5 Tests to Avoid in Back Pain
Choosing Wisely in Back Pain
On October 9, 2013, during its 28th annual meeting in in New Orleans, Louisiana, the North American Spine Society (NASS) released a list of 5 tests and treatments to use sparingly in spine and back pain care. [1] The report is part of Choosing Wisely®, an initiative of the ABIM Foundation encouraging physicians, other healthcare professionals, and patients to cut back on various medical tests and procedures that may be unnecessary or even dangerous. The list was developed by a multidisciplinary task force based on scientific evidence, expert consensus, and existing practice guidelines.
As a quick reference guide for those involved in caring for patients with back pain or spinal disease, Medscape asked rheumatologist Dr. Nathan Wei to walk us through the new recommendations.
Advanced Imaging
The Recommendation: Do not recommend advanced imaging (eg, MRI) of the spine within the first 6 weeks in patients with nonspecific acute low back pain in the absence of red flags.
The Rationale: Advanced imaging within the first 6 weeks of developing symptoms, in the absence of red flags, has not been shown to improve patient outcomes; however, it does significantly increase costs. Examples of red flags include trauma history, unintentional weight loss, immunosuppression, cancer history, steroid or intravenous drug use, osteoporosis, age older than 50 years, presence of a focal neurologic deficit, and progression of symptoms.
Dr. Wei's Bottom Line: When faced with a frustrated patient and no concrete diagnosis, turning to advanced imaging techniques can be appealing. But I think a 6-week course of conservative management is reasonable in the absence of radicular symptoms or progressive pain.
Conservative measures include brief (24-48 hours) bed rest with initiation of physical therapy. Medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants, are often beneficial. In patients who are sensitive to NSAIDS, analgesics such as tramadol can be used instead. Use of a cane while walking can help unload the back. Gradual introduction of stretching and strengthening of core muscles should be started. A lumbosacral corset might be helpful during the first 2-3 days, but the patient should be weaned after that.
Red flags are important guideposts that should alert clinicians that a more serious issue may be present. History of trauma, associated fever and chills, immunosuppression, history of cancer, osteoporosis, history of intravenous drug abuse, and progressive symptoms are the major red flags not to ignore.
As a consultant, I usually see patients who have passed the 6-week mark, so ordering an MRI is the next step
Elective Spinal Injections
The Recommendation: Do not perform elective spinal injections without imaging guidance, unless contraindicated.
The Rationale: Elective spinal injections should be performed under imaging guidance using fluoroscopy or CT with contrast enhancement (except when contraindicated) to optimize needle placement, diagnostic accuracy, therapeutic efficacy. Not using imaging guidance may result in inappropriate, and thereby less effective, medication placement and the need for additional future care and cost.
Dr. Wei's Bottom Line: Imaging is critical to ensuring accuracy as well as a good outcome. The use of fluoroscopy or CT guidance is often preferred by spine specialists. In rheumatology, we tend to use either fluoroscopy or ultrasonography, primarily because we often don't have access to a CT unit.Specifically, we are using ultrasonographic guidance more and more, which I think is superior to fluoroscopy for 2 reasons. The first is that soft-tissue abnormalities are visible, as are major vessels; this precludes the possibility of inadvertent damage. In addition, there is no radiation with ultrasonography.
Rethinking Bone Morphogenetic Protein
The Recommendation: Do not use recombinant human bone morphogenetic protein (rhBMP) in routine anterior cervical spine fusion surgery.
The Rationale: rhBMPs are a group of growth factors that control tissue architecture throughout the body, including stimulating formation and healing.Although these compounds, particularly rhBMP type 2, have been used in numerous orthopedic applications, life-threatening complications have been reported with routine use of recombinant human rhBMP in anterior cervical spine fusion surgery, owing to swelling of the soft tissues. This may lead to difficulty swallowing or pressure on the airway.
Dr. Wei's Bottom Line: BMP initially showed promise as an adjunct to help with healing. It was also explored as a possible disease-modifying therapy for osteoarthritis. Unfortunately, the formation of ectopic bone, with its attendant risks and complications, has dampened the enthusiasm for this protein. Until further studies demonstrate that BMP can be used without incurring complications, it will rest on the back burner.
Leave Nerve and Muscle Function Alone
The Recommendation: Do not use electromyography (EMG) and nerve conduction studies (NCS) to determine the cause of axial lumbar, thoracic, or cervical spine pain.
The Rationale: EMG and NCS are measures of nerve and muscle function. They may be indicated when there are symptoms that raise concern about neurologic injury or disorder, such as the presence of leg or arm pain, numbness, or weakness associated with compression of a spinal nerve. Because spinal nerve injury is not a cause of neck, mid-back, or low back pain, EMG and NCS have not been found to be helpful in diagnosing the underlying causes of axial lumbar, thoracic, and cervical spine pain.
Dr. Wei's Bottom Line: I agree and I disagree here. Purely localized back pain is generally not associated with nerve impingement; however, there are exceptions. In particular, thoracic radiculitis can be a diagnostic problem. I have seen this in patients with Lyme disease. The presence of radiculopathy may alter the course of treatment, and therefore electrical studies should be used if indicated.
The most common cause of radiculitis is generally degenerative disc disease. As a resident, I saw patients with tuberculous abscesses causing radiculitis.Fortunately, this is rare.
One should not forget that referred pain can be confused with radiculitis. An example might be gallbladder disease that causes referred pain to the tip of the scapula or ruptured ectopic pregnancy that can cause diaphragmatic irritation and "pseudoradicular" pain. Preherpetic neuralgia can also be a "fooler."
Cut Back on Bed Rest
The Recommendation: Don't recommend bed rest for more than 48 hours when treating low back pain.
The Rationale: In patients with low back pain, bed rest exceeding 48 hours in duration has not been shown to be of benefit.
Dr. Wei's Bottom Line: Bed rest is a double-edged sword. Short-term bed rest is beneficial. Longer-term bed rest, meaning longer than 48 hours, can be detrimental because it causes weakness of the paraspinal muscles and deconditioning. For uncomplicated low back pain, every attempt should be made to encourage stretching and strengthening of core muscle groups as soon as possible; an appropriate rehabilitation program should be initiated quickly.
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