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. 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.
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.
Medscape Rheumatology © 2013 WebMD, LLC
Cite this: 5 Tests to Avoid in Back Pain - Medscape - Nov 06, 2013.