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!
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.
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
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.
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.