Introduction: A Terrible Affliction

W HEN I W EN T LOOK ING FOR A SOLU TION, I

FOU ND A M UCH BIG GER PROBLEM

T he note in my calendar, put there on April14, 2008, says, Find

a spine surgeon. For decades, Id sought to avoid open warfare
with my back, but on that date, the truce officially ended.
Over the years, Id spent a fortune on chiropractic care, acupunc-
ture, physical therapy, and massage. Id signed up for Pilates, yoga,
Tai Chi, and strength training, but instead of abating, my pain inten-
sified. By 2007, I could not sit or walk comfortably for more than a few
minutes. My hip ached and my right leg was on fire. There seemed
to be no escaping the pain. Like a rat in a lab experiment, without a
prayer of avoiding the offending stimulus, I felt anxious, angry, and
trapped. When my dear friend Stacey asked me to join her on a hiking
trip in the Peruvian Andes, I told her I could not manage it. My anat-
omy was holding me hostage; instead of climbing mountains, I would
be going under the knife.
I thought fixing my back would be as straightforward as fixing
a broken wrist. Id find a surgeon and get it done. But as I made my
way through overwhelming amounts of material on the Internet, I
saw that I was wrong. As an ordinary patient, I risked drowning in a
sinkhole of hype.
However, as an investigative reporter with three decades of ex-
perience in digging for the facts, I recognized that Id arrived on the
scene at the ideal moment. Back pain treatment was a microcosm of
everything that was wrong with the health care system. Back trouble,
2 ] C R O O K E D

in all its permutations, costs the United States roughly $100 billion a
year, more than is spent annually to treat cancer, coronary artery dis-
ease, and AIDS (acquired immunodeficiency syndrome) combined.
On a per capita basis, other nationschief among them, the United
Kingdom, Australia, Canada, Germany, Sweden, Denmark, the Neth-
erlands, China, and South Koreaalso pay hefty bills.
When I did my first Internet search, I had no idea that Id spend six
years studying this topic. Nor did I realize that in the interim, proce-
dures that, for decades, had been upheld as the gold standard in spine
care would be relegated to the dusty and crowded shelves of misguided
medicine. Spine surgeons go-to procedurelumbar spinal fusion
would be discredited, primary care doctors would find that theyd
launched a prescription opioid epidemic, and interventional pain
physiciansthose who perform epidural spinal injectionswould be
faced with evidence that their shots didnt work. Federal prosecutors
would punish device manufacturers for selling spinal instrumentation
that was inadequately tested. Painkiller manufacturers and the U.S.
Food and Drug Administration would be found tucked into bed with
each other, working the drug approval process without regard to pa-
tients best interests. As the story evolved, the journalist in me relished
each appalling revelation. As a patient, however, I felt as if Id barely
avoided stepping off the curb in front of a bus. Many people, I real-
ized, were not so lucky: They got caught in a relentless loop, and were
commonly harmed in the process. As one mother, whose most recent
episode of back pain commenced when she bent forward to hand her
toddler a lollipop, wrote in an e-mail, In an effort to resolve my back
problems, Ive had a host of ridiculous medical encounters over the
last few years, some confusing, some offensive, some harmfuland I
feel completely upside down and unclear about how to best find help.
My goal with Crooked is to set the back pain industrys offerings in
their proper context, so that patients have the information they need
to make good decisions; to know what works sometimes, what works
rarely, and what can cause harm. With luck, I will spare you the side
effects of optimism bias: the very human proclivity to seek out in-
formation that supports your own views, while ignoring that which
 Introduction: A Terrible Affliction[ 3

does not. Patients have a tendency to overestimate the benefits of

treatments, while underestimating the downside, especially when in
the presence of a health care provider who would prefer not to admit
that he doesnt know. Whether he or she wears a white coat, hospital
scrubs, or workout gear; cracks your back; cossets you with heating
pads; sticks you with needles; or hands you a set of free weights (and
then ignores you in favor of his Twitter feed); remember that every
stakeholder wants and needs your business.
Epidemiologist and internist Richard Deyo, a keen thinker about
these issues, and the Kaiser- Permanente Endowed Professor of
Evidence-Based Medicine at Oregon Health and Science University,
summarized the problem: Theres this very mechanical view of the
human body, he said, one that suggests that you can find out whats
broken and replace it or fix it.
These expectations did not arise in a vacuum, he emphasized,
eyebrows lifting slightly above the black frames of his glasses. Those
of us in the medical profession are probably guilty of creating them.
We seem to be doing more and more, but theres no evidence that
people are getting better pain relief. [Industry players] are just mak-
ing money hand over fist from back pain patients who are desperate
for something that will help them. Theyre very easy targets. Anyone
who says he has something that might help can set up a practice and
hang out a shingle without an iota of proof, and make a pretty good
living off of it.
It is fair to say that all professionsin medicine, commerce,
finance, or governmentharbor many who are ethical and well
intentioned, as well as some who are greedy and unscrupulous. It is
not always easy to tell one from the other in advance, or even in retro-
spect. And it is remarkably easy, as so many patients have discovered,
to undergo a series of treatments and procedures that are both unnec-
essary and terribly destructive.

You can approach this book in the conventional waystarting

with part I, where I examine what the scientific evidence says doesnt
4 ] C R O O K E D

work and why, before moving to partII, where I tell you what experts
say you need to know in order to get on the road to recovery. Or, as
I suspect will be the preference of many long-suffering chronic back
pain patients, you can reverse that plan and dive right into part II,
jump-starting your return to function before heading back to read
part I.
Successful rehabilitation is never passive: It requires sweat, per-
sistence, and a lifetime of hard work. Although it wont be easy or
quick or painless, by the time you finish this book, youll know how
to avoid therapeutic dead ends. No matter what youve heard, back
pain is not the unsolvable enigma of modern medicine. So stand by:
Youre about to learn what it takes to win this game.