On the ACN Group Website they have several different pages explaining what they do. Here are a few with my comments

1. Back pain, sprains, and other related conditions continue to contribute to the increasing costs in today’s health care system. At ACN Group, we specialize in providing low-back, soft-tissue, and joint rehabilitation solutions. We aim to manage costs and help each patient find the right combination of medical treatment, self-care, and preventative education he or she needs to stay healthy.

(In my case they have done none of the above. They have denied me care since December of 2007. My Chiropractor Dr Keller has talked with Joseph Carpino extensively about my condition. Carpino and his associate have done nothing to help in my case. They have asked for extra paper work from me of which I have done but still deny me treatments that I have paid for through the insurance company. They have not offered any advice in the way of help except to say there must be something else when it has been proven time and again not only by my chiropractor but also by my medical doctor, the neuro surgeons and back pain specialist I have seen in the last 3 years that chiropractic does help me with my pain, to be able to take care of myself, and to be able to walk. That surgery will not help in my case.

2. Complementary Medicine ACN Group has been providing complementary care services since 1997. Currently, our complementary care networks include practitioners specializing in acupuncture, massage therapy, dietary counseling, and naturopathic medicine. We continue to grow this area of our business with plans to add other specialties in the future. Dedicated to Providing Complementary Medicine As consumer interest in complementary medicine grows, we recognize that consumers need guidance in choosing the right provider. Our network of complementary medicine practitioners are credentialed and meet screening requirements designed to help ensure that consumers get quality care. Along with our high-quality network, we offer choice in treatment therapies and simplify the selection process – making it easy for consumers to choose the health care option that best fits their needs.

(If this is so then why is it that Joseph Carpino cannot suggest an alternative to help me, but instead just denies the chiropractic treatments that has been proven over and over again to benefit my condition. Instead he seems to accept the fact that my body is being destroyed by the opiates and the neuropathy medicine I take now because of the neurological pain I have by the pinched nerves caused from the Degenerative Disc Disease, Scoliosis, Spinal Stenosis, and has come to Incontinence of body functions.

3. Disease Management Chronic low-back and soft-tissue conditions are a common problem – in fact, more than 80% of people will experience some form of low-back pain in their lifetimes. ACN Group’s disease management program is designed to provide patients with relevant data and information to help them recover from low-back, joint, and soft-tissue conditions. Disease Management Process Our disease management process is based on providing evidence-based information to patients and health care professionals. Through our proprietary database system and processes, we use data to identify at-risk members, gauge treatment effectiveness, gain insight about specific conditions, and more. With this valuable information in hand, health care professionals, patients, and our staff can work together to create successful treatment plans. Managing Care, Improving Quality of Life Our disease management program includes information management, education for health care professionals, and a focus on self-care programs for patients. This combination reduces health care visits, improves the quality of life for patients, and ultimately reduces costs for our customers.

(If the ACN provides evidence based information to the patients why is it they will not talk with the patient? They also do not send any information as far as help for my condition. They only started sending me denial letters again starting March 08 after the last one in Dec 07 exactly 4 months between time. They have now denied me treatments through September 08. In 2007 I was denied treatments from June though out the rest of the year and had to pay out of pocket. I just called the ACN and talked with Cathy (Kathy). She informed me that the help they offer is through my chiropractor and not directly to me. This is different from what the ACN has on their web site. They lead one to believe that they will help the patient and give them information pertaining to this fact. I asked Cathy information on what they consider maintenance care she told me it was what I have since I have been seeing a chiropractor since 2005 for the same thing. Also she said I would need to send an appeal to United Healthcare with the documentation from my doctor that chiropractic is supportive care of which I have done with a letter sent by Dr. Schumacher in 2005 and again in 2008. My Neuro Surgeon will not operate on me because of the server curvature and the many degenerative discs that are gone that I have as he said it would not be helpful in my case. In conclusion: I feel that the ACN Group does not completely look at the papers sent to them or take into consideration each individual case but in stead try very hard to see where they may be able to refuse help to the patient. The ACN web site is only able to approve or deny treatments according to Cathy and are not able to take appeals or talk with the patient according to United Healthcare rules to the ACN.

With the ACN Group in MN having made 4 mil in 2007

http://www.hoovers.com/acn-group/–ID__104230–/free-co-factsheet.xhtml 

Key ACN Group Finacials

Company Type        Subsidiary of UnitedHealth Group

Fiscal Year-End       December

2007 Sales (mil.)      $4.0 (est)

2007 Employees        57

I would think that the ACN would be able to give patient care a bit more consideration especially when it has been proven time and again that the care is in the best interest of the patient.

September 2, 2005 Vallencia Lloyd
Director of Managed Care Certification and Surveillance
New York State Dept. of Health
Corning Tower, Rm 1911
Empire State Plaza
Albany, NY 12257 RE: Oxford Health Plans/ACN Group ConsolidationDear Ms. Lloyd: This letter is written on behalf of the American Chiropractic Association (”ACA”) and its 1,154 members practicing and residing in the State of New York. We understand that the department is currently reviewing a proposed arrangement between Oxford Health Plans and the ACN Group. This arrangement would, as we understand it, permit ACN Group to manage Oxford’s chiropractic benefit. We would like to take this opportunity to provide information we believe has an important bearing upon New York residents and the delivery of quality chiropractic services. Specifically, the ACA has received an increasing number of complaints from our doctor members across the country and, in particular, from New York pertaining to the practices and policies of the ACN Group. In that connection, the ACA has requested New York Chiropractic College (NYCC), the only accredited chiropractic educational institution operating in New York, to review and analyze the criteria utilized by the ACN Group. The full analysis is enclosed with this letter. Please note one conclusion of the NYCC analysis states: “If NYCC were to use ACN material above as a cornerstone for our educational process, we would need to significantly alter our curriculum, protocols and practices and would expect to see a significant decline in positive patient outcomes.” (emphasis added). In addition, our review of the data has revealed a disturbing pattern of various methods of withholding benefits that have been purchased by the patient and/or employer but, in fact, are restricted under the guise of medical necessity. Insurers have long been charged with the duty to review claims for medical necessity. Organizations such as NCQA, and URAC exist to accredit managed care organizations to certify that, among other quality measures, no abusive restrictions of benefit payments or care authorizations that would jeopardize patient care can occur. The recent growth of Pay-for-Performance Programs has stirred concern at the ACA due to the potential of abuse of the link between performance and cost-control. These types of Programs have recently been evaluated by the American Medical Association, who determined there was a need for formal Principles and Guidelines to ensure fair access to quality patient care, and to serve as a standard for ethical operations of these Programs. These Principles include: ensuring quality of care, fostering the patient/physician relationship, offering voluntary physician participation, use of accurate data and fair reporting, and providing fair and equitable program incentives. The data collected by the ACA show that some managed care networks, including in our view the ACN Group, that have oversight over chiropractic care are in violation of these AMA Principles. Authorization for care is denied for arbitrary reasons without review of the patient’s medical record, including: patient is not improving quickly enough so care is deemed ineffective, or the patient is improving, therefore care is no longer deemed necessary. Although networks such as the ACN Group show an extensive amount of research, statistics, and algorithms to ensure that there is a consistent process behind authorizations, actual claims evidence shows a huge disparity between company written policy and actual utilization management decisions. The research cited in denials represents a narrow view of very selective research that [is] not clinically supported by the profession and does not represent the wide body of research currently available. As a result, the ACA is very concerned that some of these denials of care are not clinically sound and may jeopardize the health and well-being of patients. Chiropractic care has often proven to be the only effective treatment for patients with chronic problems that need supportive care. There is a disturbing trend with chiropractic networks to routinely deny supportive care based on the simple fact that the patient has been treated in the past for the same diagnosis. The ACN Group, for example, has an algorithm for supportive care, but routinely denies this to patients often only authorizing 4 or 5 visits when the patient may have a benefit on their policy for 20 visits. The effects of such restriction of care are many. First, the patient is misled to think that the benefit stated in their Summary Plan Description is available for use at the discretion of their physician and the patient’s own determination that they need to see the doctor. Second, the fact that a benefit is represented to a patient or employer who then expects access to the value it is stated to provide in terms of care - this becomes deceptive and, in our view, represents and illusory benefit. The goal of chiropractic is efficient care - the best possible clinical outcomes in the most cost-effective manner. When care is restricted and results in poor outcomes, efficient care is not achieved. We simply have restricted care. As non-compliance with the plan of care in other clinical professions results in poor outcomes, restriction of care by the insurer/network has the same result except in this case, the patient does not have a choice. Also enclosed is specific information which includes the following: 1. ACN - Summary of Issues: This outline summarizes the many complaints ACA has received pertaining to the ACN Group activity. 2. Managed Care Networks - New York Complaints: This outline identifies specific complaints from New York doctors on a variety of managed care organizations including the ACN Group. 3. Analysis ACN Group Summary Data: Prepared by Jeffrey F. Simonoff, Ph.D, professor at New York University. This is a detailed analysis of ACN Group statistical procedures. While highly technical nature, Dr. Simonoff has stated that: “the [ACN Group] summary statistics certainly suggest that such [cost and visit limiting controls] could be affecting practice by (in effect) truncating the number of visits from above.” We believe this analysis supports our contention that the services are artificially being reduced by ACN’s statistical maneuvering and therefore benefits are being denied that have otherwise been promoted, and paid for by employers to the detriment of the patient’s health and well being. He also stated in a follow up letter that, “If different patients have different treatment needs (based on their medical condition), and different doctors treat different mixes of those patients (that is, some doctors are more likely to treat more seriously affected patients, while others are more likely to treat milder cases), an overall mean and standard deviation provides a very poor summary of expected treatment requirements, and the variability from patient to patient of such requirements.” Finally, under N.Y. COMP. CODES R. & REGS., tit. 10, § 98-1.12 (2004), it appears that those organizations doing utilization review in New York should have a Quality Assurance Program in place to assess the program’s effectiveness. This is also a requirement of URAC which accredits ACN Group. Our concern is that, ACN Group states that it is not hearing of any complaints from doctors, yet the ACA has had hundreds of complaints submitted since March, 2005. We would be happy to meet with you to provide more detailed discussion of the above-referenced information and problems with the ACN Group. We would also be happy to appear and provide public testimony in connection with these concerns. We would specifically request that your department commence a formal inquiry into the effects of ACN Group policies and limitations on patient care before any final approval of further ACN Group management services. Please feel free to contact me with any additional questions and we thank you for your time in the consideration of this information. Sincerely,
Garrett F. Cuneo
ACA Executive Vice President

CC: Kathleen Shure,
Director of Managed Care
New York State Dept. of Health
Corning Tower, Rm 1483
Empire State Plaza
Albany, NY 12257

Are Your Patients Being Harmed by Chiropractic Managed Care Networks?Dynamic Chiropractic,  Sep 1, 2005  by Edwards, James

The American Chiropractic Association (ACA), as part of its ongoing aggressive campaign to correct the wrongful practices of certain chiropractic managed care networks, is asking doctors of chiropractic nationwide to provide additional information that will assist in putting an end to these practices. Among the wrongful practices that the ACA is gathering information about are the following:* Automatic downcoding or limiting physician discretion in the planning of care: The doctor submits the network’s forms after examining the patient and is advised of the frequency, duration and type of care that will be covered. Requested treatment is often reduced or denied. Claims are downcoded without the doctor of chiropractic being provided the opportunity to provide any documentation supporting the claim as submitted.* Bundling: The submitted CPT code is incorporated into another submitted CPT code.* Improper utilization review, including refusal to recognize coding modifiers: Managed care organizations sometimes refuse to recognize “modifiers” that chiropractors append to CPT codes to report a service or procedure that has been performed and which has been altered by some specific circumstance.* Performance management issues: Managed care networks often disregard the doctor’s discretion to diagnose and treat, and limit the number of visits, X-rays and modalities. Doctors say they are reprimanded and threatened with the loss of their contract when the care they prescribe is outside the managed care organization’s set standards.Over the past three years, hundreds of doctors of chiropractic have contacted ACA and completed “managed care data collection” forms, detailing their troubling experiences with chiropractic networks; the names of several specific organizations have emerged. According to the data collected by ACA, doctors of chiropractic are most troubled by the actions of American Chiropractic Network (ACN), American Specialty Health Plans (ASHP) and Landmark Healthcare. These carriers routinely deny requested treatment and improperly reduce and deny reimbursement, putting patients and quality of care at risk, according to doctors who contacted ACA. The following eight-point summary regarding ACN/United Health Care is not a final document or a legal analysis, but it does provide an excellent overview of some of the information that has been obtained to date.

1. Illusory Benefit: A benefit is advertised to the employer and employee/patient that is not available for use because ACN reviewers routinely will deny requested care based on “medical necessity.” Thus, the patient may have paid for a 20-visit benefit, but can not use it as they or the doctor feel is needed.

2. Evidence-Based Guidelines: ACN attempts to keep chiropractic care within restrictive boundaries supposedly justified by evidence-based guidelines. The information they reference consists of articles and studies that show how chiropractic was not effective for the type and duration of certain treatments. This literature is available upon request or can be found on the ACN Web site: www.acnprovider.com. ACN states that United Health Care does not provide coverage for rehabilitative care; they will only provide for symptom (pain) relief.

3. Coding Issues: Doctors complain about denials of adjustments and-therapies being done together. ACN routinely denies more than one therapy being done during a visit. Evidence received indicates codes that are billed are changed to different codes and paid at a lower rate. Changing the code changes the medical record of treatment provided and is very serious.

4. Treatment Decision-Making: ACN does not regard the provider’s medical judgment and requires that their own forms be completed so that ACN staff (who have never examined the patient) can determine the appropriate plan of care. These forms are a cursory description of the patient’s problem and are not a sound basis on which to judge medical necessity. The CPT definition for the exam encompasses taking, the history, performing the exam, and medical decision-making. The doctor does not have an effective manner through which to elaborate the complexity of the patient’s history, and patients must describe their symptoms by bubbling in preset responses on the Neck or Back Index. If more than one answer is appropriate, the patient may only select one. Data must fit into ACN’s format so that physician performance can be monitored. ACN’s operations manual states that notes should be submitted when CMT codes above 98940 are used and when X-rays are needed, but they are never requested, and when submitted, are never read. When doctors are placed on the Performance Improvement Program because of “overtreatment,” they are threatened with loss of in-network status based upon the treatment that ACN has authorized.In some states, ACN clinical consultants (doctors) are not licensed in the state they are working in, and an argument has been made in one state that these doctors are practicing medicine without a license.Patients whose condition necessitates a higher frequency or duration of treatment are often not allowed the care they need. The end result is a poor outcome that leaves the patient dissatisfied with chiropractic treatment in general and may mean that they will not seek it again.

5. Peer Comparison: In addition to questionable literature and research, ACN determines medical necessity based on statistical data of care delivery on similar patients by one’s peers. When the care delivery of a DC does not fit into ACN’s statistical benchmarks, they determine that the care was not necessary. The statistical flaw is that the doctors they consider to be comparable peers are also being threatened with loss of revenue, patients, network status, etc., and to stay in the network are either undertreating, or providing treatment that they do not bill for.ACN is now beginning to review out-of-rtetwork “peers” as well, but the problem is that now they too are having their performance measured and can be threatened with loss of the right to treat UHC patients. As a result, ACN does not have a valid statistical control group (either in or out of their network) to compare to.

6. Punitive Treatment: ACN appears to be attempting to reduce benefits for chiropractic to cover only minimal problems that can be treated with a few visits. Other than cost control, there is no justification for telling doctors, “You have too many 98941s, too many X-rays, and too high E/M codes.” This punitive treatment is in direct conflict with the AMA’s standards for Pay-for-Performance Programs (www.ama-assn.org/go/pfp), which state that such.programs should do the following (my emphasis added in italics):* “Ensure quality of care. This must be the program’s most important mission. To ensure that is the case, evidence-based quality-of-care measures, created by physicians across appropriate specialties, must be used. Variations in patient care must be allowed based on the treating physician’s judgment and should not affect program rewards.”* “Foster the patient-physician relationship. Programs must not pose obstacles to treating patients based on their health conditions, ethnicity, economic circumstances, demographics or treatment compliance.”* “Offer voluntary physician participation. Doctors must not be forced to take part, and the programs must not undermine the economic viability of practices that do not join. The initiatives must support participation by physicians in all practice settings by minimizing potential financial and technological barriers.”* “Use accurate and fair reporting. Accurate data and scientifically valid analytical methods must be used. Physicians must be allowed to review, comment on and appeal the results before their use.”* “Provide fair arid equitable incentives. Programs must rely on new funds. They should reward physicians, rather than punish them. Incentives should be provided for implementation of information technology. Programs should reward all participating physicians who meet the goals.”

7. Discrimination: States should identify whether they, have equality laws that would provide for the same payment for CPT codes regardless of the treating provider. For example, if a physical therapist is paid to perform an ultrasound treatment, is the same rate paid to a doctor of chiropractic providing the same treatment?

8. Summary: To provide appropriate care that is consistent with their scope of licensure and practice, a doctor of chiropractic must put himself/herself at risk of loss of revenue, loss of patients, and possibly loss of their contract with ACN. For some doctors, ACN patients represent as much as 60 percent of their practice and loss of in-hetwork status can be devastating. In addition, doctors have been barred from signing on as providers in other networks because of having been terminated from ACN.The guiding priority of doctors of chiropractic must be to improve the well-being of the patient, not the bottom line of managed care networks.

Rest assured that the ACA has heard your complaints … is carefully analyzing the data … and will take all regulatory and legal steps necessary to help ensure that chiropractic patients receive quality care.Author’s note: The opinions expressed in this article are solely those of the author and do not necessarily represent the opinions, policies or positions of the American Chiropractic Association. This article is available online at www.chiroweb.com/columnist/edwards. You may also leave a comment or ask a question at his “Talk Back” forum at the same location. James Edwards, DC. Previous articles, a “Talk Back” forum and a brief biography of the author are available online at www.chiroweb.com/columnist/edwards.James Edwards, DCAustin, Texasjamesedwards@jamesedwards.comCopyright Dynamic Chiropractic Sep 1, 2005
Provided by ProQuest Information and Learning Company. All rights Reserved

Low back pain in young adults

The cause of low back pain, especially in young adults, is frequently degenerative disc disease. Although this condition can cause symptoms of low back pain over a long period of time, the good news is that the pain is usually manageable with various conservative treatment options (meaning treatments that don’t involve surgery).

Low back pain treatment goals

The vast majority of people with degenerative disc disease experience low back pain symptoms that flare up periodically, but don’t get worse over time. For those people, the main goals for managing low back pain caused by degenerative disc disease are usually:

• Achieving enough pain relief to be able to engage in an exercise and rehabilitation program
• Preventing the application of excess stress on the disc through proper ergonomics and posture
• Trying to manage the low back pain and maintaining an ability to function enough at home and at work

Most types of surgery for ongoing, debilitating pain and loss of function from degenerative disc disease are fairly extensive, so it is usually in the best interest of most patients to manage their low back pain using non-surgical approaches and self-care. Over time, the low back pain and other symptoms of degenerative disc disease will usually subside. This happens because the disc starts to become stiffer with age, and a stiffer disc stabilizes the motion segment and thus reduces pain. However, this is a very slow process that occurs over many years.

Article continues below

Low back pain treatments

Pain from degenerative disc disease is caused by a combination of instability at the motion segment and inflammation from the degenerated discs. Both the instability and the inflammation have to be addressed for the treatment to be effective.The treatments for degenerative disc disease are either passive (done to the patient) or active (done by the patient). Usually a combination of treatments is used to help control the symptoms. Passive treatments are rarely effective on their own—some active component, such as exercise, is almost always required.

Passive treatments for low back pain from degenerative disc disease may include:

• Pain medication. Typical pain medications used to treat the low back pain include acetaminophen, NSAIDs, oral steroids, narcotic drugs, and muscle relaxants. Each type of medication has strengths, limitations, and risks, and the patient’s particular low back problem and overall health will determine which pain reliever, if any, is indicated.
• Chiropractic manipulation. Manual manipulation by a chiropractor or other qualified health professional is thought to help relieve low back pain by taking pressure off sensitive neurological tissue, increasing range of motion, restoring blood flow, reducing muscle tension, and creating a series of chemical reactions in the body (such as endorphin release) that act as natural painkillers.
• Epidural injections. An epidural injection into the spine delivers steroids that can provide low back pain relief by decreasing inflammation in the painful area.
• TENS units. These devices deliver mild electrical stimulation that overrides the painful signals sent to the lower back.
• Ultrasound. For acute low back pain, ultrasound may be used to warm the area, which in turn brings blood flow and healing nutrients to the area.
• Massage. Therapeutic low back massage is thought to provide low back pain relief by improving blood flow, reducing muscle stiffness, increasing range of motion, and raising endorphin levels in the body.

In addition, heat and/or ice therapy, acupuncture, behavioral therapy, and other therapies often provide enough low back pain relief to allow the patient to progress with his or her exercise and rehabilitation program.

Active treatments for low back pain may include:

• Exercise. For the vast majority of patients, the only way to achieve long-term healing is active exercise, which usually includes a combination of strengthening, stretching, and low-impact aerobic exercise.
• Quitting smoking. For patients who smoke, doctors recommend quitting smoking to improve blood circulation and healing. Chronic tobacco use is closely linked to chronic low back pain.
• Weight loss can reduce low back pain in overweight people by lessening the amount of stress on the low back’s muscles and ligaments.
• Ergonomics. Proper lifting techniques, ergonomic furniture, supportive footwear, and avoiding static posture for prolonged periods of time can help take pressure off the low back.

The following pages provide additional information on the main treatments usually used to treat low back pain from degenerative disc disease, including:

• Exercise and physical therapy
• Pain medications
• Pain management techniques
• Chronic pain and depression

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• Low back pain and degenerative disc disease treatments
• Exercise and physical therapy
• Pain medications
• Pain Management Techniques for Degenerative Disc Disease
• Chronic pain and depression

Next: Exercise and physical therapy

Peter F. Ullrich, Jr., MD
May 3, 2006

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Published Online First: 6 October 2006. doi:10.1136/ard.2006.052522
Annals of the Rheumatic Diseases 2007;66:330-333
Copyright © 2007 BMJ Publishing Group Ltd & European League Against Rheumatism

Lumbar disc degeneration: association between osteophytes, end-plate sclerosis and disc space narrowingStephen R Pye ¹, David M Reid ², Mark Lunt ¹, Judith E Adams ³, Alan J Silman ¹, Terence W O’Neill ^{1 1} arc Epidemiology Unit, The University of Manchester, Manchester, UK
² Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, UK
³ Clinical Radiology, Imaging Science and Biomedical Engineering, The University of Manchester, Manchester, UK Correspondence to:
Correspondence to:
Dr T W O’Neill
arc Epidemiology Unit, The University of Manchester, Oxford Road, Manchester M13 9PT, UK; terence.o’neill@manchester.ac.uk <!– var u = “neill”, d = “manchester.ac.uk”; document.getElementById(”em0″).innerHTML = ‘‘ + u + ‘@’ + d + ”//–> Background: Lumbar disc degeneration is characterized radiologically by the presence of osteophytes, end-plate sclerosis and disc space narrowing. Aim: To determine the strength of the association between increasing severity of combinations of these features in a population sample of men and women. Methods: Men and women aged 50 years were recruited from a primary care-based community health index in Aberdeen, UK. Participants had lateral spinal radiographs performed according to a standard protocol. The intervertebral disc spaces (L1/2–L4/5) were evaluated for the presence of anterior osteophytes, end-plate sclerosis and disc space narrowing using a graded semiquantitative score (grade 0–3). Log linear modeling was used to determine the associations (pairwise) between increasing severity of these features, with the results expressed as ß coefficients and 95% confidence intervals (CIs). Results: There were 286 men (mean age 65.3 years) and 299 women (mean age 65.2 years) with spinal radiographs, yielding a total of 2340 assessable lumbar vertebral levels. In all, 73% of vertebral levels had evidence of osteophytes, 26% of sclerosis and 37% of disc space narrowing. Increasing severity of osteophyte grade was associated with an increasing severity both of sclerosis and of disc space narrowing, whereas the severity of sclerosis was associated with the severity of narrowing. This was true at all vertebral levels. The strongest association, however, was between osteophytes and sclerosis (ß coefficient = 2.7, 95% CI 2.4 to 3.1). For sclerosis and narrowing the ß coefficient was 1.9 (95% CI 1.7 to 2.1), whereas for osteophytes and narrowing the ß coefficient was much weaker at 1.2 (95% CI 1.1 to 1.3). There was no important influence of vertebral level on any of these associations. Conclusion: The association between increasing severity of osteophytes and end-plate sclerosis is stronger than for other combinations of radiographic features of lumbar disc degeneration.

Abbreviations: LDD, lumbar disc degeneration 

                                Anna Villarrel Jenkins D.C. Esq

website: http://www.chirobd.ohio.gov .e-mail: chirobd@mail.peps.state.oh.ushomas J. Allenburg, D.C., CEO

 Executive Director “

Spinal Stenosis

Article Last Updated: Dec 13, 2007

AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Cervical and Thoracic Stenosis
• Lumbar Stenosis
• Clinical Presentation
• Radiologic Studies
• Natural History and Conservative Measures
• Surgical Treatment
• Conclusion
• Multimedia
• References

Author: Amir Vokshoor, MD, Staff Neurosurgeon, Department of Neurosurgery, Spine Surgeon, Diagnostic and Interventional Spinal Care, St. John’s Health Center

Amir Vokshoor is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, and American Medical Association

Coauthor(s): Ali R Jamali, MD, Assistant Professor of Orthopedic Surgery and Internal Medicine, Department of Orthopedic Surgery, Eastern Virginia Medical School

Editors: K Daniel Riew, MD, Professor, Department of Orthopedic Surgery, Washington University School of Medicine; Chief, Cervical Spine Surgery, Department of Orthopedic Surgery, Barnes-Jewish Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; William O Shaffer, MD, Associate Professor & Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Author and Editor Disclosure

Synonyms and related keywords: spondylosis, spinal canal narrowing, neurogenic claudication, myelopathy, focal stenosis, lateral recess syndrome, cervical spondylotic myelopathy, CSM, ligamentum flavum hypertrophy

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INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Cervical and Thoracic Stenosis
• Lumbar Stenosis
• Clinical Presentation
• Radiologic Studies
• Natural History and Conservative Measures
• Surgical Treatment
• Conclusion
• Multimedia
• References

Spinal stenosis refers to the narrowing of the spinal canal anywhere along its axis. Although the disorder often results from acquired degenerative changes (spondylosis), spinal stenosis may also be congenital in nature. In some cases, the patient has acquired degenerative changes that augment a congenitally narrow canal. The canal components that contribute to acquired stenosis include the facets (hypertrophy, arthropathy), ligamentum flavum (hypertrophy), posterior longitudinal ligament (OPLL), vertebral body (bone spurs), the intervertebral disk, and the epidural fat. Congenital stenosis may predispose an individual with mild degenerative changes to become symptomatic earlier in life. Spinal stenosis is most common in the cervical and lumbar areas.^{1, 2}

Stenosis of the central cervical and thoracic spine may result in myelopathy from cord compression.^{3, 4} Canal stenosis in the lumbosacral region often results in radicular pain, neurogenic claudication, or both.

Lateral canal stenosis at any region of the spine may lead to nerve root compression. The patients may experience radicular pain, weakness, and numbness along the distribution of the affected spinal nerve. Lateral recess syndrome in the lumbar spine is a result of such focal stenosis.

Treatment can be conservative or surgical. The modes of conservative therapy include rest, physical therapy with strengthening exercises for paraspinal musculature, bracing, use of optimal postural biomechanics, nonsteroidal anti-inflammatory medications, analgesics, and antispasmodics.

Surgical decompression is indicated in persons who experience incapacitating pain, claudication, neurologic deficit, or myelopathy.^{5, 6} Concomitant stabilization is reserved for individuals in whom segmental instability is suspected (ie, patients with spondylolisthesis showing abnormal movement on dynamic studies). 

This is one of the things I have wrong with my back and United Healthcare and the ACN do not think I need care.

 Degenerative Spondylolisthesis of the Lumbar Spine

Thomas G. Lowe, M.D.

Degenerative changes in the spine are often referred to those that cause the loss of normal structure and/or function. Degenerative Spondylolisthesis (DS) is a disorder that causes the forward motion (slip) of one vertebral body over the one below. The term Spondylolisthesis is formed from two Greek words; spondylo meaning vertebra and olisthesis meaning to slide on an incline. DS is most common in the lumbar spine (L4-L5) and may cause low back pain.Symptoms and Non-Operative Treatment

Typical symptoms include low back pain, muscle spasms, thigh or leg pain, and weakness. Interestingly, some patients are asymptomatic and learn of the disorder following spinal radiographs.

Low back pain associated with DS is treated non-operatively. During the acute pain phase, bedrest may be recommended for a few days. Activities involving heavy lifting and stooping are prohibited to prevent stress to the lumbar spine.

Drug Therapy

During the acute phase of low back pain, drugs may be prescribed. Some of these may include narcotics, acetaminophen, anti-inflammatory agents, muscle relaxants, and anti-depressants.

Narcotics are used on a short-term basis partially due to their addiction potential. When low back pain is caused by muscle spasm, a muscle relaxant may be prescribed. Muscles relaxants are usually used no longer than one week and have sedative effects. Depression can be a factor in chronic low back pain. Anti-depressant drugs have analgesic properties and may improve sleep.

Bracing and Physical Therapy

Other conservative non-operative treatment may include a custom-made brace. A brace is designed to reduce the loads (weight) to the lumbar spine. Physical therapy may be added to the treatment plan. Forms of therapeutic exercise including stretching may improve the flexibility of the trunk muscles. Other non-aerobic exercises may help to improve muscular endurance, coordination, strength, and facilitate weight loss. Exercise also helps to combat anxiety and depression.

Disease Progression and Neurologic Deficit

Although degenerative spondylolisthesis may cause a vertebra to slip forward, that does not always mean the disorder is progressive. The vertebral segment may be stable without any neurologic compromise. Surgery becomes a consideration when the disorder causes neurologic deficit, such as incontinence or the slip progresses. Spinal fusion and instrumentation may become a consideration if slippage exceeds three millimeters. These surgical procedures stabilize the spinal column.

The surgeon bases his/her decisions on the patient’s medical history, symptoms, radiographic findings, as well as the degree and angle of the vertebral slip. Patients who use tobacco or are obese are known to have lower rates of success with fusion. Nicotine hampers the fusion process and obesity places excessive weight on the lumbar spine.

Spinal Fusion and Instrumentation

Spinal fusion and instrumentation are combined. Spinal fusion uses the patient’s (preferred) own bone harvested from the iliac crest (pelvis). Donor bone is an option. Spinal instrumentation uses medically designed implants such as screws and cages. The implant(s) holds the vertebral segment secure facilitating fusion. Instrumentation provides more rapid pain relief, recovery, and may eliminate the need for bracing following surgery. Two surgical procedures that utilize spinal fusion and instrumentation are termed Anterior Lumbar Interbody Fusion (ALIF) and Posterior Lumbar Interbody Fusion (PLIF). The difference between the two procedures is the surgical approach to treat the disorder (front or rear).

In Conclusion

Although aging adults can expect some degenerative processes to occur in their spines, this certainly does not point to a future facing disability. In general, spondylolisthesis only affects a small percentage of the population. Overall, most degenerative disorders of the spinal can be treated non-surgically with good outcomes.

Last Updated: 02/10/2008

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In this thorough overview of Degenerative Spondylolisthesis, Dr. Lowe describes the importance of the correlation of the patient’s symptoms, the physical examination and the radiographic findings. As he states, many patients with the radiographic finding of DS are successfully treated nonoperatively. Unless there is significant neurologic impairment, a trial of conservative care is generally warranted. If the patient’s symptoms are persistent, then surgical intervention may be appropriate. In terms of a surgical option, decompression (to address nerve related symptoms) and stabilization/fusion are the two most often considered components. Depending upon the patient’s pattern of symptomatology and radiographic findings decompression alone, fusion alone, or a combined decompression and fusion may be considered by the treating surgeon. As described by Dr. Lowe, instrumentation is generally used in conjunction with fusion to provide initial stability to the involved area and to optimize fusion success rates.

So since I am a big time reader, a researcher (mostly Medieval) and general detective (you can run but you can’t hide!) I was thinking of putting some of the stuff that I have stored away and not forgotten into books.

I thought I would try my hand first at a Historical Fiction about Anne Bolyen then maybe some pagan how to books that don’t give all the fluffy nice stuff  (wheres the beef?) but real stuff to sink your teeth in.

 This is one of the reasons why I bought the new laptop. Also I have a bad chair and can’t sit at the PC desk for long and the laptop does travel.

So anyone have any advice on how to go about this?

 Also if there is anything you really want to see in a pagan type book what would it be?                                                    I had thought about maybe collecting all the different stuff I have personally used like one book one protections, another on cleansings, etc. See where I’m going with this?

Anyways this is all a few years down the road before anything may get published if it does. So wish me luck!