural history of the diseases."

November 16, 2004 at 05:01 PM | Permalink


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very good site! Can I introduce Bristol website: backachetherapy.co.uk.Chinese backcare therapist website to give you a wealth of information about back pain as well as educate you about Chinese backcare therapy. Chinese exarmy doctor,(TCM doctor)specialises in lower back pain relief (eg.sciatica),adopting acupressure massage therapy and acupuncture,he worked in China army hospital over 20 years as medical practitioner.ring:07967525168.

Posted by: zhentong han | Mar 17, 2006 3:43:43 PM

Thank you Joe for re-confirming what my late, OB/GYN Father told me years ago: Never have back surgery if you can avoid it at almost all costs. It just messes the back up more. So, I live with the foibles that are me and work to deal with various aches and pains with other means, such as exercise and massage. What are they thinking!!!!!!!!!!

I'd also love to own a Maybach - or at least drive or be driven once in it. Exquisite over-consumption. - Matt

Posted by: Mattp9 | Nov 16, 2004 7:08:37 PM

Well, then, what *does* the good doctor recommend for back pain?

Posted by: Phillip Winn | Nov 16, 2004 5:50:50 PM

My neurologist had a unique perspective on spine surgery because he had it done to himself on three different occasions. He told me i absolutely did not need it. i shudder to think people are being advised to have back surgery by doctors who have no firsthand experience with the kind of recovery it might involve.

so thats my advice - go to a spine specialist who has actually undergone the operation himself.

Posted by: hornsofthedevil | Nov 16, 2004 5:27:01 PM

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