Back Pain Treatment – The Diagnostic Dilemma
Michelle Spencer asked:
In most cases of physical illness or disability, the general rule is that without a specific diagnosis of where the pain is coming from, or what is its cause, there is little chance of treating that pain or hastening recovery. When it comes to most back pain treatments, however, no such rule applies.
It’s much more important to see which patient has the disease than which disease the patient has, to paraphrase the renowned Canadian physician and medical historian Sir William Osier. For back pain patients, the statement is particularly true. Back muscle pain, bone spurs, even pinched nerves can mean significantly different things to different people.
“Symptoms and pathology do not always correlate in back pain,” says physiatrist Stanley Herring, on the board of directors of the North American Spine Society. Indeed, a study reported in the New England Journal of Medicine found that of ninety eight people without back pain, almost two-thirds were shown to have one or more herniated disks or other spinal abnormality when scanned by a technique called magnetic resonance imaging or MRI. You don’t treat the MRI, you treat the patient.
Irregularities in an MRI do not always mean injury; because they don’t show cause, tests can reveal abnormalities with which you were born, but that have nothing to do with your present pain.
Nevertheless, a lot of MRIs, and many other diagnostic tests, are being performed. In 1993, the North Carolina Back Pain Project examined the patterns of diagnostic test use among primary care physicians and the specialty practices of orthopedic surgeons and chiropractors. Researchers found the availability of both basic diagnostic technology (such as X-rays), and of sophisticated imaging tests (such as computerized tomography and MRIs) “has broadened in recent years,” and, along with it, so have doctors’ tendencies to use them. According to the study, “the use of imaging for diagnosis appeared to occur too early and too frequently.”
Since then, the pendulum seems to have started toward the other direction. “I think there has over the past five years or so been some movement for physicians to become more conservative in utilization of diagnostic tests,” says Timothy S. Carey, M.D., M.P.H., professor of medicine at the University of North Carolina at Chapel Hill, who coauthored the study “Especially early in the back pain.”
This isn’t the only study that supports federal Agency for Health Care Policy and Research (AHCPR) guidelines in recommending a conservative approach to diagnostic testing. In its controversial report, accused by some of being more cost-conscious than patient-conscious, the AHCPR divided acute back pain into “red flag” pain that needs a lot of care and investigation; and the pain that needs supportive treatment but will get better no matter what you do.
Red-flag patients might include those who have had serious trauma, such as a fall from a ladder, and require X-rays to rule out fracture; patients with a history of infection, which is a rare cause of back pain; patients with a history of malignant cancer; those with weakened bones from steroids or osteoporosis; and patients who have been in pain for an extended period of time, generally thought to be more than four to six weeks. Worsening neurological findings (say, numbness in the foot on Monday, and weakness in the foot on Tuesday) would also be among the red flags.
In most other cases, “little is lost by delaying diagnostic testing for several weeks to determine whether spontaneous recovery will occur,” concurs the North Carolina Back Pain Project study.
“Over 90 percent will be better prior to six weeks on their own,” says Dr. Carey, adding, “While the good news is chances are it’s going to get better, the fact that it has a good prognosis doesn’t make it hurt any less.”
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In most cases of physical illness or disability, the general rule is that without a specific diagnosis of where the pain is coming from, or what is its cause, there is little chance of treating that pain or hastening recovery. When it comes to most back pain treatments, however, no such rule applies.
It’s much more important to see which patient has the disease than which disease the patient has, to paraphrase the renowned Canadian physician and medical historian Sir William Osier. For back pain patients, the statement is particularly true. Back muscle pain, bone spurs, even pinched nerves can mean significantly different things to different people.
“Symptoms and pathology do not always correlate in back pain,” says physiatrist Stanley Herring, on the board of directors of the North American Spine Society. Indeed, a study reported in the New England Journal of Medicine found that of ninety eight people without back pain, almost two-thirds were shown to have one or more herniated disks or other spinal abnormality when scanned by a technique called magnetic resonance imaging or MRI. You don’t treat the MRI, you treat the patient.
Irregularities in an MRI do not always mean injury; because they don’t show cause, tests can reveal abnormalities with which you were born, but that have nothing to do with your present pain.
Nevertheless, a lot of MRIs, and many other diagnostic tests, are being performed. In 1993, the North Carolina Back Pain Project examined the patterns of diagnostic test use among primary care physicians and the specialty practices of orthopedic surgeons and chiropractors. Researchers found the availability of both basic diagnostic technology (such as X-rays), and of sophisticated imaging tests (such as computerized tomography and MRIs) “has broadened in recent years,” and, along with it, so have doctors’ tendencies to use them. According to the study, “the use of imaging for diagnosis appeared to occur too early and too frequently.”
Since then, the pendulum seems to have started toward the other direction. “I think there has over the past five years or so been some movement for physicians to become more conservative in utilization of diagnostic tests,” says Timothy S. Carey, M.D., M.P.H., professor of medicine at the University of North Carolina at Chapel Hill, who coauthored the study “Especially early in the back pain.”
This isn’t the only study that supports federal Agency for Health Care Policy and Research (AHCPR) guidelines in recommending a conservative approach to diagnostic testing. In its controversial report, accused by some of being more cost-conscious than patient-conscious, the AHCPR divided acute back pain into “red flag” pain that needs a lot of care and investigation; and the pain that needs supportive treatment but will get better no matter what you do.
Red-flag patients might include those who have had serious trauma, such as a fall from a ladder, and require X-rays to rule out fracture; patients with a history of infection, which is a rare cause of back pain; patients with a history of malignant cancer; those with weakened bones from steroids or osteoporosis; and patients who have been in pain for an extended period of time, generally thought to be more than four to six weeks. Worsening neurological findings (say, numbness in the foot on Monday, and weakness in the foot on Tuesday) would also be among the red flags.
In most other cases, “little is lost by delaying diagnostic testing for several weeks to determine whether spontaneous recovery will occur,” concurs the North Carolina Back Pain Project study.
“Over 90 percent will be better prior to six weeks on their own,” says Dr. Carey, adding, “While the good news is chances are it’s going to get better, the fact that it has a good prognosis doesn’t make it hurt any less.”
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