Worsening low back pain treatment

Yes, the title on this post is correct. I’m here today to talk about the worsening treatment of low back pain, not worsening pain. A number of organizations have published evidence-based guidelines on appropriate management of low back pain, including the American College of Physicians, the American Pain Society, the American College of Radiology, and DHSS’s Agency for Healthcare Research and Quality.

While the guidelines vary a bit, they all recommend a conservative approach initially as long as no red flags are present. Low back pain is common, affecting up to a quarter of adults every year, and it almost always clears up on its own within a few weeks to months. The guidelines recommend a restrained approach to imaging, narcotics, and referrals to specialists. Imaging is a particularly slippery slope. L-S spine xrays deliver a high radiation dose to the gonads (the equivalent gonadal exposure of almost 400 chest xrays). Spine MRI’s frequently show abnormalities, even in patients with no back pain, so pathology detected by MRI may have nothing to do with the pain. But after the pathology is identified, it can be hard not to act on it.

Medication management for low back pain is also a sticky wicket. NSAIDs and acetaminophen are generally recommended as initial treatment, with narcotics reserved for truly severe pain, which is uncommon. Yes, narcotics provide a different kind of pain relief, but once a person gets started on them, they can be hard to stop, since pain often flares when opioids are withdrawn.

Since back pain, even when bad, will usually ease as the weeks go by, there is little that orthopedists or pain management specialists should be doing for these patients. In fact, they should not even be seeing them, at least for the first couple of months, if no red flags are present.

Physicians are well-versed in clinical practice guidelines. We hear about them at meetings, we read about them in our journals and on-line. For many medical conditions, we are usually adept at following the guidelines. But for low back pain, we are not doing a very good job. In fact, our performance seems to be worsening. At least these are the findings of a study just published in JAMA Internal Medicine. Researchers looked at almost 24,000 visits for low back and neck pain across the country. The results are sobering. Looking at how medical practice changed over the ten year period between 1999-2000 and 2009-2010, the following was observed:

  • NSAID and acetaminophen prescribing dropped by 33%
  • Narcotic prescribing increased by 50%
  • Referrals to specialist physicians more than doubled
  • Ordering of spine MRI or CT increased by 57%

These numbers were not affected by whether the patient saw their own PCP or not, nor were they affected by the patient’s age, gender, nationality, or geographic region.

This information is disappointing. We should be able to improve. Why aren’t we clinicians better at following established national guidelines for back pain? There are myriad reasons, including ever-shorter appointment times and patients’ expectations and demands for immediate answers and quick fixes. Nonetheless, we need to try harder. Practicing evidence-based medicine for back pain requires a little more time and a little more communication. We can and should educate our patients about the natural history of back pain, the risks of radiation, the risks of finding insignificant problems on MRI which then lead to more invasive studies, the risks of narcotics. It helps if we reassure our patients that if their pain is not improving in 6-8 weeks, we will see them again and take things further. Not all patients will accept such an approach, but having good communication can help.

While conservatism in back pain management is generally to be preferred, it is also important to be aware of red flags which may mandate a more aggressive and rapid work-up, since back pain can sometimes be the harbinger of a serious problem. Common red flags include:

  • Unexplained weight loss
  • Unexplained fevers
  • Nocturnal back pain
  • Older age groups
  • History of trauma or cancer
  • No response to conservative measures after 6-8 weeks
  • Significant neurological symptoms (e.g. bladder or bowel dysfunction, LE weakness, sensory levels)

Practicing medicine is tough, time-consuming, and often stressful. Our difficulty following guidelines for back pain are emblematic of the difficulty practicing medicine in the 21st Century. But we need to try harder.

Richard Fleming, MD

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