Canada's Costly Spine Surgeon Backlog

A May 13, 2011 Globe and Mail article written by Lisa Priest emphasized the waste and mismanagement in our health care system in regards to back pain.  Back pain is very common, with 80 % of the population suffering from a severe episode in their life.  Upwards of 85% of this back pain is diagnosed as mechanical or non specific back pain.  The small minority have more severe neurological or bony involvement, yet high tech tests such as MRI or CT are ordered by doctors, and with a 60% false positive rate, often find abnormalities that have nothing to do with the symptoms, but lead to a referral to a spine surgeon.

The unnecessary tests are leading to massive health care costs - $24 million a year in Ontario alone.  The avalanche of referrals has caused 60 of the 120 spine surgeons in Canada to close their practices to new patients at some point.  In an unscreened practice, upwards of 90% of the patients that attend a spine surgeon are not surgical candidates, creating a logjam for patients who truly need the referral and surgery. 

 Dr. Daryl Fourney of Saskatoon states that “the overwhelming majority of people with spine problems can be treated with physical treatments, whether it be exercises or spinal manipulation or medications”.  Dr. Fourney pioneered a program in Saskatchewan to train family physicians to discern which patients need to see a spinal surgeon.  There is an incentive built in, with access to diagnostic imaging and expedited surgical referrals for their patients.  The province has started to see a reduction in referrals to spine surgeons.

Hence the prescription to reverse the gridlock is a triage system, made up of primary care physicians, physiotherapists and chiropractors, to help differentiate patients who potentially need surgery.   Patients who then do not require a referral to a spine surgeon would be sent to other health care providers for treatment, and tracked to see if the treatments are working.  The Ontario government estimates this would require $3 million a year, but save the health system upwards of $20 million or more in unnecessary testing and referrals. 

Atlas Realignment and Blood Pressure Reduction

A 2007 pilot study in the Journal of Human Hypertension showed a sustained blood pressure lowering effect with a procedure designed to correct atlas vertebrae misalignment similar to that seen by giving two different antihypertensive drugs at the same time.  The study design was randomized, double blind, with a placebo control and had 50 participants.

The practitioners in the study were from the National Upper Cervical Chiropractic Association (NUCCA) who limit their practice to precise, delicate manual alignment of the C1 or atlas vertebrae.  Unlike other vertebrae which interlock, the atlas relies on soft tissue to maintain alignment, and therefore is vulnerable to displacement.  Minor misalignment of the atlas vertebrae can potentially compromise the brainstem neural pathways and vertebral arteries.  

The study was 8 weeks in duration, with a blood pressure baseline originally taken and weekly thereafter along with atlas measures pre and post adjustment.  Outcomes in changes from the treatment showed a reduction of systolic blood pressure (-17 +/- 9 mm Hg NUCCA vs -3+/- 11 mm Hg control) and diastolic blood pressure (-10+/- 11 mm Hg NUCCA vs -2+/- 7 mm Hg control).  Most antihypertensive drugs yield an 8 mm Hg drop in blood pressure.  What is most impressive is that the reduction in blood pressure persisted at 8 weeks and was not associated with pain or pain relief or any other symptoms that could be associated with a rise in blood pressure.  

Citation: Journal of Human Hypertension (2007),1-6