Medical Services and Department of Medicine High Value Care: Optimal Approach to Imaging for Low Back Pain Ilana Richman MD, Primary Care and Outcomes

Medical Services and Department of Medicine

High Value Care: Optimal Approach to Imaging for Low Back

Pain

Ilana Richman MD, Primary Care and Outcomes Research Fellow

Anne Smeraglio MD, Resident in Internal Medicine


Objectives

• Differentiate patients with back pain due to a specific etiology versus those with nonspecific back pain

• Identify patients who should and should not be referred for imaging for low back pain

• Discuss the rationale for deferring imaging in patients with low-risk back pain


Case 1

• 45 year old man with a past medical history of hypertension comes to clinic reporting three weeks of nagging low back pain.

• Pain is dull, moderate in intensity, does not radiate, somewhat relieved by over the counter analgesics, made worse with long periods of sitting or standing, better with lying down


Case 1

• What is your differential diagnosis?• What other questions would you ask?• What would you focus on in your

physical exam?


Case 1

• No weight loss, personal history of cancer, history of AAA, neurological symptoms, fevers, chills, or escalating pain

• Neurologic exam is completely normal


Case 1

• Does this patient require imaging of the low back? Why or why not?


Case 2

A 49 year old woman with comes to clinic with a complaint of back pain. She has a history of stage 3A ER/PR+ breast cancer that was treated two years ago with chemotherapy and surgery. She is currently taking tamoxifen. Her pain started last week after bending over for several hours gardening. It is dull, centered over the lumbar area, alleviated with ibuprofen, somewhat better with rest. No fevers or chills. No new neurologic symptoms.


Case 2

• What additional history would be helpful?

• What would you look for on exam?• Would you image this patient?• If so, with which modality?



• You will encounter low back pain very frequently in your continuity clinic


Questions We Will Answer In this Hour

• Why do we image patients with low back pain?• What are the common causes of low back pain?• When is imaging appropriate and can we use the

history and exam to guide this decision?• When imaging is appropriate, which modalities

should we use?• Which patients do not need imaging immediately

and what happens if we image them anyway?• How are we doing?








Why Do Patients Receive Imaging for Low Back Pain?

• Patient preference: • Worried about serious pathology• Want to understand the reason for a new

symptom Want to feel validated or cared for

• Provider preference: Concern for serious underlying pathology Worried about “missing something” Because imaging exists Want to please patients


Imaging: Supply Sensitive Care?

Baras J D , and Baker L C Health Aff 2009;28:w1133-w1140



• Why do we image patients with low back pain?• What are the common causes of low back

pain?• When is imaging appropriate and can we use the





What proportion of back pain is musculoskeletal in etiology and will typically resolve with conservative measures?

A. 25%

B. 60%

C. 85%

D. 98%


What proportion of back pain is musculoskeletal in etiology and will typically resolve with conservative measures?

A. 25%

B. 60%

C. 85%

D. 98%


Common Causes of Acute Back Pain

• Presumed musculoskeletal (85%)• Spinal stenosis (3%)• Disc bulge/herniation (4%)• Compression fracture/other fracture (4%)• Infection (0.01%)• Malignancy (0.7%)• Inflammatory arthritis (0.3-5%)• Visceral disease (AAA, pancreatitis, etc.)

Chou et al. Ann Intern Med. 2007;147(7):478-491



• Why do we image patients with low back pain?• What are the common causes of low back pain?• When is imaging appropriate and can we use

the history and exam to guide this decision?• When imaging is appropriate, which modalities




When is Imaging Appropriate?

• “Red Flag Symptoms” Symptoms suggestive of underlying specific pathology

including malignancy, fracture, infection etc. No universally agreed upon list

• Neurologic symptoms New bowel or bladder dysfunction Sensory disturbances Weakness Radicular symptoms Pseudoclaudication

• Neurologic signs: weakness, numbness, abnormal reflexes, abnormal sphincter tone etc.


ACP Guidelines Red Flag Symptoms

• Age >70• History of malignancy• History of AAA• Fever or recent infection• Weakness, bowel or bladder disturbance• Unremitting (>6 weeks) or worsening pain• Trauma• Weight loss• Immunosuppression• Prior surgery• Prolonged corticosteroid use or known osteoporosis


Are Red Flag Symptoms Helpful?

Deyo et al., JAMA. 1992;268(6):760-765


Are Red Flag Symptoms Helpful?Spinal Fracture

Downie A et al. BMJ 2013;347:bmj.f7095


Are Red Flag Symptoms Helpful?Malignancy

Downie A et al. BMJ 2013;347:bmj.f7095


Bottom Line

• Imaging is appropriate when you suspect a specific pathology and the patient might benefit from intervention

• Two caveats: Not all pathologies are emergencies and

not all require immediate intervention (or intervention at all)

The history and physical are admittedly imperfect but better than nothing for informing your decision-making








Which Imaging Modalities are Appropriate?

Clinical Situation Imaging Urgency

Imaging Modality

New neurologic deficit including progressive motor weakness Immediate MRI

Cauda equina syndrome Immediate MRI

Suspicion for spinal infection Immediate MRI

Major risk factors for cancer or high clinical suspicion for cancer

Immediate Plain films + ESR/CRP

Risk factors for compression fracture Deferred Plain films

Suspicion for ankylosing spondylitis Deferred Plain films

Signs and symptoms of radiculopathy and a candidate for invasive treatment

Deferred MRI

Signs and symptoms of spinal stenosis and a candidate for invasive treatment

Deferred MRI

Lower suspicion for malignancy but with some risk factors Deferred Plain film + ESR/CRP

No criteria for immediate imaging or pain resolved after 1 month

No imaging

Chou et al. Ann Intern Med. 2007;147(7):478-491





should we use?• Which patients do not need imaging

immediately and what happens if we image them anyway?

• How are we doing?


Who does not need imaging?

• Patients with “nonspecific” back pain: Acute (<6 weeks) No historical features that suggest a

particular underlying condition No radicular symptoms or

pseudoclaudication Normal neurologic exam


Question

• When imaging patients with nonspecific back pain, how many will have evidence of a herniated disc?

A. 10%

B. 20%

C. 50%

D. 80%


Answer

• When imaging patients with nonspecific back pain, how many will have evidence of a herniated disc?

A. 10%

B. 20%

C. 50%

D. 80%


The problem with imaging is that you find things…

Imaging Modality in Healthy Middle Aged Patients

Herniated Disc Bulging Disc

Degenerative Disc

Stenosis

Plain radiographs - - 20% -

CT 20-27 - - 0-3

MRI 30 (9-76) 50 (20-81) 60 (46-91) 1-21

Jarvik et al., Ann Intern Med. 2002;137(7):586-597


And Then Do Things…

Baras JD and Baker LC Health Aff 2009;28:w1133-w1140


And More Things…

Graves et al. HSR. 49:2 (April 2014)


Will We Cause Harm by Deferring Imaging?

Chou et al., The Lancet, Volume 373, Issue 9662, 2009, 463 - 472








How Are We Doing?

• Utilization of imaging• Appropriateness of imaging• Cost associated with imaging


Utilization of Imaging

Carey TS et al. N Engl J Med 1995;333:913-917.


Trends in Imaging Utilization

Deyo, JABFM, 2009 Jan-Feb;22(1):62-8.


Costs Associated with Imaging

Chou et al., Ann Intern Med. 2011;154(3):181-189


Overall Costs for Back Pain are Increasing

Martin et al., JAMA. 2008;299(6):656-664.


Without an Obvious Return on Investment

Martin et al., JAMA. 2008;299(6):656-664


Is Imaging Use Appropriate?

Emery et al., JAMA Intern Med. 2013;173(9):823-825


Back to the Cases

• Case 1: Would you image? What would you say to the patient if he

requested imaging? What options for conservative

management are there?

• Case 2: Would you image? What modality would you choose?


Summary

• Nonspecific low back pain is common and usually self-limited

• Certain features of the history and exam are helpful for distinguishing back pain likely to be due to specific pathology

• Imaging is usually not indicated for patients with nonspecific back pain and not only is costly but can result in additional interventions

Documents

Medical Services and Department of Medicine High Value Care: Optimal Approach to Imaging for Low Back Pain Ilana Richman MD, Primary Care and Outcomes