Five common tests and treatments for back pain may be unnecessary, ineffective or increase the risk of complications, according to new recommendations from the North American Spine Society (NASS), a group that represents more than 8,000 physicians who specialize in spinal care.
“Because back pain is so prevalent and debilitating, desperate patients flock to their spine specialists’ offices armed with advice and anecdotes from well-meaning family, friends and online sources,” said F. Todd Wetzel, MD, a professor in the Department of Orthopedic Surgery and Sports Medicine at Temple University School of Medicine in Philadelphia.
“We hope this list of recommendations will help spine care providers and their patients cut through the noise and make informed care decisions together.”
The five things that doctors should not do in the absence of “red flags” that might indicate a more serious problem are:
- Don’t recommend bed rest for more than 48 hours when treating patients with low back pain.
- Don’t perform elective epidural spinal injections without imaging guidance.
- Don’t use advanced imaging (such as an MRI) of the spine within the first six weeks in patients with non-specific acute back pain.
- Don’t use bone morphogenetic protein (a compound that stimulates bone formation) for routine anterior cervical spine fusion surgery.
- Don’t use electromyography (EMG) and nerve condition studies to determine the cause of axial lumbar, thoracic or cervical spine pain.
NASS says the effectiveness of the tests and treatments has never been proven or can lead to life threatening complications. Medical conditions that could justify having the treatments include a history of trauma, unintentional weight loss, immunosuppression, history of cancer, intravenous drug use, steroid use, or osteoporosis.
The list was created by a multidisciplinary task force appointed by NASS that studied scientific evidence, existing clinical practice guidelines, and expert opinion. The final list was approved by the NASS Board of Directors.
“The content of this list and all of the others developed through this effort are helping physicians and patients across the country engage in conversations about what evidence-based care they need, and what we can do to reduce waste and overuse in our health care system,” said Richard Baron, MD, president and CEO of the ABIM Foundation.
Epidural steroid injections (ESI) have become one of the most common treatments for back pain, with nearly 9 million spinal injections in the U.S. in 2011. Studies have shown the procedure often gives only short term pain relief and has high failure rates for conditions such as sciatica.
Spinal shots given without imaging to help place the needle can puncture the spinal membrane and cause arachnoiditis, a chronic inflammation of the spine.
“Elective spinal injections, such as epidural steroid injections, should be performed under imaging guidance using fluoroscopy or CT (cat scan) with contrast enhancement to ensure correct placement of the needle and to maximize diagnostic accuracy and therapeutic efficacy. Failure to use appropriate imaging may result in inappropriate placement of the medication, thereby decreasing the efficacy of the procedure and increasing the need for additional care,” NASS states in its guidelines for the procedure.
But some who suffer from arachnoiditis say ESI’s aren’t worth the risk, even with imaging.
“The multitude of risks attributed to epidural steroid injections outweighs the transient benefits. Risks include arachnoiditis, meningitis, stroke, paralysis and death to name a few,” says Terri Anderson, who had over 20 spinal injections to treat a ruptured lumbar disc and now suffers from arachnoiditis.
“Fluoroscopy, while advocated as a safety measure, cannot prevent neurologic injury, nor guarantee that the injection will not inadvertently violate the dura and deposit the steroid in the intrathecal space or spinal cord and permanently damage delicate neural tissues.”
The NASS’s list of treatments and tests to avoid is part of Choosing Wisely, an initiative of the ABIM Foundation to encourage physicians to be better stewards of health care resources and to help their patients make better choices in their treatment.