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Medical Miracle or Mirage? Time will Tell


By Brenda Carland and John F. Marr
Maine Employers' Mutual Insurance Company

Medicine is ever changing and we love it! In the world of Workers' Compensation we are always looking for the next cure. We have improvements to current treatments and brand new procedures in constant development. However, we are also always skeptical of the quick fix. Furthermore, we detest costly procedures that don't fit the convenient text. Consequently, we suffer a pseudo bipolar disorder of our own making.

Undoubtedly, backs and knees are the bane of our claims existence. We set up reserves, in the range of hundreds of thousands of dollars, to cover the procedures and incapacity that seem without end. We know that there aren't any cure-alls and after years of failed procedures and dashed expectations we become jaundiced. After a while we damn anything that doesn't fit cleanly into the fee schedule as being medical adventurism. After all, we are charged with protecting the coffers from thieves of any persuasion.

Unfortunately, the injured worker, looking for relief, and the adjudicator, concerned with helping humankind mend, don't often hold our prudence in esteem. They push hard to have new procedures utilized and fall to the Siren song of medical pioneers who promise that the best is yet to come. We, the jaded claims lot, have to figure out if it is a miracle or a mirage. Do we pay now or pay later? This is a conflict that will go uninterrupted, of that you can be sure!

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We certainly can't pay for every new medical procedure that is dreamed up. We should demand that the research is clear and arguably sound, if not convincing. Whether we like it or not, we are going to be part of the testing ground. Medicine, far too often, doesn't lend the answer very quickly. Procedures and practices once thought to be cutting edge have been relegated to the infamy of bloodletting.

Today we are offered at least two procedures that promise to help injured workers heal and return to a normal and productive life. Since one promises to repair the back and, the other, the knee, it is wise to know more about them. Anything that portends to offer relief to sufferers of pain is worthy of thoughtful reflection - if not election.

One of the more recent developments for the treatment of chronic discogenic low back pain is the IDET procedure. Discogenic back pain is characterized by continuous low back pain, possibly with radiation into one or both legs, and is aggravated by even some of the most typical everyday activities such as standing or sitting. The cause of this pain is felt to be degeneration of the discs with tiny fissures in the disc covering. This allows disc material to escape, irritating nearby nerves.

Traditionally, treatment options have been: 1) long-term medications, 2) surgery in the form of spinal fusion, or 3) simply living with the pain. Approximately three years ago, however, a new treatment was developed which has offered a less invasive treatment option for those patients afflicted with chronic discogenic pain. This treatment is called IDET, or Intradiscal Electrothermal Therapy.

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Under fluoroscopy, a physician specially trained in spinal treatments and injections, inserts a small catheter into the affected disc. This catheter heats the internal disc material, sealing the small fissures. The patient is sent home with restrictions consisting of rest for several weeks. After the rest period, a slow rehabilitation phase is begun.

To date, results have been positive, with 81 percent of patients saying they noticed significant improvement in pain and function after treatment. Long-term follow-up studies are continuing and results are expected to be positive.

There are certain inclusionary criteria that must be met in order to undergo this procedure. The cost associated is approximately $5000 plus the cost of physical therapy. Compared to the approximate $100,000 cost of a spinal fusion, the IDET procedure could well be a cost-effective, viable option for patients with an often frustrating medical problem.

Some knee injuries improve with time and rest. Certain severe knee injuries may require joint replacement. Despite advances in joint replacement materials and surgeries, artificial knees usually last only 5-12 years. Cartilage replacement may become a treatment for worn out knees in the future. But for now, only tiny pieces of defective cartilage can be replaced. Thus, in an effort to try to improve joint healing, autologous (one's own) chondrocyte (cartilage cell) implantation (transplant) was developed.

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To perform the operation, a scope is placed inside the knee (arthroscopy) and a piece of healthy cartilage (full of cells called chondrocytes) is removed. The piece is minced into bits, filtered, and the chondrocytes are allowed to grow and multiply in a culture dish in the lab for 11-21 days. Following the growth period, under anesthesia, the knee is cut open and the damaged cartilage is cut out. A special flap is cut from the covering of the shinbone nearby, and is used to bridge the gap in the cartilage. The chondrocytes from the lab are injected underneath the flap in hopes that new cartilage will grow. A few days later, the patient may begin to bear weight on the joint. Rehabilitation for six months is required. There have been Olympic-level athletes who, after the prescribed rehabilitation, have been able to return to their previous level of activities and athletics.

Here's the challenge, what do you do with this information? If you forego these options you may save your company tens of thousands of dollars in medical care. However, you may leave an injured worker without relief and recovery. You may find, on the other hand, that this procedure provides only temporary relief and recovery. For now, there isn't a certain answer to the dilemma of choice that we face. Only time will tell.

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