back pain: value driven workup and treatment · axial low back pain without radiculopathy, spinal...
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A C P C O L O R A D O 2 0 1 4 C H A P T E R M E E T I N G
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JASON FRIEDRICH MD PM&R, SPORTS MEDICINE, PAIN MEDICINE
KAISER PERMANENTE- COLORADO DEPARTMENT OF NEUROSURGERY
Back Pain: Value Driven Workup and Treatment
Disclosures
None
Questions For Today
1. What are the evidence based indicators (timing, red flags, clinical findings) for imaging, both plain films and MRI, in low back pain?
2. What is the evidence for epidural steroid injections in LBP?
3. Are different types of injections more effective for LBP?
Less Is More
Application of “Less Is More” to Low Back Pain Srinivas, Deyo, Berger
Arch Intern Med 2012;172(13):1016-1020
Indicators for Imaging- Why Care?
Conscientious spine imaging = #1 on National Physicians Alliance top 5 primary care activities for “Promoting Good Stewardship in Clinical Practice”
“Don’t do imaging for low back pain within the first 6 weeks unless red flags are present”
Indicators for Imaging- Why Care?
Overused and expensive Lumbar MR imaging up 307% between 1994-2005 (yet increased
spine related disability between 1997 and 2005)1,2 Avoiding imaging in first 6 weeks has potential cost savings of
$300 million/year for plain films and MRI combined1 Questionable benefit Poorly correlated with symptoms and outcomes2,3
Many “abnormalities” found in asymptomatic patients4,5,6 Harmful “patient labeling”, chasing incidental findings, radiation, higher
surgical rates, higher cost to the patient1
Worse outcomes, more disability and decreased sense of well-being1, 2, 7
Indicators for Imaging
Most importantly Will It Change Management?
Not:
Will it alleviate anxiety?7 Will it save me some time?
Will it protect me from litigation? Will it improve my patient satisfaction scores?
Adapted from ACP/APS guidelines8
in Roudsari B, Jarvik JG. Lumbar Spine MRI for Low Back Pain: Indications and Yield. AJR. 2010:195;552.
Possible cx Hx/PE (RED FLAGS) Imaging Additional Studies
Cancer (0.7%)
H/O CA w/ new LBP MRI ESR
Unexplained wt loss Fail to improve after 1 mo Age>50
X-rays
Multiple risks present Xrays or MRI
Vertebral Infection (0.01%)
Fever with new LBP IV drug use Recent Infection
MRI ESR and/or CRP
Cauda Equina Syndrome (0.04%)
Urinary retention Motor deficits mult. levels Fecal incontinence Saddle anesthesia
MRI None
Severe/Progressive neurological deficit
Progressive motor weakness MRI Consider EMG/NCS
Chou 20078
Red Flag Conditions
Specific causes (non-red flag conditions)
Hx/Exam Imaging Additional Studies
Vertebral compression Fracture (4%)
Steroid use Osteoporosis Older age
X-ray None
Ankylosing Spondylitis (0.3-5%)
AM stiffness Improves with exercise Alternating buttock pain Second half of night pain Younger age
X-rays (AP pelvis or SI joint)
ESR and/or CRP (+/- HLA B27)
Herniated Disc/Lumbar radiculopathy
Back pain with leg pain in specific nerve root distribution +SLR or +CSLR
None None
Sxs present > 1 month (and not improving)
MRI +/- EMG/NCS
Spinal Stenosis Radiating leg pain Older age Pseudoclaudication
None None
Sxs present > 1 month (and not improving)
MRI +/- EMG/NCS Chou 20078
Indicators for Imaging: Red Flags
Almost all have identifiable risk factor Metastatic cancer8, 9
History of cancer (+LR=14.7) Unexplained weight loss (+LR=2.7) Failure to improve after 1 mo (+LR=3.0) Age > 50 (+LR= 2.7)
Infection: fever, IV drug use, recent infection, immunosupression Cauda equina syndrome: urinary retention (90% sensitivity; if no
retention, then probability of CES is 1/10000), saddle anesthesia, LE weakness, gait abnormality
Compression fracture: trauma, older age, steroid use, contusion/abrasion (combination reduced false positives)10
Inflammatory disease: younger age, morning stiffness, improvement with exercise, alternating buttock pain, awakening due to back pain during second half of night8
Yellow Flags?11
Risk Factors for Chronicity/Disability Should not by itself guide decision for imaging Depression/Mood issues Social issues/poor support network/poor coping Work-related issues/litigation/seeking disability Sleep disturbance Fear-avoidance/Kinesiophobia Deconditioning Family history of disability/chronic pain Early Imaging1,2,7,11
Indications for Imaging: Clinical Findings
Goal: Identify red flags and evaluate for “severe or progressive neurologic deficits”
Exam should include L4, L5, and S1 dermatomes, myotomes, and lower limb DTRs
Above approach thought to capture 99% of serious spinal pathology11
Indications for Imaging: Summary
1. Will it change management? 2.MD role in LBP = rule out the rare things that can
kill or paralyze, then reassure and activate 3.Evidence does not support imaging with a goal of
chasing down “pain generators” or alleviating anxiety
4.Early imaging is harmful 5. Little guidance on imaging in chronic LBP3
• N=283 • Patients from prospective RCT: Sciatica Trial (surgery vs
prolonged conservative care) • Favorable outcome = complete or nearly complete
disappearance of symptoms at 1 year • Includes both surgical and non-surgical patients
At 1 year: MRI findings
Disc herniation
Nerve Root Compression
Scar Tissue
Favorable outcome
35% 24% 86%
Unfavorable outcome
33% 26% 75%
Epidural Steroid Injections12,13,14
Axial low back pain without radiculopathy, spinal
stenosis, failed back surgery syndrome Sparse/inconclusive evidence, but show no clear benefit
(above placebo).
LBP with radiculopathy Lots of studies
Variable short-term benefit; may not be better than epidural saline Best study indicates TFESI significantly better than IMST,
TFLA, TFNS, IMNS for radicular pain due to HNP (NNT = 2-3 for >50% improvement at 1 month, NNT=4-6 for 3 mo, 4-9 at 6 mo, 5-14 at 12 mo)15
Very strict inclusion criteria
Epidural Steroid Injections
Friedly 200816 Large veteran population Mixed diagnoses: HNP, radiculopathy, spinal stenosis, DDD,
other LBP syndromes No decrease in opioid use
No conclusions on return to work13
Epidural Steroid Injections
No clinical practice guideline (0/18) recommends ESIs for lower back pain without neurological involvement11,12
Other Injections for LBP
Soft-tissue Facet-Specific Interventions Disc-Specific Interventions Spinal cord stimulator
Axial pain not currently an indication No RCTs Low quality studies with mixed results
Soft-tissue Injections for LBP
Insufficient or poor evidence to support efficacy or make recommendation11, 12
-6/18 CPGs recommend against soft-tissue injections -2/18 support use (Belgium) -10/18 cite insufficient evidence (including ACP)
Soft-tissue Injections IM steroid (no good data; not proven better than placebo) Prolotherapy (no better than saline or local anesthetic control
injections)12 TPIs (with local anesthetic superior to placebo at 2 weeks only;
adding steroid does not improve efficacy; likely no better than acupressure)12
Dry Needling (probably as good as a TPI)12 Botox (mixed/sparse/low quality evidence)17
Facet Joint-Specific Injections
IA facet injections11,12 6/18 CPGs recommend
against; 2/18 for; 10/18 insufficient evidence (including ACP/APS)
Best study underway and yet to be published
Medial Branch Blocks11,12 Role is more diagnostic than
therapeutic No placebo controlled trials
for therapeutic effect ACP/APS: Insufficient
evidence
Radiofrequency Ablation11,12 Mixed results/difficult to
interpret Minimal benefit beyond sham12 or
lumbar facet injections18 ACP/APS: Insufficient evidence Landmark trial was observational
(N=15)19: 2 differential diagnostic medial
branch blocks minimum of 80% relief on each),
and precise technique utilized 60% achieved >90% improvement
for 12 months No other study has achieved such
favorable results
Other Injections for LBP
Disc Specific Interventions Intradiscal injection IDET Nucleolysis
No intradiscal procedure has consistently proven better than placebo ACP recommends against intradiscal steroid
injection and poor evidence to evaluate IDET or nucleolysis12
Other Injections for LBP: Summary
1. Epidural steroid injections are NOT indicated for axial lower back pain
2. NO interventional treatment has consistently proven better than placebo for axial low back pain
3. As of now, it is not clear that identifying a specific “pain generator” and targeting that with an intervention really improves outcomes on a population level
Closing Remarks
“Less Is More” when it comes to low back pain Avoid “poor standards of care” “Don’t do imaging for low back pain within the first 6 weeks
unless red flags are present”
No interventional treatment has consistently proven
better than placebo for axial low back pain i.e. very high NNT on population level Some limited success with interventions in difficult to identify
subpopulations of low back pain
Closing Remarks
Role of MD in low back pain Rule out red flags (things that kill/paralyze) Identify factors that may affect treatment response
Inflammatory disease Yellow flags (of chronicity/disability)19
Error on side of reassurance, encourage movement, and getting back to ordinary activities as normal as possible20
Fear–avoidance beliefs predict disability better than pain levels or underlying diagnosis21
The END
http://www.wsib.on.ca/files/Content/DownloadableFileTheBackBook/BackBookEnglish.pdf
International anti-disability propaganda
• NPR morning edition 1/13/2014: Pain In the Back? Exercise May Help You Learn Not to Feel It
References
1. Srinivas SV, Deyo RA, et al. Application of “Less is More” to Low Back Pain. Arch Intern Med. 2012;172(13):1016-20
2. Chou R, Qaseem A, et al. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care from the American College of Physicians. Ann Intern Med. 2011;154:181-89
3. El Barzouhi A et al. Magnetic Resonance Imaging in Follow-up assessment of Sciatica. NEJM. 2013;368(11):999-1007
4. Boden SD, Davis DO, et al. Abnormal MR scans of the lumbar spine in asymptomatic subjects. A prospective invesitgation. J Bone Jt Surg. 1990;72:403-8
5. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137:586-97
6. Jensen MC, Brant-Zawadzki MN, et al. MRI of the lumbar spine in people without low back pain. NEJM. 1994;331:69-73.
7. Webster BS, Bauer AZ, et al. Iatrogenic Consequences of Early MRI in Acute, Work-related, Disabling Low back Pain. Spine. 2013;38(22):1939-46.
References 8. Chou R, Qaseem A, et al. Diagnosis and treatment of low back pain: A
joint clinical practice guideline from the American College of Physicians and ther American Pain Society. Ann Intern Med. 2007;147:478-491
9. Henschke N, Maher CG, et al. Red flags to screen for malignancy in patients with low back pain (Review). Cochrane Collaboration. 2013; 2
10. Williams CM, Henschke N, et al. Red flags to screen for vertebral fracture in patients presenting with low back pain (Review). Cochrane Collaboration. 2013;1
11. Dagenais S, Tricco AC, et al. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine. 2010;10:514-29
12. Chou R, Atlas SJ, et al. Nonsurgical interventional therapies for low back pain. A review of the evidence for an American Pain Society Clinical Practice Guideline. Spine. 2009;34(10):1078-93
13. Friedrich JM, Harrast MA. Lumbar epidural steroid injections: indications, contraindications, risks, and benefits. Curr Sports Med Rep. 2010;9(1):43-9
14. Staal J, de Bie R, et al. Injection therapy for subacute and chronic low back pain. Cochrane Database Syst Rev. 2008: CD001824
References
15. Ghahreman A, Ferch R. The efficacy of transforaminal injection of steroids for the treatment of radicular pain. Pain Medicine. 2010;11:1149-68
16. Friedly J, Nishio I, et al. The relationship between repeated epidural steroid injections and subsequent opioid use and lumbar surgery. Arch Phys. Med. Rehabil. 2008;89:1011-5.
17. Waseem Z, Boulius C, et al. Botulinum toxin injections for low-back pain and sciatica. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD008257.
18. Lakemeier S, Lind M, et al. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double blind trial. Anesth Analg. 2013;117:228-35.
19. Dreyfuss P, Halbrook B, et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine. 2000;25(10):1270-7.
20. The Back Book, 5th impression 2008. 21. Zale EL, Lange KL, et al. The relationship between pain-related fear and
disability: a meta-analysis. J. Pain. 2013;14(10):1019-30