Why can’t my severe and disabling low back pain be cured?

Why our for-profit American health care system might be the reason!

This is the burning and painful question asked by tens of thousands of individuals each day in America and around the world.  Given that we live in a world of medical and surgical technological wizardry, why should so many people with severe chronic low back pain (LBP) go either undiagnosed or uncured?  It’s true that there are several rare or at least very uncommon conditions that can cause this type of pain and are difficult to diagnose, but there is one cause that is very common and is being totally ignored by those that could make a difference.  This condition is the cause of the symptoms in up to one fifth of all individuals with low back pain.  What makes this problem a little bit scary is the fact that it’s not being taught to most of those who could cure this type of pain.  They are not even taught how to diagnose it!

This primary pain generator causing all this low back pain is the sacroiliac joint, which continues to hide out in the shadows of our esteemed teaching institutions even though prestigious journals have published successful studies on surgical cures for this type of chronic pain starting almost a century ago and continuing right up to today. The main problem for individuals facing life with continuing chronic and severe disabling pain from the sacroiliac joint is not that no one in the medical field knows about it, but that surgeons don’t, and are not being taught that many times they could be the ones to cure them.  Each day in America thousands of patients with this type of severe chronic pain are manipulated, injected and drugged to temporarily remove their sacroiliac joint pain only for it to come back after short intervals.  The pain doctors and chiropractors can hold on to these people indefinitely as they are not constrained by the insurance system.  I call this the never ending “revolving door” of temporary pain relief for these tens of thousands of individuals.  Even though they might have a diagnosis, they aren’t being offered an opportunity to get their pain cured.

Is a cure possible for those with this pain who have not been cured by all the various forms of conservative treatments to include injections?  The answer is yes, but it usually takes surgery to make the ultimate difference and get such patients out of chronic pain.  Our surgical literature is replete with surgical techniques and patient studies to show that this is true.  The burning question then is why isn’t every patient with this type of pain, who despite all reasonable and accepted conservative treatments has not been cured, referred to a surgeon for consultation?  The short answer is because of America’s capitalistic for-profit health care system.

Entrepreneurial surgeons and industry have become so financially enmeshed in device manufacturing for low back pain that literally billions of dollars flow into their hands as long as two major factors remain stable.  The first is that the multibillion-dollar spinal surgery instrumentation industry is not diminished in any way, and the second is that the average low back pain patient is kept ignorant about the major causes for their pain and the treatments available for each.  In this current scenario the industrial giants and those invested surgeons supporting them can dictate what is causing low back pain, who should be operated on, and how such operations should be done.  They accomplish this through the large national and international educational societies for spine surgeons (e.g. NASS, AAOS, CNS and so on) by infusing millions of dollars into these organizations in an abundance of ways. This money is used for education, marketing and, most important, political influencing all to enhance industries control over the extremely profitable spinal surgery market in America. The other contributing effect is that the entrepreneurial surgeons supporting this cause are both large components in the political structure of these teaching organizations and they do the bulk of surgeon education.

What exactly is happening as a result of all this that is not good for the tens of thousands of “revolving door” sacroiliac joint pain patients and those who live with severe low back pain without an accurate diagnosis?  There are many factors that must be considered in order to answer that question.

First and foremost is the fact that industry would take a major financial hit if it were to start including the sacroiliac joint as one of the routine causes of severe low back pain.  Since the entire spine industry for low back pain is built on the massive billion-dollar infrastructure of manufacturing implants for the spine, including the sacroiliac joint would require an enormous financial investment.  This investment would have to include learning why the sacroiliac joint generates pain, what methods can be used to best surgically treat it, and the creation of the devices that would work best in the long run to benefit patients. Then they would have to spend millions on getting FDA approval for these devices, as the best ones out there do not have a predicate to fall back on from pre-FDA days.  This would involve patient studies proving that their devices actually work and don’t cause harm to patients.  Industry abhors being monitored.  That costs money one way or another.  To add insult to injury for industry, sacroiliac joint surgery just doesn’t pay as well as spinal surgery.

Then there is the process of getting orthopedic and neurosurgeons educated and trained to diagnose a painful sacroiliac joint, learn all the formidable anatomy that surrounds this joint, be able to conservatively treat such a patient to avoid surgery, select an appropriate surgical patient for SIJ surgery, how to perform the surgery, and how to rehabilitate and follow such a patient appropriately.  Industry would of course have to enlist organizations like NASS and all the others to assist them in this education effort.  Even though these powerful teaching societies are mere vassals for industry, it will still cost industry millions to influence them. It is only after all of this that the average patient with new low back pain has a chance of being routinely checked for sacroiliac joint pain during a routine low back pain examination.

This is why medical schools don’t teach about surgery for sacroiliac joint pain, it is not taught in surgical residency programs and spinal fellowships, there are no board questions on orthopedic surgery or neurosurgical board examinations, and there are no instructional course lectures on this subject in the annual surgical society’s educational meetings.  This is why the average person having new low back pain will not be checked for a potentially painful sacroiliac joint during their routine exam by their surgeon.  The end result for the patient is frequently endless therapy and injections, a currently large number of failed lumbosacral spinal fusions, and a plethora of people suffering from undiagnosed low back pain. Also this lack of diagnosis and definitive treatment add to the overall opioid crisis in America.

Unless there is a major paradigm change for how chronic severe and disabling low back pain in America’s for-profit health care system is handled, we as a scientific health care surgical community will continue to be “stuck in the mud”, and tens of thousands of with sacroiliac joint pain will continue to suffer!

I have struggled with the for-profit system in America as an advocate for those with chronic sacroiliac joint pain to little or no avail.  My approach now is more “grass-roots” in the form of a book entitled “Sacroiliac Joint Pain: For Tens of Thousands the Pain Stops Here”.  This is written for the lay person with the hope that as each individual with sacroiliac joint pain becomes educated as to how low back pain is diagnosed and treated in America, slowly they will learn to ask the right questions of the establishment and get from them the diagnosis and the pain relief they deserve.

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