There is no such thing as “bloodless” surgery – let’s make that clear. There is, however, blood loss that is insignificant, like when you cut yourself shaving, and then there’s significant blood loss such happens after major trauma cases with multiple fractures. As surgeons, often responsible for that blood loss, we try as much as we can to minimise blood loss, and hence the need for transfusion. And before you ask, if you’ve lost red cells, then there is nothing available yet that can replace the oxygen carrying capabilities of those red cells like, you guessed it, red cells.
Placing a patient on a well padded and designed operating table is often the first step in minimising blood loss. The “Jackson table” is, in my opinion, currently the best table for large posterior spinal cases. It allows the abdomen to hang free and the pads are soft and well positioned. Other positions, such as on the side, can also be used for different approaches which minimise blood loss simply due to their anatomy. An ALIF, for example, can be an operation that involves very small amounts of blood loss just by it’s approach.
Many of us practice “minimally invasive surgery”. This is poorly defined as everyone has a different opinion of what it means, but in principle it is about doing an operation through a smaller incision than how it was done before. Whilst it may appear like these techniques lose less blood, often the blood loss is kept hidden. Muscles are still being retracted and dissected, and bones are being cut, both of which lead to blood loss, but because the skin incisions are so small, often that blood is kept inside the skin. In the long term the body with resorb that blood, but in the short term effectively that blood is out of your circulation and so it still lost to you.
It’s important to tell your surgeon what medications and supplements you’re taking. Many of these can increase blood loss, and cause postoperative epidural haematomas that may press on the spinal cord. We also often use a medication called tranexamic acid, which has been proven to reduce blood loss during your operation.
Like many other surgeons I use a machine during my large operations called a “cell saver”. This takes the blood that you have lost, washes it, and allows us to give you back your red cells. It doesn’t give you back all your blood, like platelets and clotting factors, but it does give you back your oxygen carrying red cells.
When it’s needed
Of course, despite our best efforts, a blood transfusion is sometimes necessary after elective procedures. In trauma cases where we’re often dealing with multiple fractures and abdominal bleeding, transfusions save lives. Fortunately in Australia we have a very safe and efficient blood donor system run through the Red Cross. Yesterday I gave my 98th donation, and if you’re able to, I recommend you consider donating as well. Every time you give blood, you can just about guarantee that your blood is going to someone who may die without it. I’ve even learnt something about my own blood. My platelets are a very rare type (HLA 1bb 2bb), with less that one percent of the population having the same, and they can be used to treat Neonatal Alloimmune Thrombocytopenia, a rare but often catastrophic bleeding disorder of newborns.
So why don’t you consider giving blood? You’ll be saving someone’s life, and one day you might need the gift that a donor made for you.
Before I go on, please do not read this as a criticism of all chiropractors. You need to understand that there are two bodies that represent chiropractors within Australia. There is the Chiropractic and Osteopathic College of Australasia (COCA), and the Chiropractors’ Association of Australia (CAA). I believe that anybody practicing in the health professions should always employ evidence-based techniques and treatment regimes, myself included. If you want a chiropractor who practices based on evidence, you’ll be more likely to find one within the ranks of the COCA than you will in the ranks of the CAA though. For example, of the fifty chiropractors openly expressing anti-vaccination lies on their websites documented here, most of them are members of the CAA. None are members of COCA.
A recent article in The Age, by Julia Medew and Amy Corderoy, has outraged chiropractors, or more specifically, the CAA. If you want to know how much it has outraged them, you only need to read this press release by the CAA, and see the report on their outrage here. The Age hasn’t even acknowledged their outrage, which must add disappointment to their already overflowing cup of emotion.
The article was startling for several reasons. Firstly, it described the case of a four-month old baby treated by a chiropractor with a fractured neck. Yep – a fractured neck. Did the chiropractor cause it? We don’t know, but suffice to say that it appears from the information available, that the parents took the baby to a hospital ED after an “adjustment” by a chiropractor, and the baby was found to have a fracture in his or her cervical spine. I was not and am not part of the treating team. Maybe the fracture occurred before the adjustment. In that case the chiropractor possibly missed the signs and symptoms of a fractured neck – disappointing for someone who’s had “five years of university training” as we keep hearing. The other option is that the chiropractor caused the fracture. Either way, it’s not a shining endorsement.
The other startling aspect of the story was the claim that chiropractors visit hospitals and provide adjustments without the hospital’s permission. More can be read on those allegations here.
So what is the reaction of the CAA? Outrage. Take a read of the media release. They appear to know in great detail the results of the investigation of the case by AHPRA, despite those results being confidential. Yet, they know. And they tell us that The Age article “smeared the Chiropractor” – despite the name of the chiropractor not being mentioned. Kinda hard to smear someone when you don’t name them. This sort of confusion occurs when you are outraged.
Then we get to,
“National President of the CAA, Dr Laurie Tassell said, “It remains the case that not a single serious adverse event has been recorded in the medical literature (world-wide) involving a qualified Chiropractor treating a child since 1992.”
This Claim is obviously part of the gift pack you receive when you join the CAA, as it’s the same Claim made by Tony Croke on Catalyst. The CAA lodged a complaint against Catalyst for criticising this Claim, and the complaint was only today dismissed by an independent investigator. More outrage. Lots of it.
So what of the Claim? I contacted Bevan Lisle, Communications Director of the CAA today about the claim, and his response was, well, less than satisfactory in my opinion. You see, The Claim, as we shall refer to it as, has several weak points. Firstly, a health practitioner who claims to have no adverse events is someone who does not practice. Secondly, as they have no systematic method of compiling adverse events, they simply aren’t looking for them. It’s like claiming there’s no stars out while you’re down a mine shaft. Thirdly, by Claiming that there has never been even a single adverse event, the documentation of just one is enough to falsify the Claim. Lastly, the word “involving”, or as Bevan put it, “associated with”, doesn’t mean they caused the event – it just means the chiropractic treatment was “connected” with the event. So how does the Claim stand up?
As defined by the FDA, a Serious Adverse Event (SAE) can be of several types. One is
Disability or Permanent Damage: Report if the adverse event resulted in a substantial disruption of a person’s ability to conduct normal life functions, i.e., the adverse event resulted in a significant, persistent or permanent change, impairment, damage or disruption in the patient’s body function/structure, physical activities and/or quality of life.
I had to help Bevan today with his definition of SAE, so let’s be clear in case anyone else doesn’t know it.
A slipped capital femoral epiphysis is a serious event, and a delayed diagnosis meets the criteria of a SAE. The paper here describes 12 delayed diagnoses because of attendance at either a physiotherapist or a chiropractor. Remember, we only need one case “associated” with chiropractic care after 1992 to disprove the Claim. Hence, the Claim is apparently false.
This paper also describes fractured ribs associated with chiropractic care. Published after 1992, associated with chiropractic care. The Claim is therefore false. Surely?
This paper also describes a litany of SAE’s associated with chiropractic care. The events were all in 1992 or before, so technically lie outside the Claim, but still make for shocking reading.
The CAA, when asked for comment, stands by the Claim. It’s like a mantra. Even in the face of the investigation of the four-month old baby, they still repeat the Claim. It happened after 1992, was associated with chiropractic care, and is a SAE. Time to retract the Claim?
Instead of expressing outrage at one of their members, the CAA prefers to express outrage at journalists, and probably now myself, at what they see as a smear against an unnamed chiropractor. In fact, in a brilliant example of double talk…
CAA president Dr Laurie Tassell (Chiro) said there was no doubt the baby had a hangman’s fracture. “The official report made it quite clear that the chiropractor did not cause the injury but unless AHPRA releases the report we can’t use those findings,” he told Medical Observer.
See what he did there? He can’t use the findings, but here they are anyway. But he can’t use them, OK?
And we’re meant to believe him. We’re meant to trust the CAA to have the public’s interest in mind. We’re meant to see them as a peak representative body whilst they repeat the apparently false Claim, talk in double talk, and rather than express sympathy or even a whim of accountability, prefer to express their own outrage.
Here’s my message to the CAA: instead of expressing outrage, why don’t you start behaving like professionals, start regulating yourselves, start looking for adverse events and start reporting them openly like other medical professionals do, stop tolerating anti-vaccination garbage, encourage evidence based care, and for once, take responsibility.
Many of my patients have either been to a chiropractor, or ask me if they should go and see one. Some of them are aware that there is some discrepancy between mainstream medicine and chiropractic theory, but aren’t sure of the specifics. Here’s why I have problems giving an opinion on the matter.
Firstly, there’s two broad categories of chiropractors. There are those who tend to be younger, who are struggling to define their art form in terms of evidence and reproducibility. They tend to encourage sensible evidence based principles, concentrate on strengthening the spine, and treat spine-related symptoms. They are to be encouraged, because it is through them that chiropractors may gain some credibility in the medical community.
Now let’s talk about the others – the “straights”; the vitalistic, intuitive, metaphysical practitioners who remain separate from the mainstream community, and who are determined to remain that way. The irony is that they are also the one’s wanting to introduce chiropractors to primary health care roles. I’m reminded of the desire to simultaneously have and eat cake.
A short history lesson… A gent by the name of DD Palmer apparently cured a man’s deafness in 1895 by performing a manipulation on his neck, and this is the miracle upon which DD made his mark, and from which chiropractic began. A connection was made, in the minds of some, that diseases come from malalignments within the spine. Not just some, but all. They figured that by fixing these malalignments, or “subluxations”, a person could be cured of all sorts of ailments. Sounds simple, huh? Sounds like a concept that’s plausible and attractive, especially for those seeking “natural” therapies.
So here’s the kicker. There are simply no nerves, no pathways at all, that link the cervical spine to the parts of the ear to do with hearing. There is a cervical (neck) nerve branch that supplies sensation to the skin near the outer part of the ear, but no neck nerve at all within the middle or inner ear. So how does a manipulation of the neck affect hearing? Well, it can’t. No way. It’s just not plausible. No matter how hard you want to believe it, it just not possible.
When the Wright brothers built the first successful powered aeroplane, they formed the basis for the development of aircraft we see today, and people can still build replicas of the plane and fly it. The scientific principles haven’t changed – techniques and understandings have deepened, but the Wright Flyer can still fly today.
Likewise, if DD Palmer was able to cure deafness in 1895, then modern chiropractors should be able to do this as well – they should be able to fly the first plane. According to my checks, there is little evidence that this trick hasn’t been performed since. Why not? DD Palmer did it, so why aren’t chiropractors curing deaf people world wide? Surely that should be the first therapy taught to young chiropractors!
If you want another reason to doubt the concept, then what about high quadriplegics, like Christopher Reeve, who had perfect hearing, but a non-functioning spinal cord. Not malaligned or subluxed – not functioning at all. So when you hear someone tell you this story, just remember that you’re hearing it without using your spinal cord.
Some chiropractors insist that adjusting the spine can, indeed, fix your hearing, your diabetes, your child’s autism and asthma, and “enhance” your immune system. They invented the concept of “innate intelligence” to explain it, which is some sort of life force that cannot be seen, does not follow nerve pathways, yet can somehow be manipulated and adjusted by cracking a person’s neck or back. How is it that something, that cannot be seen or touched or imaged, be “adjusted”? How can you know that the supposed “adjustment” is being performed correctly, healing the “innate”, when it cannot even be measured? You’ll need to ask a chiropractor that. It’s a convenient and intuitive concept, but completely without evidence. None. And much evidence to the contrary. It’s a fairy tale, designed to make people believe.
Many chiropractors claim that they can help with middle ear infections in children, but once again, there are simply no nerves that come from the neck and go to the drainage tube (Eustachian tube) of the middle ear. They are simply not connected. No nerves in the cervical spine goes to or comes from the Eustachian tube. Is it the “innate” again? It must be, because it’s not anatomy.
At some point you’ll probably come across the term subluxation. This is a chiropractic subluxation which implies an abnormal movement of the facet joint. It is not visible on X-ray or MRI studies. This is opposed to the subluxations that I treat, which are demonstrable with imaging. If the chiropractic subluxation was the cause of disease, then why aren’t people with adolescent idiopathic scoliosis riddled with disease? After all, their spines are abnormally curved in all sorts of directions and have abnormal and unbalanced movements. Long term studies of these patients however show no difference in their health compared to the general population (unless the curvature impacts on their breathing, but this is only for people with very large curves). In the UK, the General Chiropractic Council stated that the chiropractic vertebral subluxation complex “is an historical concept” and “is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.” So throw that out as well. If you want to respect your chiropractor, ask them to never speak of subluxation.
Some chiropractors go so far as to claim that by adjusting the spine they can “boost” the immune system, to the point that you do not need vaccination. This is a very attractive sounding claim, but again, seriously flawed. There is simply no proof for the claim. Nada. And what if by “boosting” the immune system, it brings about auto-immune disease like rheumatoid arthritis? Do you want someone doing that to you? The only proven way to reduce the risk of many deadly infectious diseases is – you guessed it – vaccination.
The vitalistic chiropractors claim to address the body as a whole (vitalism), and that conventional doctors only see the body as a sum of parts. Doctors are fully aware of the entire body functioning as a whole, and any claim to the contrary is just nonsense. I’ve seen chiropractors claim that the SF-36 score (a whole-body health score) is only used by holistic or vitalistic practitioners like themselves, but even a quick browse of the literature shows that scores like this are used all the time by all branches of medicine. Contrary to their claim, conventional doctors receive an education that covers all aspects of the human body. To become a highly specialised spinal surgeon I’ve had to pass exams in fields as diverse as immunology, renal physiology, biomechanics, radiology, epidemiology, anatomy, pharmacology and pathology. Who is “holistic” now?
Let’s be honest, if your chiropractor mentions the words innate or subluxation, or attempts to provide you treatment that isn’t directly related to spinal complaints, then you’re dealing with a non-evidence based practitioner. That may be fine for you, if that’s what you’re looking for. Enjoy it. But please don’t expect it to produce anything more than the placebo effect. If that’s what you’re willing to spend money on, then that’s your choice.
As you may appreciate, there are many chiropractors actively seeking to establish themselves as evidence based practitioners. They are to be encouraged, and if they can produce good evidence, then I’ll be the first to applaud them.
Only once a treatment modality, no matter what it is (chiropractic, physiotherapy, homeopathy, and conventional medicine) can describe it’s mechanism of action, its effectiveness and its safety profile, will it, can it, should it, be accepted. Life is too short, and dare I say, the health dollar is too limited. Show me the evidence, and I will embrace.
Some of you will remember my four rules about looking after your spine. Four rules never really sat too well with me. Even though it’s an even number and the square of two, it needed to be five – i’m a decimal kind of guy after all. So after much deliberation, and some common sense, I’ve figured out my FIVE rules for looking after your back.
1. Don’t smoke.
2. Lose weight.
3. Do “Core” Exercises.
4. Maintain good posture, and lift things with a good technique, and at last
5. Avoid aggravating activities. This is the one that took me some time to realise needed to be in here. How many times do people say that their back is fine until they do gardening / lift an engine block / etc. It sounds simple, but if you can avoid those activities that cause back pain, then that’s a very simple and drug free way of looking after your back. Some activities can’t be avoided, sure, but try and not do the things that hurt. Does that mean you’re getting old? Well, how do I say it? I know – I wont.
Many young people suffer from back pain but it is usually the kind of pain that gets better by itself over a few days to weeks. Occasionally, though, back pain can persist and it may become worth investigating, especially if it is associated with leg pain, or “sciatica”. A particular condition that can cause lower back pain and sciatica in younger people is isthmic spondylolisthesis. Well what on earth is that, you ask.
Isthmic spondylolisthesis, or IS, for short, is a condition that you might think of as a stress fracture in your lower back. It usually develops when you’re a teenager, and it occurs more frequently in sportspeople that perform a lot of extension activities like gymnasts, fast bowlers and baseball pitchers, but it can occur in people who don’t play any sport either. If it is picked up when you’re really young sometimes the problem, or “defect”, can be repaired. Unfortunately, it often goes unrecognised and only later in life becomes symptomatic.
The defect is in a part of the spine called the “isthmus”, or “pars interarticularis” (pars for short). It is most common at L5, and most commonly leads to a spondylolisthesis, or “slip”, or L5 on the sacrum.
As you can see in the diagram to the right, the pars links the L5 vertebra to the sacrum. If this is broken, the L5 vertebra is only held onto the sacrum by ligaments, and these over time stretch and may fail. This includes the disc between L5 and the sacrum. If you think about it, the whole weight of your upper body – your head, arm, thorax and abdomen – is all bearing down on this segment of your spine, so it’s no surprise that over time, if there’s no bone holding them together, that the ligaments will fail.
So that’s what it is. What can be done about it? You’ll have to wait for my next post…
In many ways, this post may be the one to put me out of business, but it’s also the post which I’m sure should be my first – how to protect and look after your back. In medicine the preference is always prevention over cure, yet many of us forget to emphasise the benefits of spine health. In other words, how can we all look after the health of our spine in order to prevent injury, reduce the symptoms of spinal degeneration, and lastly to speed recovery following injury or surgery. Let’s get to the point, and keep it simple.
1. Don’t smoke. There is nothing healthy about smoking, and it is known that smoking leads to accelerated disc degeneration. It also increases your chances of an adverse event during and after surgery, and may contribute to failure of spinal fusion surgery in the neck and lower back. http://www.ncbi.nlm.nih.gov/pubmed/11339862
2. Lose weight. Every kilo your carry leads to an extra 8 kilo’s of force going through your spine. Thin people are putting less stress through their spine, and losing weight is often a very effective strategy to lessen the symptoms of a degenerating spine.
3. Exercise. Exercise will obviously help you control your weight, but strength training, particularly of the “core” muscle groups, will also help stabilise the spine and reduce some of the impacts that it sustains. Some people wear a corset device to help them with their backs. Improving your core strength works in a similar manner.
4. Maintain good posture. Maintaining a good posture will allow the spine to take loads in the way that it was designed to. Good posture also refers to good lifting techniques such as bending your knees, and holding heavy loads close to your body. Core strength will help you to also maintain a good posture.
Is that all? No. Now that you’ve read this, it’s up to you to make a start. Your GP can help you with quitting smoking, and there’s lots of resources available to you on the internet such as QUIT. Your GP and physiotherapist can also help you to lose weight in a healthy and appropriate manner – some people are even electing to have “gastric banding”, but that is something you really need to see a specialist about. Your local physiotherapist will be able to show you good core strengthening exercises, and there’s some available from the Mayo Clinic and the AAOS on the internet.
Some other great resources for learning about your spine are available via the links below: