publish surgical guidelines for back surgeries. The state of Washington publishes
a Surgical Guideline for Lumbar Fusion (Arthrodesis), which addresses the
medical necessity and clinical appropriateness of lumbar fusions, in addition to
serving as an instructional aid for physicians when treating injured workers who
present with low back pain (LBP) and associated symptoms.
Dr. Hanscom was instrumental in
working with a Washington state health
plan to implement a policy that would
only allow a lumbar fusion for a structural problem, regardless of the amount and
effectiveness of non-operative care.
The surgical guideline also clearly
states that only single-level fusions will be
approved for patients with no prior lumbar surgery. Regardless of the length and
type of conservative care, it is Dr. Hansom’s position that surgery for LBP is not
an option. The common reason given for
performing a fusion for LBP is degenerative disc disease. It has been clearly demonstrated in several papers that discs degenerate with age and have no correlation
4, 5 Degenerative disc disease is
not a structural problem.
In 2011, the Michigan Hospital Association released a patient safety alert on spine
6 The alert addressed the
key issues driving the adverse events and
provided a number of recommendations
to improve the delivery of care such as appropriate pre-operative images, site marking, and the use of pauses.
Solving Back Pain
Chronic pain is almost always a solvable
problem regardless of where it is located
in the body. It is one of the core symptoms of the MBS. There are over 30 different manifestations of the MBS, including
insomnia, eating disorders, anxiety, irritable bowel syndrome, spastic bladder,
fibromyalgia, and migraine headaches.
To implement an effective treatment plan
first requires the correct diagnosis.
LBP is almost always a soft tissue pain
arising from the tissues that support the
spinal column. However, whether pain
originates from the soft tissues, a struc-
tural problem, or is generated from the
nervous system, there are always pain
impulses processed by the brain that cre-
ate neurological pathways. The result is
similar to an athlete or musician learning
a new skill so that the circuits are memo-
rized with repetition. The problem with
pain is that the speed of the signals is
similar to a machine gun with very rapid
input. Once a pain pathway is laid down,
it is permanent. There will be pain every
time these pathways are triggered.
The solution is centered on calming
down the nervous system and re-rout-ing new pathways around the dysfunctional ones. There are three aspects of
the Defined Organized Comprehensive
• Education — it is critical to understand
that there are not only different sources
of pain, there are many variables that
affect the perception of pain.
• All aspects of pain must be addressed
at the same time. The DOCC protocol
° Goal Setting
° Physical conditioning
• The final aspect is that every patient
who has gone to pain free has taken
charge of his or her own care. People’s
lives are far too complex to be “fixed”
by the medical profession. The patient/
injured worker is the one who has to
view the medical world as a resource.
Medical malpractice insurers, workers
compensation insurers and organizations
self-insuring their workers compensation
risk can drive better outcomes. For medical professional liability insurers, educating their physician customers through
on-line courses, newsletters, podcasts
and patient safety alerts can make a big
difference in promoting effective strategies and sharing real life lessons learned.
In an ideal world, one could envision better back related protocols in office practice electronic health records, along with
the use of surgical checklists and time
outs to help avoid wrong level surgery in
the hospital setting.
For workers compensation insur-
ers and self-insureds, it is important for
claims adjusters, nurse case managers
and company risk managers to under-
stand when surgery is and is not appro-
priate. By recognizing the differences
between structural and non-structural
pain, appreciating the role sleep plays
in successfully treating back issues, un-
derstanding the importance of calming
down the nervous system, and being
knowledgeable about programs, it be-
comes easier to interact effectively with
the injured worker’s physician.
David Hanscom works for Swedish Neuroscience
Specialists in Seattle, Wash. He is a board-certified
orthopedic surgeon specializing in complex spine
problems in all areas of the spine. He has expertise
in adult and pediatric spinal deformities such as
scoliosis and kyphosis. A significant part of his
practice is devoted to performing surgery on patients
who have had multiple prior spine surgeries.
Robert Hanscom is the director of claim analytics
and reporting at Coverys in Boston, Mass., focused
on developing advanced analytical capabilities and
the enterprise-wide clinical coding unit to support
the quality, integrity and analysis of all claims and
risk management data.
Kevin M. Bingham is a principal at Deloitte
Consulting LLP in Hartford, Conn., and leader of
Deloitte’s Claim Predictive Modeling and Medical
Professional Liability practices, immediate past
chairperson of the American Academy of Actuary’s
Medical Professional Liability Committee, and an
official Academy spokesperson.
1 Carragee, E., et al. “A Gold Standard
Evaluation of the ‘Discogenic Pain’ Diagnosis
as Determined by Provocative Discography.”
Spine (2006); 31: 2115-2123.
4 Boden SD, Davis DO, Dina TS, Patronas NJ,
Wiesel SW. Abnormal magnetic-resonance
scans of the lumbar spine in asymptomatic
subjects. A prospective investigation. J Bone
Joint Surg 1990;72:403– 8.
5 Jensen MC, Brant-Zawadzki MN, Obuchowski
N, Modic MT, Malkasian D, Ross JS. Magnetic
resonance imaging of the lumbar spine in
people without back pain, N Engl J Med. 1994
Dec 1; 331(22):1525.