Friday, May 18, 2007

In this Wall Street Journal article, the issue of excessive imaging and surgeries for back pain is discussed. As PT's we have all seen the patients that have had x-rays and MRI's for simple non-traumatic back pain and wondered 'Why were these done'. The article lists common missteps doctors make when treating back pain:

  • Over-prescribe epidural steroids.
  • Order excessive imaging
  • Perform invasive surgery too soon.
  • Fail to educate patients about surgery and alternatives to surgery.
  • Fail to assess mental health.

Why do doctors do this? Physicians are very smart and good at what they do; but, they are human just like us. Fear of litigation, pressure to please the patient, and just not knowing a better way are all plausible answers. The problem is, there are studies that show unneeded imaging can lead to diminished outcomes, and lumbar fusion surgery offers negligible benefits at best for the majority of the back pain population for the risks involved.

The program is spearheaded by the National Committee for Quality Assurance and strives to reward physicians that follow the plan and to educate the public about their options besides surgery. They produced a list of 16 guidelines for MD's to follow with a few listed below.

A new program is urging doctors to follow 16 guidelines including:
Help patients quit smoking
Smokers with back pain have more severe symptoms that last longer and have poorer outcomes after spinal surgery.

Encourage patients to maintain normal activities and avoid bed rest
Bed rest can lead to problems such as joint stiffness, muscle wasting, loss of bonemineral density and pressure sores.

Use X-rays and CT scans only when appropriate
Unnecessary for first six weeks after onset of pain unless there is indication of a more serious disorder.

Use epidural steroid injections only when necessary
Not recommended unless symptoms include radiating pain (sciatica, herniated disc).

Hold off on surgery
Not recommended in first six weeks of pain onset; half of patients with radiating low back pain recover spontaneously.
Conservative care and education should lead to improved outcomes and lower costs in treating back pain in this country.


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