Low Back Pain Guidelines Aid in Management

October 3, 2012 — Radiologists have developed evidence-based guidelines for management of low back pain, according to a report in the October issue of the Journal of the American College of Radiology. The accompanying order set templates should help clinicians decide on appropriate imaging, laboratory tests, and/or referral for surgery or other invasive procedures.

"The approach to the workup and management of low back pain by physicians and other practitioners is inconstant," lead author Scott E. Forseen, MD, from the Department of Radiology, Neuroradiology Section at Georgia Health Sciences University in Augusta, said in a news release. "In fact, there is significant variability in the diagnostic workup of back pain among physicians within and between specialties."

Low back pain is one of the most frequent presenting symptoms at outpatient visits. The authors note that the results of one study showed that more than one quarter (26.4%) of adults reported episodes of acute low back pain within the past 3 months.

In the United States, annual total direct and indirect costs of back pain are estimated to exceed $100 billion, with increased use of medical imaging contributing significantly to these costs, according to the authors. However, rising spine care expenditures for medical imaging are not linked to a corresponding improvement in patient outcomes.

Management Strategy

To facilitate clinical management of low back pain, the new guidelines suggest the following strategy:

Perform a complete history and physical examination at the initial visit, including duration and nature of symptoms, presence of red flags, and symptoms of spinal stenosis or radiculopathy. Red flags include history of trauma or cancer, unintentional weight loss, immunosuppression, use of steroids or intravenous drugs, osteoporosis, age older than 50 years, focal neurologic deficit, and progression of symptoms.
Categorize patients into 1 of 3 groups: nonspecific low back pain, low back pain potentially caused by radiculopathy or spinal stenosis, or low back pain potentially associated with another specific cause suggested by the presence of red flags.
Use the evidence-based order sets provided for each category to guide the initial visit process of assessment, management, and follow-up.
Use evidence-based order set templates at the 4-week follow-up visit to guide decisions regarding appropriate imaging, laboratory testing, referral for invasive procedures, and/or surgical consultation.

"We have presented a logical method of choosing, developing and implementing clinical decision support interventions that is based on the best available evidence," Dr. Forseen said in the news release. "These templates may be reasonably expected to improve patient care, decrease inappropriate imaging utilization, reduce the inappropriate use of steroids and narcotics, and potentially decrease the number of inappropriate invasive procedures."

Order Set Templates

For nonspecific low back pain present for less than 4 weeks without red flags, pharmacotherapy may include acetaminophen, nonsteroidal antiinflammatory drugs, and/or skeletal muscle relaxants. In some cases, tramadol, opioids, and/or benzodiazepines may be appropriate.

Activity level could be normal or with specific restrictions. Other interventions could include giving the patient an educational back pain pamphlet, physical or occupational therapy consult, and follow-up in 4 weeks.

For low back pain due to radiculopathy or spinal stenosis, any or all of the above interventions could be appropriate. Use of gabapentin could be considered.

Imaging procedures and laboratory testing are generally reserved for low back pain potentially associated with another specific cause suggested by the presence of red flags. Suspected causes warranting imaging are malignancy, discitis/osteomyelitis, and fracture.

Magnetic resonance imaging (MRI) of the lumbar spine without and with contrast is the preferred imaging workup, but computed tomography (CT) of the lumbar spine without contrast is suitable if MRI is unavailable or contraindicated. Other tests may include lumbar spine radiography, technetium 99m bone scanning, erythrocyte sedimentation rate, and/or C-reactive protein.

Workup of low back pain associated with focal neurologic deficit and progressive or disabling symptoms may include MRI of the lumbar spine without contrast (and with contrast in some cases), myelography and postmyelography CT of the lumbar spine, lumbar spine CT with or without intravenous contrast, and/or electromyography/nerve conduction velocity.

"A carefully designed [clinical decision support] system may be reasonably expected to improve patient care, decrease inappropriate imaging utilization, reduce the inappropriate use of steroids and narcotics, and potentially decrease the number of inappropriate invasive procedures," the guideline authors conclude. "Ideally, these templates could also be used to develop transparent criteria for payer coverage determinations with regard to imaging, medications, procedures, and surgical interventions."

The guideline authors have disclosed no relevant financial relationships.

J Am Coll Radiol. 2012;9:704-712. Abstract