November/December 2017- Oh My Aching Back by Advocates for Better Health

November/December 2017

Oh My Aching Back

In This Issue: • • • •

Low Back Pain—To Treat or Not to Treat TCMS Receives Emmy Award Celebrating 10 Years Smoke-Free Luminary of Twin Cities Medicine

All in the Family The Crutchfield family has created a rich medical legacy in the Twin Cities. The Twin Cities was recently named as the â&#x20AC;&#x2DC;Best Place to Live in the United Statesâ&#x20AC;&#x2122; (Patchofearth.com). Why not? Weâ&#x20AC;&#x2122;re green; we have great food and entertainment, and a robust job market. But what really makes a city great? The people. And what makes great people? Great families. Our Capitol City boasts a great family of its own: The CrutchďŹ elds. Arriving to pursue education, Dr. Charles Crutchfield Sr. and Dr. Susan Crutchfield became two of Minnesotaâ&#x20AC;&#x2122;s best-known and respected physicians over the past half century. The first African American woman to graduate from the University of Minnesota Medical School in 1963 (at age 22, also the youngest, ever!), Dr. Susan achieved diplomate status on the American Board of Family Medicine, spending twenty years practicing occupational medicine as Vice President and Medical Director for the Prudential Insurance Company of America and has served in a range of positions including medical director of McAllister College and the Metropolitan Health Plan. Dr. Charles Sr. broke ground as the first African-American OB/ GYN in Minnesota. An Alabama native, he went from â&#x20AC;&#x153;shining shoes and picking cotton to saving lives.â&#x20AC;? An early sign of success, Dr. Charles Sr. was Intern of the Year at Ancker (now Regions) Hospital. In over 40 years of practice, he has delivered nearly 10,000 babies between Fellowships in the American College of OB/GYN and teaching at his alma mater. As civic leaders, Dr. Susan served as chair of the Minneapolis Childrenâ&#x20AC;&#x2122;s Hospital Board, and Dr. Charles served as chief of OB/ GYN at United Hospital. They continue to work tirelessly to improve childrenâ&#x20AC;&#x2122;s health and health care access for minority women. The Crutchfieldsâ&#x20AC;&#x2122; children and grandchildren excel in medicine, law, movie production, photography, philanthropy, and cultural education. Their accomplishments are featured regularly in published accounts of historical and present-day St. Paul. Their son, Dr. Charles III is one of our communityâ&#x20AC;&#x2122;s leading dermatologists with a practice known as a national model of delivering effective care. He serves as team dermatologist for the Twins, Vikings, Timberwolves, and Wild. He is a frequent guest on TV and radio, has published more than 100 dermatology articles, co-authored a textbook and childrenâ&#x20AC;&#x2122;s book on sun protection, and holds multiple patents for skin medication.

Charles Crutchfield Sr., MD and Charles Crutchfiled III, MD, present day

Charles Crutchfield Sr., MD and Susan Crutchfield, MD at the U of M Medical School graduation in 1963. Charles Crutchfield III, was 3 years old.

â&#x20AC;&#x153;My parentsâ&#x20AC;&#x2122; stature as physicians made practicing medicine in Minnesota easy,â&#x20AC;? he explains. â&#x20AC;&#x153;Here I am. Same city. Same name. People come to me as a doctor because of their reputations. I do my best to honor the Crutchfield name by serving my patients to the best of my abilities.â&#x20AC;? Dr. Charles III established the â&#x20AC;&#x153;Doctors Charles and Susan Crutchfield Annual Lectureshipâ&#x20AC;? at the University of Minnesota. Focused on advancing the treatments for â&#x20AC;&#x2DC;Skin of Color,â&#x20AC;&#x2122; the Crutchfield Lectureship fittingly reflects a commitment to improving lives in Minnesota and beyond. â&#x20AC;&#x153;My parents and I have the same philosophy,â&#x20AC;? says Dr. Charles III. â&#x20AC;&#x153;When you do something you love in a place you cherish, it is not work at all. I love the ability to use my skills to help people in my community when they most need it.â&#x20AC;? The best place to live, indeed.

&KDUOHV ( &UXWFKILHOG ,,, 0' is a graduate of the Mayo Clinic Medical School and a Clinical Professor of Dermatology at the University of Minnesota Medical School. Dr. CrutchďŹ eld is an annual selection in the â&#x20AC;&#x153;Top Doctorsâ&#x20AC;? issue of Mpls. St. Paul Magazine and is the only dermatologist to have been selected as a â&#x20AC;&#x153;Best Doctor for Womenâ&#x20AC;? by Minnesota Monthly magazine since the inception of the survey. Dr. CrutchďŹ eld has also been selected as one of the â&#x20AC;&#x153;Best Doctors in America,â&#x20AC;? an honor awarded to only 4% of all practicing physicians. Dr. CrutchďŹ eld is the co-author of a childrenâ&#x20AC;&#x2122;s book on sun protection and dermatology textbook. He is a member of the AOA National Medical Honor Society, an expert consultant for C I T E H T AES WebMD and CNN, and a recipient of the Karis Humanitarian Award from the Mayo Clinic School of Medicine. L OF APPROVA L SEA

1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

CONTENTS VOLUME 19, NO. 6 NOVEMBER/DECEMBER 2017

IN THIS ISSUE

The Painful Reality By Richard R. Sturgeon, MD

PRESIDENT’S MESSAGE

Pain, Success and Celebrations By Matthew A. Hunt, MD

TCMS IN ACTION By Sue Schettle, CEO LOW BACK PAIN

Page 32

•

Colleague Interview: A Conversation with Ensor E. Transfeldt, MD

•

A Neurosurgeon’s Perspective on Managing Low Back Pain By John Mullan, MD

•

SPONSORED CONTENT:

The Conundrum of Treating Chronic Spine Pain: Could a “less is more” approach improve outcomes and cost-effectiveness? By Charles Kelly, MD

Page 7

Page 5

•

Diagnosis and Management of Kyphosis, Including Scheuermann’s Kyphosis, in Children and Adolescents By Tenner Guillaume, MD, and Walter Truong, MD

•

Occupational Medicine Considerations in the Management of Low Back Pain Injuries By Ralph S. Bovard, MD, and Zeke J. McKinney, MD

•

Low Back Pain Treatment Alternatives: Opioids, Surgery, Interventional Pain Management By David Schultz, MD

Changing Climate and Minnesota Communities By Bruce D. Snyder, MD

Advance Care Planning CPT Codes: a quick overview

Students Support Health Equity with the Physician Advocacy Network

Reﬂections on the Minnesota Freedom to Breathe Act By A. Stuart Hanson, MD

Medical Student Thank You/In Memoriam Career Opportunities

Page 29

MetroDoctors

LUMINARY OF TWIN CITIES MEDICINE

John H. Moe, MD The Journal of the Twin Cities Medical Society

November/December 2017

Oh My Aching Back

In This Issue: • Low Back Pain—To Treat or Not to Treat • TCMS Receives Emmy Award • Celebrating 10 Years Smoke-Free • Luminary of Twin Cities Medicine

Low back pain presents many challenges to both patients and physicians alike. Surgical options and non-surgical management are discussed. Articles begin on page 7. November/December 2017

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Stephanie Misono, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Mac Garrett Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Erica Nelson Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

November/December Index to Advertisers TCMS Ofﬁcers

Classiﬁed Ad .......................................................23

President: Matthew A. Hunt, MD President-elect: Thomas E. Kottke, MD Secretary: Andrea Hillerud, MD Treasurer: Nicholas J. Meyer, MD Past President: Carolyn A. McClain, MD

Crutchﬁeld Dermatology..................................... Inside Front Cover Ear, Nose & Throat Specialty Care .............26

TCMS Executive Staff

Entira Family Clinics .......................................30

Sue A. Schettle, Chief Executive Ofﬁcer (612) 362-3799; sschettle@metrodoctors.com

Episcopal Homes of Minnesota ....................17

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

Fairview Health Services .................................31

Karen Peterson, Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com

Honoring Choices Minnesota ............................

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

Lakeview Clinic .................................................31

HealthPartners...................................................... 6 Outside Back Cover M Health .............................................................11

Grace Higgins, Project Coordinator, Physician Advocacy Network (612) 362-3706; ghiggins@metrodoctors.com

Mankato Clinic ..................................................13

Annie Krapek, Assistant Project Coordinator, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com

St. Cloud VA Medical Center ............................

Mounds Park Academy...................................... 9 Inside Back Cover

Sadie Rubin, Program Coordinator, The Convenings (612) 362-3724; srubin@metrodoctors.com

St. David’s Center ............................................... 2

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reﬂect the ofﬁcial position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Erica Nelson 4084 Jana Ave. NE St. Michael, MN 55376 phone: (763) 497-1778 fax: (763) 497-8810 e-mail: erica@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

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November/December 2017

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IN THIS ISSUE...

The Painful Reality

LIKE ALMOST EVERYONE, I have had some acute low back

pain. Also like most everyone else, fortunately these episodes have been self-limited. In between these half dozen episodes, I have enjoyed a symptom-free lifetime. Lucky me. In this issue, our authors have explained our clinical approach to patients who present with back pain. Several emphasized conservative initial approach for at least six weeks. Four out of five episodes typically will resolve with this treatment plan. The subsets of patients who suffer chronic or chronic recurring low back pain face a more challenging course. An enlightened overview of the field was provided by our Colleague Interview. Others added additional information pertaining to specific surgical procedures, interventional pain treatments, cord stimulating technologies and integrated team approaches. If symptomatic at the end of this initial low key period, further evaluation and imaging come into play. MRI has become the imaging of choice. It goes beyond superior anatomic details and provides pathophysiological insights that can impact treatment decisions. Next treatment decisions thence go forward. Children create unique challenges, especially as to congenital Kyphosis. That team included two informative case studies. One cannot pick up a paper or listen to the news without hearing of financial trouble in the Health Care World. Increased costs reside largely in the population with chronic diseases. The three highest cost conditions were CV disease, diabetes, and spine care. Of the three, spine care costs had the fastest rise over a 17 year study. Back pain is the leading cause of disability in persons under age 45. It is second to respiratory tract infection as a reason to see a physician. It is the leading industrial health complaint. The average direct cost per industrial back injury involving at least one lost workday is over $24,000. All authors espouse a team approach and a therapeutic relationship to these patients. There is not a surgical cure for

By Richard R. Sturgeon, MD Member, MetroDoctors Editorial Board

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many chronic patients. Longer term conservative non-surgical treatments are called for. Muscle toning, stretching, cognitive therapy programs, interventional pain treatments or exercise programs with or without anti-inflammatory meds are examples. Of note are accompanying psychological issues and in some cases the need for work place restructuring. And our very newsworthy dilemma — the use of opioids. It is not easy. We risk overuse, addiction and fatal overdoses, while striving for relief of pain. We have traveled from sins of under-treating pain to our current situation of using too much opioid, at least according to some. Unhappy collateral damage of the opiate crisis can lead to unfortunate under-treatment in regards to some patients’ pain. Our authors have demonstrated the depth and breadth of low back pain issues. Remember, many positive imaging findings are present in both symptomatic and asymptomatic patients. You are not off the hook… Which of these findings is clinically significant can only be determined in concert with a detailed exam and history. At that point, involving the patient in treatment decisions can sometimes be choosing between bad choices. An additional responsibility is to carefully apply a cost/benefit analysis in our approach to these unfortunates with chronic low back pain. During his career Dr. Moe, our Luminary, was a magnet for other eminent surgeons and a long line of worldwide fellowship trainees. Our medical community continues to benefit and our patients enjoy a community standard of superlative spine care.

November/December 2017

President’s Message

Pain, Success and Celebrations MATTHEW A. HUNT, MD

his month’s issue of MetroDoctors focuses on the spine. It is an area that goes hand in hand with the opioid crisis. Previous studies suggest that over half of patients who take opioids regularly have chronic back pain as one of the factors driving their use. But the challenge of back problems is larger than just opioid use. Back problems have an incredible impact on the quality of life of patients. On average, patients suffering from back problems have quality of life scores as measured by the EQ-5D that are worse than patients with diabetes, COPD, heart failure, or peripheral vascular disease. Spine diseases are the most common cause of musculoskeletal pain. The burden of low back pain globally causes more years lived with disability than any other condition. Costs associated with spinal disease were approximately $46 billion per year in 2009-11 in the U.S. Solving individuals’ problems with back pain can be complex. Patients come to the doctor with an expectation for a fix for the problem, and often perceive back pain as a problem that should be ‘solved.’ Looking at the data above, it is clear that spinal disorders have a huge impact on patients, but often the treatments provide incremental benefits, and many times a ‘cure’ for these problems can be challenging to find. As technology and understanding advances, we also take on cases that we may have walked away from just a few years ago. But the path forward is not always smooth, particularly from the patient’s perspective. Multiple rounds of PT, injections, multiple surgeries, alternative therapies, and chronic pain medications are all things that patients with chronic back pain have to face. These are the characteristics of a chronic problem, not one that has a simple fix. Overall I am optimistic that we continue to try many different approaches and strategies to help this enormous problem, as it is imperative that we improve this burden on our patients’ quality of life. Fall means that change is in the air! I am looking forward to working with the MMA to help select a new CEO. Bob Meiches has provided great service to the MMA over the past 10+ years and deserves our thanks. I want to thank the incredible team at Twin Cities Medical Society for making this a successful year. We are fortunate to have executive staff that keeps our programs running at full speed. Sue Schettle, CEO; Nancy Bauer, Associate Director and Managing Editor of MetroDoctors; Karen Peterson, Executive Director and Lynn Betzold, Program Coordinator, Honoring Choices MN; Grace Higgins, Project Coordinator, and Annie Krapek, Assistant Project Coordinator, of the Physicians Advocacy Network; and Sadie Rubin, Project Coordinator, The Convenings keep our organization working to improve the health of the communities in the Twin Cities. Success at the local government level with our T21 and Menthol efforts, statewide with Honoring Choices and The Convenings (which won an Emmy, by the way), seems to keep on coming! I know that incoming President Tom Kottke will make sure that next year is even better than this one in collaboration with the great staff that power this organization. Lastly, I am sad to tell you that Sue Schettle has accepted a job as the CEO of the Association for Residential Resources in Minnesota. This organization supports providers, businesses and advocates dedicated to leading the advancement of home and community-based services supporting people living with disabilities in their pursuit of meaningful lives. It is a mission that Sue feels passionate about and represents a positive change for her personally. Sue has been an incredible leader at TCMS for the past 16 years, and I will personally miss her insight and guidance. We all owe her a debt of gratitude for her work. In the interim Nancy Bauer has agreed to step into this role while the Executive Committee embarks on a search for a permanent CEO. And Sue has told me we will be able to rely on her for a transition period. 4

November/December 2017

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TCMS IN ACTION SUE A. SCHETTLE, CEO

A letter of management agreement has been signed between TCMS and Physicians Serving Physicians. The agreement is intended to secure management for PSP operations and assist with fundraising to help build a stronger ﬁnancial foundation for the program. Sue Schettle is currently managing the operations and has hired Karen Dickson, MD as a consultant to assist in the further development of PSP. Both Sue and Dr. Dickson have been meeting with health system leaders throughout Minnesota to help raise the awareness of the unique offerings of PSP and to ask for assistance in building a stronger PSP into the future. TCMS Members Highlighted at MMA Annual Meeting

The following TCMS physicians were presented with awards by outgoing MMA President David Agerter, MD at the Minnesota Medical Association’s Annual Conference held on September 23: • Christopher Reif, MD, received the President’s Award which recognizes a physician who has given much of his or her free time to help improve the association. • Benjamin Whitten, MD, received the Distinguished Service Award. This award is given to a physician who has made outstanding contributions to medicine, the MMA and the physicians of Minnesota during his or her career.

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• Medical Students Alexander Feng and Nathan Ratner received the Student Leadership Awards, recognizing exemplary leadership in service to fellow medical students, the profession of medicine and the broader community.

that creatively and effectively use corporate, non-proﬁt and broadcast resources to showcase the power of broadcasting to advance mission or message.” TCMS Shares our Public Health Model Across the Country

Thanks to a Physicians Foundation leadership grant, TCMS is able to share our non-dues revenue public health model with county, state and national medical associations. The “Physician Advocacy Network” model works to engage, educate and empower physicians to advance public health priorities. This model has allowed us to train over a thousand physicians on public health issues and to advance important policies in cities, counties and at the state level. Pete Dehnel, MD is serving as the Medical Director for this project.

Emmy Award for Honoring Choices MN Partnership in The Convenings

I am thrilled to report that TCMS received an Emmy Award on October 7th for its partnership in The Convenings, along with partners: The Bruce Kramer Collaborative, KARE-11, TPT and funding partners Allina Health, HealthPartners, CentraCare Health and George Family Foundation. The Convenings is a statewide initiative that includes live events hosted by Cathy Wurzer of MPR. Since 2016, The Convenings has organized six communities around meaningful conversations about what matters most now and at the end of our lives. The Convenings project brings to life the charge of the Emmy Board of Governors Award “…to honor visionary, long-standing relationships

St. Paul Takes on Menthol Tobacco

Photo by Midwest Emmys

Physician Wellness Program Continues to Evolve

The Convenings Partners: Cathy Wurzer, Sue Schettle, Bill Hanley

The Journal of the Twin Cities Medical Society

TCMS President-elect Tom Kottke, MD, and Board Member Tyler Winkelman, MD, recently testiﬁed in support of St. Paul’s ordinance to restrict menthol tobacco sales to adultonly tobacco shops. University of Minnesota medical students and Physician Advocacy Network members Alex Feng, Ed Walczak, Nick Pricco and Dave Bergstrand also attended hearings in support of the ordinance. At the time of publishing, the city had not yet held a ﬁnal vote on the ordinance. November/December 2017

Finding strong, new solutions for chronic spine pain Approximately $90 billion was spent on spine care in the U.S. from 1996 to 2013. Clinicians at HealthPartners Physicians Neck & Back Center and researchers at HealthPartners Institute are working together to find strengthbuilding alternatives to costly spine imaging and invasive procedures. HealthPartners Institute is one of the largest medical research and education centers in the Midwest. Weâ&#x20AC;&#x2122;re part of an integrated health care organization that includes hospitals, clinics and a health plan. Our teams are helping transform health care across the nation.

450+ ACTIVE RESEARCH STUDIES EACH YEAR Charles E. Kelly, MD Physicians Neck & Back Center

Low Back Pain

Colleague Interview: A Conversation with Ensor E. Transfeldt, MD

nsor E. Transfeldt, MD is an Orthopedic Spine Surgeon at Twin Cities Spine Center and serves as Medical Director, Allina Health Spine Development Program. He received his medical degree from the University of Witwatersrand in Johannesburg, South Africa and completed an internship in surgery at Baragwanath Hospital, also in Johannesburg. A residency and subsequent fellowship in orthopedic surgery were completed at the University of Toronto. Dr. Transfeldt served as a John H. Moe Spine Fellow at Twin Cities Scoliosis Spine Center/University of Minnesota. He is board certiďŹ ed in Orthopedic Surgery and is a Fellow of the Royal College of Surgeons. Dr. Transfeldt has received numerous awards and honors for his work related to spinal surgery and scoliosis and is a sought after speaker both nationally and internationally.

Please describe the difference between cervical spine and lumbar spine maladies, i.e. trauma-degenerative etiologies, treatment approaches, effectiveness and consequences; biomechanical options? The biomechanical principals of the cervical and lumbar spine are much the same. Each has vertebral segments with discs anteriorly and facet joints posteriorly, and each is subject to the same processes and conditions of malfunction and pain. The main difference between the two regions lies in the anatomy. There are two vital structures (neurological and vascular) housed within the cervical vertebral column that make this region unique. There are organs lying in juxtaposition to both the cervical and lumbar spine that need to be considered in anterior approaches as well. A) Neurological Structures within the Vertebral Column: Both regions have nerve roots that supply essential motor and sensory function to the extremities. However, the spinal cord typically ends at the L1-L2 level. Below these levels is the cauda equina, which offers greater resistance to injury by stenosis, occlusion or manipulation than the cervical spinal cord. Neurologic involvement

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The Journal of the Twin Cities Medical Society

is seen particularly in conditions of degenerative stenosis and traumatic canal occlusions. Nerve Root Pathology: Can occur in cervical and lumbar spine, and may result in radiculopathies affecting a limb. In the lumbar spine, nerve roots can be decompressed with relative ease and with minimal risk through a posterior approach that frequently does not require a fusion. In the cervical spine, however, a greater number of radiculopathies require a more complicated anterior approach because the spinal cord cannot be readily retracted posteriorly to access the nerve roots. The removal of the disc anteriorly in the cervical spine results in the need for doing fusions more frequently following such anterior decompressions. Spinal Canal Stenosis: Lumbar stenosis or occlusion, although more common than cervical stenosis, rarely results in severe neurologic deďŹ cits, and decompression can be done more easily without much risk from posterior and even anterior approaches. The spinal cord housed in the cervical spine is much more vulnerable to compression or manipulation than the cauda equina. This (Continued on page 8)

November/December 2017

Low Back Pain Colleague Interview (Continued from page 7)

vulnerability plays a role in clinical ﬁndings of primary conditions such as stenosis and fractures, as well as in the surgical treatment of occlusive spinal canal conditions. The results of severe cord injuries may result in severe tetraplegia and even respiratory arrest if the injury is high enough in the neck. Cauda equina injury is less common and rarely results in paraplegia and occasionally, loss of bowel and bladder sphincter control. More often in these cases, there is a greater capacity for more independent living and function versus cervical spinal cord injury. B) Vascular Structures within the Vertebral Column: Both regions have major vessels located anterior to the vertebral column. The aorta and iliac arteries are important for lower extremity viability. The carotid arteries supply vital blood supply to the brain. However, the vertebral arteries, lying within the vertebrae from C1 to C6 can be affected by primary pathologies but also pose a major threat to safety in reconstructive surgery. The vertebral arteries are a critical source of blood to the brainstem. Important Organs/Structures Adjacent to the Spine: Trachea and esophagus are important vital structures in the neck for anterior approaches but most surgeons are able to do their approaches to the spine. The more complicated anterior surgical approach to the lumbar spine is now more commonly done by a general or vascular surgeon to avoid injury to abdominal and pelvic organs.

Are there new treatments for (or what is the most effective treatment for) Osteoporosis, with or without compression injury; effective prevention strategies? More effective and safer bone enhancing and bone forming drugs have been developed and are being trialed. The most effective treatment for those in the ‘at risk’ population is prevention. Diet and awareness are important. The future in treating osteoporosis appears to be in molecular genetics. Annual studies and early clinical trials have shown that implantation of mesenchymal stem cells can safely and effectively enhance bone regeneration.

The medical device industry — what do you see as their strengths and pitfalls? What are your observations about industry and clinician consulting/partnerships? The medical device industry is clearly important in helping to bring newer and innovative treatments to providers for practical use.

November/December 2017

Strengths: Companies in the medical device industry have the resources and capacity to develop new products and perform research on a large meaningful scale. Their support staff, including sales, makes new products accessible and available to providers and patients throughout the world. Industry definitely has the capacity to expedite meaningful innovation. Pitfalls: Unfortunately, many of the companies in the industry are beholden to shareholders to show profit and return on investment. There is, therefore, a risk of focusing on profit rather than quality. Occasionally, in their haste to bring new products to market for early returns, products may not be fully developed or investigated for safety and quality. We have seen many irrelevant products that function as gimmicks rather than provide useful improvement. Observations about Industry and Clinician Relationships: Partnerships between industry and surgeons are clearly beneficial if patient-centric care is the focus, as opposed to profit for either party. Clinicians are in a good position to advise, innovate and participate in research. We have seen that in numerous cases, some companies have utilized partnerships for marketing purposes rather than for the purpose of developing new and improved products. Unless a clinician is providing useful intellectual property or patents to the development of a product, he/she should not be paid royalties for the sale of that product. Consulting agreements need to be scrutinized for the usefulness that the clinician provides in the design of the products. Payments for participation in research and trials should be commensurate with the clinicians’ expenses and time. There are numerous reasons for the escalating costs in healthcare. Clinicians, hospitals, payers and industry should work together in reducing these costs. There needs to be a more patient-centered approach to value in healthcare. Value can be defined as quality and outcomes of care over the cost of care. Appropriate care (correct indications) should also be a factor in the equation.

Neurosurgery, general orthopedic surgery, osteopathy, spine subspecialty surgery: Who should do what? Is there a core training/competency threshold or requirement? If so, is it meaningful and effective, and if not should there be? And who should deﬁne and monitor? Spine care should be patient-centered, not specialty-centered. It needs to be integrated between all the providers to maximize diagnosis and treatment. There needs to be a clear, coordinated effort among all providers to avoid overutilization such as unnecessary tests, inappropriate, and/or ineffective treatment. Provider

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documentation of outcomes and quality measures would be a meaningful way to prove which treatments and providers are most beneficial and cost effective for patients. Surgery of the spine should definitely require core competency, but can be done by either Neurosurgeons or Orthopedic Spine surgeons who, at a minimum, are board certified in their specialty. Complex revision or reconstructive spine surgeons should also have fellowship training. Non-surgical spine specialists are, in most cases, the initial point of contact for patients with back pain, and they are able to provide good quality spine care. However, there are many knowledgeable surgeons who understand and currently practice appropriate evaluation and care. In addition, there are many lower cost non-MD providers that are capable of providing outstanding care. Physical therapists, for example, have been shown to provide outstanding spine care at more affordable prices in Canada and in some health care systems in the USA.

Degeneration of the spine usually involves degeneration of both the disc and the facets and both may be the source of pain. Occasionally, one or the other may be the predominant source of pain. Discogenic pain is characteristically worse with bending forward (ﬂexing) and sitting or activities that place greater load on the disc. Facet syndrome simply implies that most of the pain is arising from the facets. Any activity loading these posterior facet joints is likely to aggravate the pain. Extension movements producing pain is characteristic of facet syndrome. More commonly, pain will come from both. The importance of distinguishing which pattern of pain (discogenic or facet) lies in the design of the type of physical therapy and exercises to be prescribed. If a patient has facet syndrome, they are more likely to respond favorably from PT if the exercises are of the ‘ﬂexion routine.’ These include abdominal muscle strengthening and pelvic tilt exercises. Extension exercises should be avoided.

How does facet syndrome, as a cause of low back pain, compare to lumbo-sacral disc disease in frequency, ease of diagnosis and effectiveness of treatment?

Please discuss recent research and development advancements in diagnosis and/or treatment of low back pain etiologies.

Discs are the anterior articulation between vertebrae (building blocks of the spine) and facets are the posterior articulation.

There are many exciting developments but to mention a few, recent research has focused on disease processes such as disc (Continued on page 10)

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ACADEMIC RIGOR WITH MEANING & PURPOSE

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WORLD LANGUAGE BEGINS IN KINDERGARTEN

BRAND NEW!

MAKERSPACE

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SPORTS TEAMS AND AFTER SCHOOL CLUBS

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November/December 2017

Low Back Pain Colleague Interview (Continued from page 9)

degeneration at a molecular and genetic level. We are now beginning to understand the mechanisms that result in disc degeneration at a molecular level. This has resulted in attempts to manipulate and promote disc regeneration using a stem cell approach and research. The mechanisms and pathways of pain and its perception have also been studied using advanced invivo brain imaging technologies. There are structural and psychometric changes in the brain in chronic pain. Understanding these mechanisms of pain at a molecular level has also allowed us to improve management of pain through neuromodulation and behavioral therapy. Evidence-based medicine (EBM) has been useful to evaluate the outcomes of different treatments for managing low back pain. The Spine Patient Outcomes Research Trial (SPORT) has been useful to evaluate the role of surgery in disc herniation, spondylolisthesis and spinal stenosis. These studies have also emphasized the role and importance of non-operative treatment. Minimally invasive surgical techniques have dramatically reduced the magnitude, morbidity, and complications of many surgical procedures. This has led to faster recovery and earlier return to function. Advanced image guided techniques such as intra-operative MRI & CT scan, including robotics, have made many surgical procedures safer and more efﬁcient.

Please discuss the management of vertebral body fractures, specifically the controversy about vertebroplasty and kyphoplasty. Vertebroplasty and kyphoplasty were developed for the management of symptomatic painful vertebral compression fractures without neurologic deficit. Vertebroplasty involves percutaneous injection of bone cement (polymethyl methacrylate). Kyphoplasty is a technique where a balloon is inserted percutaneously into the compressed vertebral body and is then inflated to realign the endplates of the vertebrae and then bone cement is injected. These procedures are minimally invasive and indicated for severe pain in fresh compression fractures of the vertebral bodies or progressive collapse of the vertebral bodies in the acute phase. Controversy regarding the use of these techniques has arisen because of their widespread use in chronic fractures where pain relief has not been achieved.

night sweats, weight loss, loss of appetite, general malaise, history of malignancy and neurological symptoms and signs. Persistent severe pain in the very young and very old or the debilitated and immune compromised also demand special evaluation. Tumors and infections are the most common causes and should be diagnosed early.

What suggestions can you offer to minimize the use of opioids for low back pain relief? Opioids should be used very sparingly. There may be times patients experience intractable pain and do not get relief from antiinﬂammatories or other non-opioid analgesics. In these cases, providing short periods of reprieve with opioids is reasonable. However, patients need to be aware of the high risk of developing dependence (addiction). Studies have shown that opioid naïve patients given generous amounts of opioids after spine surgery will still be taking them in 10-25% of cases one year later. We need guidelines for the use and prescription of opioids in surgeries and clinical conditions. Cognitive behavioral therapy has been shown to be very effective in reducing use of opioid medications with spine pain. This helps patients to understand the mechanisms of pain and teaches coping strategies.

In what circumstances should no surgery be done? Spine surgery has not been shown to be as effective for patients with axial spine pain, i.e. low back pain or neck pain due to multilevel disc degeneration alone. Surgery should also be avoided in patients with excessive comorbidities when the beneﬁts of surgery are in doubt.

Any other comments related to low back pain you would like to offer to our readers? Managing back pain is a journey. The most important aspect of low back pain (LBP) is for patients to understand is that LBP is common and can be self-managed. LBP becomes more frequent with increasing age. It occurs in episodes and the best way to reduce and prevent episodes is to be active and do daily exercises. Maintaining a strong core is very important. Practicing good posture and mechanics is also a key feature.

Warning signs about back pain — when to do imaging vs conservative management. ‘Red ﬂag’ symptoms to pay attention to, and that call for advance imaging and more scrutiny include: severe night or rest pain, 10

November/December 2017

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is for recovery.

Better treatment options for chronic pain and injuries. Pain-free living starts with innovative treatment options. The orthopaedic team at University of Minnesota Health uses the latest research and state-of-the-art technology to care for patients with chronic pain and injuries. Every case is unique, so our providers work with a variety of specialists to help each patient meet their individual treatment goals. We oďŹ&#x20AC;er specialized care for most orthopaedic conditions, including sports injuries, shoulder problems, joint replacement, spinal pathology, orthopaedic oncology and hand surgery.

To schedule a consultation, referral or appointment: 612-672-7000 Learn more at mhealth.org/ortho

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Low Back Pain

A Neurosurgeon’s Perspective on Managing Low Back Pain

cute low back pain is commonly defined as low back pain lasting six weeks or less. Patients experiencing acute low back pain may also have leg pain, numbness or paresthesia because the lower extremity radicular nerves travel through the lumbar spine on their way to the legs. In the United States, acute low back pain is the second most common reason to visit a primary care physician. The lifetime prevalence of acute low back pain is estimated to be between 60% and 90%. The peak incidence of acute low back pain is between the ages of 30 and 50 years. Women are affected slightly more commonly than men. 85% of acute low back pain patients never achieve a specific diagnosis. Patients and physicians are often concerned that a specific case of acute low back pain might be caused by something serious such as a spinal infection or tumor. Physicians also carefully consider other non-spinal diagnoses such as renal colic, pelvic inflammatory disease, urinary tract infection, retrocecal appendicitis and abdominal aortic aneurysm. Most physicians are familiar with the cauda equina (compression) syndrome consisting of bilateral leg pain, numbness and weakness, saddle anesthesia and urinary retention. The initial management of acute low back pain often consists of controlled physical activity, physical therapy, nonsteroidal anti-inflammatory medication, opioids when necessary and oral corticosteroids. With these measures one can reasonably expect 80% to 90% of patients to recover in six to eight weeks. The most

By John Mullan, MD

November/December 2017

likely specific diagnosis is low back strain or a minor disc herniation. Occasionally physicians should deviate from the initial conservative approach. For example, a cancer patient’s low back pain might be caused by metastatic disease. Early diagnostic testing is indicated for cancer patients because early radiation therapy and/or surgery may be indicated to prevent paralysis. Likewise, immunocompromised patients or intravenous drug abusers may be harboring discitis or osteomyelitis and should be imaged early. Some patients have uncontrollable pain and for those patients, early imaging is indicated rather than subjecting them to six weeks of misery without a specific diagnosis. Finally, patients with progressive leg weakness or the cauda equina syndrome should be referred for early imaging. A cauda equina syndrome is an emergency because of the risk of a significant permanent neurological deficit without prompt surgical intervention. The imaging modality of choice for acute low back pain is the lumbar MRI scan. If patients have significant pain after six weeks of conservative care they usually can be placed into three categories based on their symptoms: patients with primarily persistent low back pain; patients with persistent significant posterior leg pain; and finally, patients with persistent significant anterior thigh pain. MRI scanning is indicated at this point. Patients with previous spinal surgery should be scanned with and without contrast to help distinguish between old granulation tissue and new disc herniation. If an MRI scan is contraindicated then a plain CT scan is the next best choice but likely a repeat CT scan with intrathecal contrast will be

required during the work-up, especially if surgical planning is required. Incidental ﬁndings are common on imaging so the results have to be interpreted in the context of the patient’s clinical presentation. The straight leg raise test is helpful when evaluating patients with persistent primarily posterior leg pain. A positive result usually indicates a soft disc herniation. A negative test suggests a diagnosis of stenosis. At this point a trial of an epidural steroid injection is a good option. At three weeks after the injection one can determine if the injection worked and if the effect was lasting. Persistent posterior leg pain caused by disc herniation or stenosis responds very well to surgery. Fusion surgery usually is not necessary except in cases of multiple reherniations from the same disc, preexisting spinal instability or required extensive bony removal. The less common patients with persistent anterior thigh pain are a little more complex. Osteoarthritis of the hip, pelvic or abdominal pathology and an inguinal hernia can all cause anterior thigh pain. Again, the examination helps. If the

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Patrick’s test or FABER test (for Flexion, Abduction, and External Rotation) of the ipsilateral hip produces pain, it is suggestive of a hip joint disorder on the same side. A standard physical examination may point to the abdomen or pelvis. A hernia test can reveal an inguinal hernia. If these are negative, then an epidural steroid injection can be ordered and may be successful. Persistent radicular pain responds well to surgery like posterior thigh pain. For patients with persistent low back pain and not much leg involvement there are several diagnoses to consider. These include lumbar strain, discogenic pain, spondylolysis, degenerative scoliosis, compression fracture, tumor, and infection. The MRI can help sort out the possibilities. Patients with relatively normal scans can be reassured that they will get better with time. For these patients, a referral to a physical medicine and rehabilitation physician is an option to consider and depends on the treating physician’s preference. The MRI scan may return a diagnosis of spondylolysis which is a stress fracture of the pars interarticularis and is often associated with spondylolisthesis which is the forward slippage of one vertebra in relation to the next one below it. Usually the two vertebrae are seen to move abnormally in relation to each other on flexion and extension plain x-rays. These patients can be managed conservatively with additional time and physical therapy, but often require surgery to stabilize the spine by fusing the two vertebrae together. The surgical success rate for lytic spondylolisthesis is often quite high because the instability causing the pain is treated. A diagnosis of discogenic low back pain requires the presence of abnormal discs seen on the MRI scan, characteristic low back pain and the absence of other diagnoses. Most degenerative discs, however, are not painful. Discogenic low back pain patients often find sitting to be the most uncomfortable position. Conservative management with time, therapy, exercises and medication is usually sufficient, but occasionally discogenic low back pain can become chronic and disabling. Lumbar fusion surgery can be performed to eliminate the offending disc, especially if MetroDoctors

the disease is limited to a single level, but it is not always successful. Lumbar compression fractures are commonly seen in the osteoporotic elderly and can be quite painful. The recommended treatment is early mobilization with a LSO (lumbosacral orthosis) brace, time and medication. Patients often ﬁnd their braces uncomfortable and stop wearing them. I have not seen an osteoporotic compression fracture come to surgery. Degenerative scoliosis causes pain because of the stress to the spine and surrounding soft tissues caused by the loss of coronal balance. If conservative measures fail and pain becomes debilitating, fusion surgery can be considered but often the disease spans many levels and the surgery can be quite extensive. Elderly osteoporotic patients often are not candidates for surgery. In summary, acute low back pain patients should be treated conservatively for six weeks, unless clinical red ﬂags are present, and most will get better. For patients with persistent pain an MRI scan is warranted and the subsequent management depends on the results of the scan and the details of the clinical exam. Additional conservative care, injections and referrals to specialists such as physiatrists and surgeons may be appropriate. Decompressive surgery without spinal fusion can be helpful for radicular pain, but in cases of multiple recurring disc herniations, required extensive bony removal or preexisting instability, spinal fusion may become necessary. Spinal fusion surgery can also be helpful in cases of persistent low back pain caused by spondylolysis and sometimes in cases of degenerative scoliosis and discogenic disease. John Mullan, MD earned his doctorate degree from the University of Chicago in 1987 and completed his Neurosurgery residency at the University of Minnesota in 1994. Dr. Mullan practices at Abbott Northwestern Hospital and his primary areas of interest are spinal surgery and stereotactic radiosurgery for brain tumors. Dr. Mullan can be reached at jmullan@neurosurgicalassocs.com or by US mail at Neurosurgical Associates, LTD, 800 East 28th Street, 305 Piper Building, Minneapolis, MN, 55407.

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November/December 2017

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The Conundrum of Treating Chronic Spine Pain Could a “less is more” approach improve outcomes and cost-effectiveness? Contributed by Charles Kelly, MD

A recent article in JAMA1 reviewed the costs of care for chronic conditions from 1996 to 2013. The three highest-cost conditions were cardiovascular disease, diabetes and spine care. Of the three, spine care costs had the fastest rate of rise; about $90 billion was spent on spine care over the 17 years studied. The cost could be justifiable if the outcomes were significantly improved, but by many measures, spinal outcomes have flatlined and, in some studies, are even worse than in the past few decades. These data raise the pressing question of what can we do as health care providers and insurers to improve the outcomes and quality of life for these patients in the most cost-effective way. The natural history of spine pain is such that acute low back pain, without any significant “red flags,” has an 80 to 90% chance of resolving within three months. Therefore, guidelines have been implemented for using less imaging and treatment while allowing patients with acute pain to recover spontaneously. However, it is well established that the cost of spine care is significantly higher in patients with chronic or chronic-recurrent pain. As much as 85% of the total cost of spine care occurs in this subgroup. To make a significant change in the treatment of spine pain, we need to target the group with chronic and chronic-recurrent pain. Identification of the exact cause of the pain is one of many difficulties in the evaluation of patients with chronic spine 18

November/December 2017

pain. Conservative specialists estimate that we are unable to identify the exact cause up to 85% of the time2 yet we continue to perform imaging studies and procedures to try to identify the exact cause of the pain. Do Imaging and Procedures Lead to Better Outcomes?

A recent study3 revealed that denervation treatment was no better than exercise therapy in three separate randomized controlled trials. Discograms have not been shown to improve fusion outcomes but are still performed regularly. In addition, studies have shown that obtaining imaging and performing procedures in patients with chronic spine pain can increase their perceived disability. Multiple studies have revealed significant abnormal anatomical magnetic resonance imaging findings in patients with no history of spine pain. A recent article discussed how giving patients wrong diagnoses can cause confusion and depression. Therefore, it is critical that we, as providers, be prudent when ordering tests and properly inform our patients of the true significance of any findings. Another dilemma involving patients with chronic spine pain consists of the often-associated psychological factors. Significant efforts have been made to introduce cognitive behavioral treatments and strategies into long-term spine treatment. This approach has grown to include cognitive behavioral programs, different medications and other interventions.

However, the effect of these treatments has varied, and a 1996 study revealed that cognitive behavioral programs did not improve outcomes beyond that of an active rehabilitation program. A recent study from the Department of Veterans Affairs4 showed that a simple phone call to a patient once a week was as effective as a formal cognitive behavioral program. It is important that we address this issue with patients, but what patient criteria warrants the intervention? What should that intervention be? The data on treatment results for chronic spine pain are not encouraging. Insurance companies have shown that patients with chronic spine pain are often treated with multiple modalities with only temporary results, leading to a high recidivism rate. Many patients go on a

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“medical merry-go-round” seeking treatments. Studies have shown that, if patients have persistent significant spine pain for longer than a year, they are at significant risk for depression and perceived disability. Many patients end up choosing expensive surgical procedures with unpredictable outcomes. Therefore, it makes sense to implement an algorithmic approach to care for patients with chronic spine pain. If we provide the most cost-effective outcome at the right time (about 12 weeks), chances are excellent that we can shrink the pool of patients needing more treatment. This could also significantly reduce the psychological consequences of prolonged pain. Relieving Pain by Increasing Strength

An intensive, specific strengthening program is an option that has shown results. Clinicians at HealthPartners Physicians Neck & Back Center believe that passive modality treatments for patients with chronic spine pain produce, at best, a temporary benefit and do not add to the outcome or reduce recidivism. Therefore, we do not provide passive modality treatments for patients with chronic spine pain. In our experience, over 90% of patients with chronic or chronic-recurrent symptoms are significantly deconditioned, with most having more than a 50% strength deficit on initial testing. We use strengthening equipment that isolates the key “core” spinal musculature that unloads and stabilizes the spine. This specialized medical equipment allows us to measure and increase muscle strength very effectively. When patients complete our program, their strength is often doubled or tripled, and their pain and function are significantly improved. We administer the Oswestry Low Back Disability Questionnaire and the Neck Disability Index questionnaire at the beginning and end of our program, and we have consistently averaged a roughly 60% improvement in scores. We instruct patients in a maintenance program after discharge, and a study5 we published revealed that 94% maintained their strength a year after MetroDoctors

discharge. Please visit our website for other articles on our data and outcomes. However, some patients are not candidates for this approach, and we are constantly trying to identify subgroups for whom our program is not a viable option. Exercise intolerance and certain psychological issues are, of course, contraindications. Other contraindications are severe spinal instability with radiculopathy and post fusion patients who have a pseudoarthrosis and\or metal loosening. We also avoid severe osteoporosis and acute fractures but will treat some post lumbar fusion patients who have a non solid fusion. We are also working to identify key factors for success. We try to address psychological issues with consistent messaging to patients. From triage to the final appointment, we consistently emphasize the importance of patients taking ownership of their condition and of completing the program. We teach patients that exercise, regular program attendance and acceptance of soreness are critical. They might not feel improvement in their pain until their strength significantly changes further on in the program. This is difficult, because patients must continue to pay copays and deductibles, invest time and arrange transportation to appointments. However, if patients complete our program, they have a 75% less likelihood of spending “spine” dollars in the next year than a control group that sought care outside of our clinic. This was revealed in a recent total cost of care study completed by the HealthPartners Informatics Department. Changing the Approach to Spine Pain

The stakes are high for these patients. We all know the debilitating effects of chronic spine pain on well-being. In addition to quality-of-life issues such as employment loss, inactivity, lost productivity, opioid dependence and depression, significant indirect effects have been identified. The current state of spine pain treatment and outcomes of that treatment demand that we change our approach significantly. We all want what is best for our patients, but we definitely have to improve patient

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selection for different treatments. We need to vigorously search for the best evidencebased treatment for each patient. Perhaps it is best to limit our treatment options to those with proven outcomes, because over treating can also be detrimental. A July 2012 article in the Archives of Internal Medicine6 argued for a “less is more” approach to the treatment of acute spine pain. Perhaps we should revisit this philosophy for the population with chronic spine pain as well. Before establishing Physicians Neck & Back Center (PNBC), Dr. Charles Kelly was exposed to patients with chronic back pain not responsive to treatments and surgery available to him as a primary care physician. Wanting to help patients alleviate their pain, he, together with Dr. Brian Nelson and Dr. Joseph Wegner founded PNBC in 1990. The PNBC approach to alleviating pain and improving function for chronic neck and back patients is based on restoring the spinal function, activity level and personal independence. Dr. Kelly has also conducted several research studies and published the results in peer-reviewed medical journals. He has been “Associate Medical Director at PNBC” from 2008 to 2016 and Medical Director in 2017. Dr. Kelly is Board Certiﬁed in Internal Medicine and has been practicing conservative spine care since 1988. References 1. Dieleman JL, Baral R, Birger M, et al. US spending on personal health care and public health, 1996-2013. JAMA. 2016;316(24):2627-2646. 2. Determining what is diagnosable and what is not. The Back Letter. 2017;32(2):13-21. 3. Juch JNS, Maas ET, Ostelo PT, et al. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: The Mint randomized clinical trials. JAMA. 2017;318(1):68-81. 4. Heapy AA, Higgins DM, Goulet JL, et al. Interactive voice response-based self-management for chronic back pain: The COPES Noninferiority Randomized Trial. JAMA Intern Med. 2017;177(6):765-773. 5. Nelson BW, O’Reilly E, Miller M, et al. The clinical effects of intensive, speciﬁc exercise on chronic low back pain: a controlled study of 895 consecutive patients with 1-year follow up. Orthopedics. 1995 Oct;18(10):971-981. 6. Srinivas SV, Deyo RA, Berger ZD. Application of “less is more” to low back pain. Arch Intern Med. 2012;172(13):1016-1020.

November/December 2017

Low Back Pain

Diagnosis and Management of Kyphosis, Including Scheuermann’s Kyphosis, in Children and Adolescents

pinal curvature can present in several forms during childhood or adolescence. The most prevalent and widely recognized form is scoliosis, a sideways-bending that can leave the spine resembling an “S” or “C” shape. Kyphosis is a less common form of spinal curvature characterized by a forward-bending of the spine, resulting in rounded, hunched or stooped posture. Normally, children and adults have some kyphosis (up to 50 degrees) in the upper back area, but too much curvature can lead to pain and posture issues. A form of kyphosis that develops in otherwise healthy children is called Scheuermann’s disease, or Scheuermann’s kyphosis. Kyphosis can also develop in children who have congenital conditions or chromosomal abnormalities, to varying degrees of severity. Prevalence While it is normal to have some degree of kyphosis in the thoracic spine, hyperkyphosis or excessive kyphosis can become problematic. In the general population, including children and adults, up to 21% of individuals have hyperkyphosis. Elderly women who have osteoporosis, for example, are at increased risk due to loss of bone mass, and hyperkyphosis in elderly individuals can put them at signiﬁcantly increased risk of falls. Children with weak bones are at increased risk as well. In typically developing children, the risk of Scheuermann’s kyphosis is between 1% and 8%. Detecting Hyperkyphosis Scoliosis is typically detected when a parent or primary care provider, upon viewing a child’s spine from the front or back while they bend forward, observes an abnormal prominence on one side which is associated with body wall or rib cage rotation. Conversely, hyperkyphosis is more easily recognizable because of the hunchbacklike appearance it creates. Teenagers, for instance, have a natural inclination to slouch their shoulders; this is called postural kyphosis and can be self-corrected. But when an adolescent is asked to stand up straight and physically cannot, consultation with a specialist can help pinpoint the cause, whether Scheuermann’s kyphosis or another underlying reason for structural kyphosis. Unlike scoliosis, pain is another indicator of hyperkyphosis. Discomfort may be focused in the thoracic spine, where the curvature occurs, but pain may also be experienced in the lumbar spine. This is because some children become so kyphotic that, in order to compensate and

By Tenner Guillaume, MD, and Walter Truong, MD

November/December 2017

stand straight, they’re pulling their lumbar spine back. This puts pressure on the lower back and can result in excessive lordosis (hyperlordosis). The pain experienced in the low Walter Truong, MD back can be the Tenner Guillaume, MD result of muscular fatigue due to the exertion required to maintain an upright posture. It can also be due to stresses in the facet joints of the lumbar spine caused by increased pressure and compression they experience from all of the lordosis. Additionally, children who develop hyperkyphosis, especially Scheuermann’s kyphosis, tend to develop stretch marks on their backs. This is the skin’s natural response to rapidly advancing spine curvature. Treatment Guidelines Monitoring and early intervention is important to successful management of hyperkyphosis in rapidly growing children. Normal amounts of curvature generally fall between 20 and 50 degrees. Above 50 degrees is considered hyperkyphotic. At 60 degrees in a skeletally immature child, we may recommend families consider bracing. A kyphosis back brace can prevent curvature from worsening, and in rare instances correct the curvature by holding the spine straight during growth. The brace creates tension in the front of the spine, which encourages bone growth. As with bracing for scoliosis, it’s important the brace be worn consistently to maximize its effectiveness with 18 hours a day or more being ideal. For more severe kyphosis, upwards of 80 degrees or more, or if pain increases or persists, surgery might be necessary. Surgery entails a fusion procedure and includes correction of the kyphosis to within normal range. Oftentimes factors such as an individual’s pelvic orientation in space may direct how much correction is planned in a kyphosis case. In correcting the kyphosis the goal is to restore spinal balance and stability, decrease or eliminate pain, and prevent future curve progression. The objective of spinal fusion is always to fuse the smallest amount of the spine necessary to obtain desired results. MetroDoctors

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Surgery to correct kyphosis comes with higher risk for neurological injury than surgery to correct scoliosis because of the anatomy of the blood supply to the spinal cord. When kyphosis correction is undertaken the spinal cord is lengthened anteriorly which may compromise its anterior blood supply. The potential risks of excessive bleeding, infection and neurologic injury underscore the importance of high-end intraoperative monitoring and coordination among providers, including orthopedics, neurology and anesthesia. At Gillette Children’s Specialty Healthcare, a pediatric neurologist is present in the operating room during all procedures to correct kyphosis in the unlikely event that issues arise. This is a rarity, as many hospitals outsource their intraoperative monitoring. Spotlight on Scheuermann’s Kyphosis Symptoms of Scheuermann’s kyphosis typically develop between ages 10 and 15, while bones are still growing. The condition occurs equally in boys and girls. Radiographically, wedging of ﬁve degrees or more on three consecutive vertebrae is diagnostic. Schmorl’s nodes — irregularities of the vertebral endplates — must be present as well, an indicator of weakening of the spine’s growth plate. As the growth plate weakens, spinal discs herniate up into bone, creating an undulating pattern. Interestingly, individuals who do not have the spinal curvature seen in Scheuermann’s kyphosis can present with Schmorl’s nodes on their spine. This is referred to as juvenile discogenic disease or Scheuermann’s like change. These changes may be associated with pain. Most treatments for juvenile discogenic disease are nonoperative in nature with a focus on physical therapy and spinal stabilization.

A fusion was recommended, and performed, at age 18. He went home three days after surgery. Six months later he is pain-free and off to college.

Case Study 1: Initial

Case Study 1: Pre-op

Case Study 1: Post-op

A 13-year-old boy presented to the Gillette spine clinic with a 71 degree thoracic kyphosis. At the time he was quite skeletally immature. Given the combination of hyperkyphosis and skeletal immaturity, a brace was recommended. The boy wore the brace regularly (more than 18 hours each day) for 18 months. At skeletal maturity the curve had corrected to 57 degrees and he was weaned from the brace. He has been pain-free throughout.

Long-Term Implications Hyperkyphosis, if untreated or only partially treated during childhood and adolescence, can lead to increased prevalence of back pain, detrimentally affect mobility, and make activities of daily living more difﬁcult during adulthood, particularly as the aging process inevitably increases the degree of hyperkyphosis in the thoracic spine. The risk of falls or fractures in the elderly has been associated with abnormally high degrees of kyphosis. Conclusions If a non-postural hyperkyphosis is observed by a parent or primary care provider, it should be closely monitored and treated by a pediatric spine specialist. Curvature of more than 60 degrees associated with Scheuermann’s kyphosis indicates a potential need for intervention in order to alleviate the risk of future discomfort and prevent long-term symptoms into adulthood, including chronic pain. Structural kyphosis that presents in typically developing children is called Scheuermann’s kyphosis, but hyperkyphosis can accompany syndromic and congenital conditions as well.

Tenner Guillaume, MD, is a pediatric spine surgeon at Gillette Children’s Specialty Healthcare. He received a medical degree from the University of Minnesota, then completed a residency at the University of California — San Francisco and a fellowship at the Twin Cities Spine Center. His areas of interest include scoliosis (all forms), kyphosis, spondylolysis and fractures.

Case Studies 1. A 14-year-old boy was approaching skeletal maturity and had a 69 degree kyphotic curve with no pain. The Gillette spine clinic followed the boy as he grew. Over the next four years, his curve progressed to 77 degrees and his lumbar lordosis increased from 84 degrees to 100 degrees. He also began to develop back pain.

Walter Truong, MD, is a pediatric spine surgeon at Gillette Children’s Specialty Healthcare. He received a medical degree from Ohio State University, then completed a residency at the University of Minnesota and a fellowship at the University of Toronto — Hospital for Sick Children. His areas of interest include scoliosis (all forms), kyphosis, pediatric hip and knee conditions, and lower extremity alignment concerns.

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Case Study 2: Pre-Brace Lateral Thoracic Spine Xray

Case Study 2: Post-Brace Xrays

November/December 2017

Low Back Pain

Occupational Medicine Considerations in the Management of Low Back Pain Injuries

ow back pain (LBP) is the leading cause of disability in persons under age 45 and the third leading cause in persons over 45.1 The United States (U.S.) Bureau of Labor Statistics demonstrate that LBP injuries occur roughly six times as often as leg, finger, or shoulder injuries; LBP is easily the leading industrial health complaint.2 It is second only to respiratory tract infections as a reason to see a physician.3 There are over a million back injury Workers’ Compensation (WC) claims in the U.S. annually, and more than one third of occupational musculoskeletal injuries resulting in work disability are due to LBP.4,5 Fortunately, most individuals (approximately 75%) will significantly improve in 2-3 weeks, and 90-95% will have returned to all normal activities within 2-3 months time; however, upwards of 60% will have a recurrent episode within a year.6 Of greatest concern is the fact that 5-10% of individuals with mechanical LBP develop “permanent disability” accounting for upwards of 75-90% of total costs.7,8 The average direct cost (including replacement of wages, known as indemnity) per industrial back injury involving at least one lost workday in the U.S. is over $24,000 and isolated cases have exceeded $900,000.9 Indirect and intangible costs of occupational LBP, such as losses in productivity at work and home, and decreased quality of life, are more difficult to estimate.10 Additionally, many work-related injuries are never reported by the employee and/ By Ralph S. Bovard, MD, and Zeke J. McKinney, MD

November/December 2017

Ralph S. Bovard, MD

Zeke J. McKinney, MD

or employer, muddling true estimates of the impact of occupational LBP. Because of these enormous financial impacts, a triad of interests are at stake in work-related LBP. The patient wants to resolve their pain and resume normal activity (usually). The clinician wants to provide timely, cost-efficient, and appropriate care. The employer wants a healthy employee who can remain functional in their given job, in addition to avoidance of lost time injuries. The unified focus of patient care is then to minimize the patient’s discomfort and dysfunction, facilitate timely return to unrestricted work, decrease the possibility of a prolonged recovery due to disuse atrophy, and avoid disability. The overarching goal is to minimize lost work time and keep the worker in the workplace whenever possible, as the likelihood of ever returning to work decreases as time away from work increases. An unfortunate scenario can occur when an employee is discharged from an emergent care facility with a letter removing them from the workplace for several days or weeks, or

until further evaluation by occupational medicine. This often results in an individual sitting at home for days or weeks without effective management, a delayed recovery, and an unhappy employer with a recordable injury and a lost time accident. Our guidance is to refer the patient for consultation in occupational medicine at the next available opportunity, but return the worker to the workplace while providing accommodations to the employer to allow them the opportunity to offer alternative work to the employee during the interim. To achieve the objective of maximizing employee function, the treating provider should allow accommodations by the employer whenever possible. This can be specified in the form of a workability letter that is activity-specific rather than job-specific, as this allows the employer the most flexibility in providing suitable accommodations for an employee. Employees may state that their employer does not have “light duty,” or that they are unable to perform the role of a specific job. Clear

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functional restrictions for an employee allow the provider to appropriately mitigate reinjury while allowing the employee to maintain as close to their normal routine as possible. If the employee cannot do his/her normal job with accommodations, the employer has the right to ask the employee to do other work activities such as answering the phone or sorting parts. Work restrictions with respect to a low back injury should address activities such as lifting (including specifying weight limits and variations in the height from which an object is lifted to where it will be placed), bending, twisting, kneeling, squatting, sitting, standing, and walking, with each impairment specified with respect to the frequency (e.g., 50% of the workday) with which the employee can conduct such duty. Although restrictions should not identify tasks of specific jobs in general, it is essential to consider job demands whenever providing workability restrictions for individuals with back pain or a back injury. Issues of working at height, involvement in position of risk (safety-sensitive) activities, and other high-risk public safety roles such as firefighting, law enforcement, or institutional corrections deserve special consideration. Employees working at heights, e.g., roofers or arborists, also have unique concerns and protective restrictions may need to be provided in these instances. In this same context, medical therapies (e.g., medication with a sedative effect) that may impact an employee’s function must be avoided, or at least specified as part of a workability letter. Work restrictions are required to be accommodated by the employer in the WC system, increasing the incentive for employers to provide “light duty” work for employees. In the event that an employer cannot accommodate an employee’s restrictions, the employee will be removed from the workplace by the employer and their wages replaced via indemnity payments. However, the WC system can be a burden on employees and providers, as the timing and likelihood of insurer approval MetroDoctors

or indemnity payments may vary, particularly if the work-relatedness of the injury is in question. As such, involvement of a case manager or qualified rehabilitation consultant (QRC) in the care of the injured worker can be critical if it appears that there will be a prolonged or complicated course of management. Providers treating occupational injuries can aid this process by communicating with the employee, employer, insurer, and/or case manager early and regularly to facilitate optimal treatment interventions and optimal care. The impacts of work-related LBP cannot be understated. As such, providers treating occupational back injuries must consider the involved stakeholders, lost time, workability, and thorough communications in the management of these patients. Referral to or consultation with an occupational medicine physician is always an available option to assist with the complexity of these cases. Ralph S. Bovard, MD, MPH, FACSM, is the Program Director for the HealthPartners Occupational Medicine Residency. He is a graduate of the University of Minnesota Medical School and completed an MPH and Preventive Medicine Residency at the University of Arizona in 1996. He is board certified in General Preventive Medicine and Occupational Medicine, and is a fellow of the American College of Sports Medicine. Dr. Bovard has more than 30 years of clinical practice experience, working in Emergency Medicine, Musculoskeletal and non-operative Orthopedics, Occupational Medicine, and Preventive Medicine. He can be contacted at: Ralph.S.Bovard@HealthPartners. com, or (651) 293-8269. Zeke J. McKinney, MD, MHI, MPH, is a board-certified Occupational and Environmental Medicine (OEM) physician who works as the primary OEM provider at the Anoka HealthPartners Riverway Clinic. He is additionally board-certified in Clinical Informatics, which is the practice of optimizing information in the delivery of healthcare. He is the Assistant Residency

The Journal of the Twin Cities Medical Society

Director, HealthPartners Occupational and Environmental Medicine, Affiliate Assistant Professor, Division of Environmental Health Sciences, UMN School of Public Health and a Clinical Investigator, HealthPartners Institute. He can be contacted at: zeke@umn. edu, or (952) 883-6999. References: 1. Casazza BA, Young JL, Herring SA. The role of exercise in the prevention and management of acute low back pain. Occupational Medicine: State of the Art Reviews 1998;13(1):47-60. Philadelphia, Hanley & Belfus, Inc. 2. Courtney TK, Webster BS. Disabling occupational morbidity in the U.S. JOEM 1999; 41(1):60-69. 3. Hart GL, Deyo RA, Cherkin DC. Physician office visits for low back pain: frequency, clinical evaluation and treatment patterns from a national survey. Spine 1995; 20:11-19. 4. Waddell G. The Back Pain Revolution. Edinburgh: Churchill Livingstone, 1998. 5. Bureau of Labor Statistics, U.S. Department of Labor, Workplace Injuries Data, Sep 07, 2017 [www.bls.gov/data/]. 6. Carpenter DM, Nelson BW. Low back strengthening for the prevention and treatment of low back pain. MSSE 1999;31(1):18-24. 7. Frymoyer JW and Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthopedic Clinics of North America 1991; 22(2): 263-271. 8. Spitzer WO. Scientific approach to the assessment and management of activity-related spinal disorder. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine 1987; 12 (7 Suppl): S1-S59. 9. Nelson BW, Carpenter DW, Dreisinger TE, Mitchell M, Kelly CE, Wegner JA. Can spinal surgery be prevented by aggressive strengthening exercises? A prospective study of cervical and lumbar patients. Arch Phys Med Rehabil 1999;80:20-25. 10. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J. 2008 Jan-Feb;8(1):8-20.

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November/December 2017

Low Back Pain

Low Back Pain Treatment Alternatives: Opioids, Surgery, Interventional Pain Management

ow back pain is a leading cause of disability world-wide and one of the most common reasons for visiting a health care provider in the U.S. Although 90% of low back pain episodes resolve within six weeks, 60-80% of patients experience a recurrence within two years and 7% develop chronic low back pain deﬁned as continuous pain lasting more than six months. It is estimated that Americans spend $50 billion annually on low back pain treatments, with annual indirect costs to society approaching $100 billion. Managing chronic low back pain with opioid medications is increasingly controversial as the U.S. continues to experience an epidemic of opioid-induced morbidity and mortality. According to the Centers for Disease Control, the overdose death rate from prescription opioids has more than tripled from 1990 to 2013 and opioid overdose is now the leading cause of injury death in the U.S. Doctors who prescribe opioids to treat chronic low back pain are increasingly being held liable for patient overdoses, trafﬁc accidents and opioid-related patient injuries and some opioid-prescribing physicians have even been prosecuted for murder. On the positive side, opioids are not harmful to body organs even at high doses, and some chronic low back pain patients do well on moderate doses over the long term with good pain relief, better function and minimal side effects. Although all patients on long-term opioids become physically dependent on these drugs, only about 20% percent become addicted, according to National Institutes of Health data. In the U.S during 2012, there were 259,000,000 opioid prescriptions written with 16,000 related deaths. Although one

By David Schultz, MD

November/December 2017

opioid overdose death is too many, it is clear that millions of patients take opioids and do not die. Furthermore, medication alternatives to opioids are not without morbidity and mortality — acetaminophen toxicity is one of the most common causes of death from liver failure in the developed world while non-steroidal anti-inﬂammatory drugs cause extensive morbidity and mortality from gastric bleeding, cardiac injury and permanent kidney damage. Although many patients with low back pain improve over time, some do not. When low back pain is severe, disabling and persists beyond routine medical care and medication management, referral to a spinal pain specialist may be indicated. Patients with severe structural abnormality or neurological deﬁcits should be referred early for spine surgery consultation. When surgery is not immediately indicated, the interventional pain specialist may be able to help reduce symptoms, improve function and decrease the need for opioid medications and/or surgeries. Interventional pain management is a relatively new medical subspecialty which focuses on identifying and targeting the physical generators of pain using advanced imaging systems and minimally invasive

techniques. Interventional pain procedures include spinal injection, neural blockade, nerve ablation, vertebral augmentation, endoscopic disc decompression and implantation of pain control devices such as spinal cord stimulators and targeted drug delivery pain pumps. Multidisciplinary interventional pain clinics combine onsite physical therapy and behavioral health treatments coordinated with invasive procedures. In the past, chronic low back pain was often considered an incomprehensible, permanent condition with no specific diagnosis or treatment. Today, with the evolution of advanced imaging, new minimally invasive spinal interventions and innovations in implantable pain control technologies, pain specialist physicians are able to accurately diagnose and effectively treat chronic low back pain previously considered untreatable. Referral to the interventional pain clinic should be considered to provide patients with an alternative to long-term opioids and high-risk surgeries. David Schultz, MD, is the Founder and Medical Director of MAPS Medical Pain Clinics and MAPS Applied Research Center. He is a board certified anesthesiologist with additional board certification in pain medicine from the American Board of Anesthesiology, the American Board of Interventional Pain Physicians and the American Board of Pain Medicine. He has been a full-time interventional pain specialist since 1995. He is a board member and Past President of the American Society of Interventional Pain Physicians (ASIPP). Dr. Schultz serves as an Instructor for ASIPP and for the International Spinal Injection Society. Dr. Schultz is a prolific author of clinical articles and book chapters, a frequent speaker at national meetings and a principal investigator in pain research.

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The Journal of the Twin Cities Medical Society

Environmental Health — Changing Climate and Minnesota Communities “Living outside town on a rural property, the loss of electricity and power for 5 days after the storm was tough...the heat, humidity and mold flared up her asthma and the nebulizer was not an option — no power. Inhalers helped her hang on. Once power was restored, this patient still had to clear mountains of debris — downed trees and branches, mud and sludge meant hours of cutting, shoveling, and hauling. All tasks were made more difficult by her wheezing and shortness of breath.(1) Owatonna 2010 flash flood (City of Owatonna). Every Minnesota county is experiencing more climate related stresses: extreme storms, flash floods, excessive heat, droughts. Warmer, wetter conditions have extended the pollen season by almost a month worsening asthma and allergies and allowing insect vectors to spread widely across our state.(2) Most at risk are the very young and the elderly, the chronically ill, the impoverished or homeless, and outdoor workers. By mid-century Minnesota is projected to experience 5-15 more days with maximum temperatures over 95°F. As each year becomes the ‘hottest on record’ heat-related illnesses will become more frequent and will require more extensive health care interventions and community adaptations.(3) The concentration of those highly vulnerable to climate stresses varies from county to county, e.g. Traverse, Big Stone, Swift and Chippewa Counties have the highest concentrations of older adults living alone while Mahnomen, Beltrami, St. Louis, Wadena, Clearwater, and Ramsey Counties have the highest percentage of people in poverty.(2) Some of the highest rates of asthma hospitalizations are in Benton, Mille Lacs and Lac Qui Parle counties. For over 20 years Minnesota policy makers, regulators, business leaders and concerned citizens have worked together to help our transition from fossil fuels to clean, non-polluting energy. Renewable energy now provides over 20% of our power and is growing. But we need to do more, faster, to cut greenhouse gas emissions and fossil fuel pollution 80% by 2050 as specified in the 2007 Next Generation Energy Act.(4) The message from our patients is clear: breathing free, enjoying the outdoors year-round, and seeing their children have a safe future are profoundly important. References 1. Patient history–submitted June 2017 by E.Onello MD, Family Physician, Duluth. 2. Minnesota Climate Change Vulnerability Report 2014 http://www.health.state. mn.us/divs/climatechange/docs/mnclimvulnreport.pdf. 3. MINNESOTA CLIMATE AND HEALTH PROFILE REPORT 2015, MN Department of Health http://www.health.state.mn.us/divs/climatechange/. 4. Climate Solutions and Economic Opportunities, MN EQB, https://www.eqb.state. mn.us/sites/default/files/documents/CSEO_EQB_0.pdf.

By Bruce D. Snyder, MD

MetroDoctors

The Journal of the Twin Cities Medical Society

November/December 2017

Advance Care Planning CPT Codes: a quick overview Since January 2016, physicians have had two new codes to ﬁle claims for Advance Care Planning (ACP) services. This means

CPT Code

that you can now claim reimbursement when talking with your adult patients about their health care goals, values, and

Billing Code Descriptors

99497

Advance care planning by the physician or other qualiﬁed health care professional done face-to-face with the patient, family member(s), and/or surrogate. May include explanation and discussion of advance directives such as standard forms. First 30 minutes.

99498

November/December 2017

future wishes. The conversation does not have to be tied to a speciﬁc diagnosis, there are no place-of-service limitations, nor does it require completion of any patient documents. Physician specialty is not a factor in determination. Medicare will pay for ACP as an element of the Annual Wellness Visit, or as a separate Part B service when it is medically necessary. In 2016, Minnesota ranked 34th nationally in use of these codes. Honoring Choices is committed to helping raise that ranking. If you have questions about using these codes, contact your site’s coding specialist, or Honoring Choices at (612) 362-3704.

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Students Support Health Equity with the Physician Advocacy Network

tudent advocacy efforts are in full swing as the fall semester is underway. The Physician Advocacy Network (PAN) with support from the Association for Nonsmokers–Minnesota (ANSR) held the ﬁrst meeting of Student Advocates for Healthy Communities on September 26. Students from the University of Minnesota Medical School, School of Public Health, Augsburg College and St. Catherine University came together to strategize for the semester’s advocacy. Hlee Yang, a St. Catherine University Public Health student interning with the PAN, is leading this effort to organize medical and other health science students across the Twin Cities metro to support local tobacco prevention policies. The group took to social media to show support for St. Paul’s ordinance to restrict the sale of menthol tobacco to adult-only shops and signed postcards to send to the St. Paul City Council. Student members Alex Feng, Ed Walczak, Dave Bergstrand and Nick Pricco also supported St. Paul’s menthol ordinance by attending public hearings on the issue as well as reaching out to city council members directly to express the need to prioritize health equity by passing the life-saving measure. Students were also able to meet

with Council Member Dai Thao along with other community advocates. The student group formed in early 2017 and held an advocacy skills workshop with Lisa Mattson, MD earlier this year. Student advocates will have the opportunity to share their experiences with other students at another advocacy skills workshop taking place this fall. Last semester, members of the student group were essential in passing Minneapolis’ menthol restrictions in August. Students met with council members Jacob Frey and Cam Gordon in addition to submitting emails and postcards of support. In August, Hlee and PAN Project Manager Grace Higgins also joined Chris Turner of ANSR and local radio host DJ Wes of Twin Cities Radio Network to share the details of physician and student involvement in

the recent work to restrict menthol tobacco in Minneapolis and St. Paul. The group plans to continue to support measures around the metro to restrict the sale of menthol and other ﬂavored tobacco products and increase the tobacco sales age to 21. Students interested in getting involved with Student Advocates for Healthy Communities can contact Annie Krapek at akrapek@ metrodoctors.com or visit www.panmn.org for more Ed Walczak, Dave Bergstrand, Grace Higgins and details. Nick Pricco at a St. Paul public hearing on proposed menthol restrictions.

Student Advocates for Healthy Communities convened to support menthol restrictions.

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Student Advocates for Healthy Communities posted photos on social media.

The Journal of the Twin Cities Medical Society

Tyler Winkelman, MD, Grace Higgins, Alex Feng and Annie Krapek before the ﬁrst St. Paul public hearing on proposed menthol restrictions.

November/December 2017

Reﬂections on the Minnesota Freedom to Breathe Act: Tobacco, Public Policy and Public Health

Editor’s Note: October 1st marked the 10th anniversary of Minnesota’s Freedom to Breathe Act, which gave Minnesotans the right to breathe clean indoor air in restaurants and bars. As we celebrate this momentous public health victory, we are reprinting an article published in the Nov/December 2007 issue of MetroDoctors, celebrating the role of physicians in advancing tobacco control in Minnesota. Thank you to all of the physicians who worked tirelessly to ensure that today’s kids are born with the freedom to breathe!

ALL HISTORY IS IN PART fictional and personal. We perceive the course of events through the filter of our own eyes and ears, and our personal experience affects our memory. Even though history cannot truly be objective, recalling and interpreting events is a common and valuable exercise. The 2007 Minnesota Freedom to Breathe Act is a capstone on a 27-year process that began with the first in the nation Minnesota Clean Indoor Air Act in 1975. It took almost three decades to satisfactorily implement the initial legislation’s intent. Smoking at work and other public places was the norm in the 1970s. Resistance to change came in many forms especially from smokers, business leaders, politicians and some physicians. “Legislating behavior” was the cry from opponents. Does that still sound familiar? The legislative success this year brings to completion a long effort and deserves to be celebrated. We have made major public health strides in cleaning the air Minnesotans breathe. Physicians and their professional organizations are to be congratulated for the major role they played in keeping the issue alive and collaborating with health plans and other professional groups to effect a major social change.

By A. Stuart Hanson, MD

November/December 2017

Why should professional organizations like county, state and national medical societies get so involved in a public health issue? Why should physicians spend their volunteer time trying to move city councils, county boards and state legislatures? I think it is because our patients expect us to do it. We are their advocates one-to-one in the ofﬁce and as a group in public forums. We are charged by our patients to act in their best interest and they expect us to take a lead when it affects their health. I became involved with tobacco control in the mid 1970s after four or ﬁve years in practice and regularly lecturing on pulmonary rehabilitation and cardiopulmonary resuscitation. I saw myself teaching physicians and patients recovery procedures for diseases that were preventable. Eighty to 90 percent of the patients I saw had diseases that were preventable, and tobacco was the cause. Looking around my practice environment, I saw ashtrays in our waiting rooms, staff and patients smoked in our cafeteria and we asked patients whether they wanted a smoking or non-smoking room when we admitted them to the hospital. It all didn’t seem right! If we are going to leave this world a better place when we are through, tobacco control seemed like a good place to start. In discussing the issue with my pulmonary colleagues, it was obvious that we

needed to clean up our own house before we could ask others to limit indoor smoking. Park Nicollet Clinic (formerly the St. Louis Park Medical Center and the Nicollet Clinic) set about to become smoke-free in all our buildings and grounds. Our primary hospital, Methodist in St. Louis Park, wished to defer their participation. A task force representing all interested parties came up with a plan that was implemented between 1980 and 1982. As far as I know, Park Nicollet was the ﬁrst multi-ofﬁce medical practice to go smoke-free in the country except for some Indian Health Service facilities in Arizona and Alaska. When the Hennepin Medical Society (HMS) Auxiliary in 1983 passed a resolution charging the medical society to work for a smoke-free society by the year 2000, they were not talking about our county society. They meant our country. The American Medical Association (AMA) was their target. When the resolution was to come before the AMA House of Delegates, the Minnesota Delegation needed a spokesperson to present the case and to defend the resolution.

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Since I was new to the delegation, had some experience in tobacco policy and did not smoke, as did several others in the delegation, I was designated to carry the resolution. It passed by agreeing to request a study and for the staff to make a report at the next meeting. Thus began a fight over the next several meetings to define what was meant by a smoke-free society and what were the elements that needed advocacy. The Minnesota Medical Association (MMA) implemented a smoke-free workplace in 1984, and the Minnesota Department of Health (MDH) formed a task force to develop its Minnesota Plan for Non-Smoking and Health to bring to the legislature in 1985. The task force recommended the community form a coalition of interested organizations to give credence and support for moving state legislation and it was chartered January 1, 1985. Then the Surgeon General, C. Everett Koop, championed the Smoke-free Society 2000 concept at the spring meeting of the American Lung Association. The auxiliary’s resolution had developed “legs.” I had a three-month sabbatical in 1984 visiting South and Southeast Asia, China and Japan. My project was to study different countries’ approaches to tobacco control by interviewing health professionals and government officials. I found the less developed countries were hooked on tax revenues and the finance ministers were winning out over health ministers in any attempt to reduce tobacco consumption. Economics were winning over health. Pakistan, India, Malaysia, Indonesia and China were actually

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promoting tobacco use. Only Singapore and Japan, the most economically developed, had begun any elements of public policy to curb smoking. Europe had some good examples in Scandinavia to follow, but Asia was not to be emulated. I found the obvious, public policy had a major influence on how a culture approached a public health problem like tobacco and I could see the parallels in the history of the United States as we had progressed economically. The Minnesota Smoke-free Coalition 2000 (MSFC 2000) began operating in 1985 as the legislative session began and was instrumental in getting the tobacco excise tax increased and funds designated to tobacco control. Also, a Swedish group approached the MMA about starting an initiative to prevent youth from smoking. Thus another new organization, A Smoke-Free Generation, was born. In conjunction with MDH, a t-shirt give away by A Smoke-Free Generation was the largest public health intervention (in raw numbers) up to 1987. A rally at the Metrodome brought 4,000 kids from all over the state to hear the Smoke-Free Generation message from rock bands including one led by a wrestler, Jesse Ventura. The MDH had grants to give to communities, schools and to state-wide initiatives. The MSFC 2000 started a Clean Air Healthcare program to promote smokefree medical facilities. The MMA, RMS and HMS led the way. Gradually, by the late 1980s about 30 percent of the hospitals and clinics were, or were in the process of, eliminating smoking in their facilities. That was the time to ask the legislature for supporting legislation. By now the Minnesota Hospital Association was on board asking that we establish “a level playing field” for all hospitals. Competition has its benefits sometimes. After a two-year phase-in period, all medical facilities and licensed daycare facilities were to be smoke-free January 1, 1992. The rest of the decade was a holding pattern with some gains and some losses.

The Journal of the Twin Cities Medical Society

MDH lost its tobacco tax funding, which was diverted to the general fund, and the Ofﬁce of Non-Smoking and Health was eliminated. Then, the Attorney General, Skip Humphrey, and Blue Cross ﬁled a lawsuit against the big tobacco companies alleging fraudulent sales practices causing harm. In 1998 the case in Minnesota was settled for $6.2 billion over 25 years. That led to a huge national Master Settlement for other states of over $200 billion. Some of the Minnesota money was set aside to fund smoking cessation and secondhand smoke reduction in an organization now called ClearWay Minnesota. The state received an upfront sum that was set aside to fund youth tobacco education. Unfortunately, when budget shortfalls presented, the endowment for youth was consumed by the general fund and the wonderful award winning target market program by MDH was eliminated. The state will receive about $200 million per year for another 15 years, which currently goes into the general fund. Health in Minnesota is on the upswing as 2007 comes to an end. Last year we passed a major increase in the tobacco excise tax, and this year we completed the long road to breathe clean indoor air. Still, we have nearly 20 percent of adults over 18 who continue to smoke and new recruits are starting every day. Fire safe, self-extinguishing cigarettes required after January 1, 2009, will reduce secondhand smoke in homes and reduce childhood exposures. Yet tobacco products are still lethal when used as directed. The glass is half full but getting fuller. We can’t let down yet and we certainly don’t want to break the glass. A graduate of Dartmouth College and the University of Minnesota School of Medicine, A. Stuart Hanson, M.D. is a renowned clinical pulmonologist at Park Nicollet Clinic, St. Louis Park. Dr. Hanson has served in several leadership positions including Chair of the Hennepin Medical Society, President of the Minnesota Medical Association and a delegate to the American Medical Association. It is through his vision, leadership, testimony and enduring drive for a smoke-free Minnesota that the State Legislature passed the Freedom to Breathe Act. Dr. Hanson was recently honored as a recipient of the University of Minnesota’s Harold S. Diehl Award.

November/December 2017

In Memoriam GORDON E. JOHNSON, MD, passed away on September 22, 2017. Dr. Johnson practiced Family Medicine in Golden Valley, MN. Dr. Johnson joined the medical society in 1963. VIRGIL TERRANCE “TERRY” RHODES, MD, passed away on September 2, 2017. Board certiﬁed in Otolaryngology, Dr. Rhodes was a founder of Children’s Minnetonka Surgical Center. He joined the medical society in 1976. ANTHONY “TONY” SPAGNOLO, MD, passed away on September 3. Dr. Spagnolo practiced Family Medicine for 48 years in Shakopee. He was a recipient of many awards, including the Charles Bolles Bolles-Rogers Award in 2012. He joined the medical society in 1999. WILLIAM EDWARD STEPHENS, MD, passed away on September 12. He practiced General Surgery at Abbott Northwestern Hospital for 40 years. Dr. Stephens joined the medical society in 1957.

CAREER OPPORTUNITIES

November/December 2017

See Additional Career Opportunities on page 31.

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November/December 2017

LUMINARY of Twin Cities Medicine By Marvin S. Segal, MD

JOHN H. MOE, MD

The Twin Cities medical community is rightfully proud of the brilliant array of clinical giants who have graced our population through the years. Standing right with them is our current Luminary . . . let’s meet him. Dr. John Moe was born to immigrant parents on a North Dakota farm at the turn of the 20th century and spoke no English when he first entered a one-room rural schoolhouse. He became an accomplished student, later entering the University of North Dakota, and then took encouraging advice from “the greatest influence of my life, my sister” — embarking upon a career in medicine via the Northwestern University Medical School. Being of modest means, perhaps partially accounting for his great generosity in later life, he worked his way through medical school as a “first aid night doctor” in Chicago. Post graduate Orthopedic residency training during the early depression years was obtained in Arkansas, California and finally in St. Paul — leading to his long and distinguished Twin City medical career presence. Gillette Children’s Hospital was then a public state institution when he joined their staff, and their collaboration with the U of M Medical School allowed for his first academic appointment as a Clinical Assistant Professor. Dr. Moe’s association with Gillette’s many children afflicted with spinal deformities — both developmental and secondary to polio — engendered his profound life-long interest in that division of Orthopedics, eventually resulting in him being appropriately referred to as “the father of modern-day treatment of scoliosis.” His early industrious talents soon led to his 1936 appointment as Chief of Orthopedics at the Minneapolis General Hospital (now HCMC) and his 1964 appointment as Professor and Chief of Orthopedics at the U of M. John’s accomplishments are legendary in the step-wise realms of initially better understanding spinal deformities, then developing strategies for their effective treatments and finally their dissemination via education throughout the Orthopedic specialty ranks. In 1947, he attended a Contemporary Orthopedic Society meeting where the main subject was scoliosis. That topic struck home for him and he quickly incorporated approaches gathered at the meeting and applied them into 32

November/December 2017

more realistic and productive treatment techniques at Gillette — where his pioneering work led to the first known dedicated in-patient hospital spine unit. Dr. Moe’s former resident and practice partner, Dr. John Lonstein, states, “One of John’s many talents was his ability to assess other proven excellent treatment modalities and modify them so they became even better.” He worked that modification magic with the previously recognized Milwaukee Brace, the famous Harrington Rod and with plaster casts supplanting turnbuckle casts. John was a leader in research, education and organizational construct. He was instrumental in the development of the Scoliosis Research Society — thus enhancing knowledge and collaboration beyond the U.S. to Europe, Asia and the Americas, the formation of the Twin Cities Spine Center, and a Scoliosis Fellowship which to-date has trained 170 who have gone on to internationally educate and train others. Additionally, he co-authored the first definitive text on his favorite topic — Scoliosis and Other Spinal Deformities. Dr. Moe, of proud Norwegian heritage, was an accomplished accordion musician, a slick fisherman and a dedicated family man. In his 82 years of life he has been variously described as energetic, intelligent, sensitive, creative, modest, honest, generous and caring. His colleagues and the thousands of patients he successfully treated agree that he fits all of those descriptions, which shine brightly in his memory . . . a true giant, a true Luminary. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

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The Journal of the Twin Cities Medical Society