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Just Say No. I Repeat, Just Say No…

"Just Say No" words spray painted on a brick wall

In the context of last week’s post, I submit to you the following summary of a study published in the latest volume of Spine (2014;39:1433-1440).

Summary of Background Data: Guidelines advise against MRI for acute uncomplicated low back pain, but is an option for persistent radicular pain after a trial of conservative care.  Yet, MRI has become frequent and often nonadherent.

Methods: A longitudinal, workers’ compensation administrative data source was accessed to select low back pain claims filed between January 1, 2006 and December 31, 2006.  Cases were grouped by MRI timing (early, timely, no MRI) and subgrouped by severity (“less severe,” “more severe”). Final cohort = 3022 patients. Health care utilization for each subgroup was evaluated at 3, 6, 9 and 12 months post-MRI. Multivariate logistic regression models examined risk of receiving subsequent diagnostic studies and/or treatments, adjusting for pain indicators and demographic covariates.

Results: The adjusted relative risks for MRI group cases to receive EMG/NCV, advanced imaging and surgery within 6 months post-MRI risks in the range from 6.5 times the rate for the referent group (no MRI, less severe). The timely and early MRI less severe subgroups had similar adjusted relative risks to receive most services. The early MRI more severe subgroup cases had generally higher adjusted relative risks than timely MRI more severe subgroup cases. Medical costs for both early MRI subgroups were highest and increased the most over time.

Salient Discussion points:

  1.  “It is striking that the cascade of services received by the early MRI less severe subgroup was similar to the other 3 MRI subgroups. In addition, this subgroup underwent surgery significantly sooner than the timely more severe subgroup. The finding that the early and timely less severe subgroups received MRI sooner than the 2 more severe subgroups suggests that the MRI and surgery were done for inappropriate reasons."
  2. “Although a large percentage of the early MRI more severe subgroup had a radiculopathy-related diagnosis for which guidelines clearly recommend a “wait and see” approach, many providers are influenced by this diagnosis and obtain images prematurely. Such an approach can lead to heightened urgency for both providers and patients to focus on “fixing” a physical abnormality that, in many cases, resolves spontaneously within a month. Such a focus diverts patients from more appropriate noninvasive interventions that can lead to better long-term functional results.

I will reiterate what was stated last week in light of the above. Be extremely selective about your surgeon in the wake of an injury. Most injuries of the low-impact variety (i.e. sprain/strain, the most common type of work-related low back injury) are NON-SURGICAL. They are musculo-ligamentous in etiology and do not respond to surgery. In fact, you will likely fare worse postoperatively in the event you undergo a procedure (for unindicated reasons). That said, if your surgeon recommends surgery for isolated low back pain in the context of an acute injury, find another surgeon. At the very least, obtain a second opinion. Rarely (relatively speaking) is low back pain an indication for surgery post worksite injury (barring a fracture). ALL conservative efforts should be exhausted prior to even considering surgical intervention. Likely, musculo-ligamentous injuries will respond to NSAIDs, physical therapy inclusive of strength training, manual modalities and of course, the tincture of time.

Here’s another tip. Take a casual look around your surgeon’s waiting room. Are there massive, almost inexplicable numbers of patients? Do some fall into the “shady” category? Is his or her practice predominantly composed of workers’ compensation and personal injury (“legal”) cases? Does your surgeon spend less than 15 minutes with each patient? If you answered “Yes” to ANY of these questions, seek out an alternate surgeon. STAT! And no, undergoing (unindicated) surgery to escalate the value of your lawsuit against Walmart or Pepsi is NOT WORTH IT. Do not risk life and limb (despite the advice of your attorney) to augment your take-home. No one would do that, right? WRONG. Head on down to South Florida and speak to the myriad of failed-back sufferers who “wished they hadn’t.”

Instead, ask probing questions of your surgeon as per the conclusions of the journal article: “The study results provide evidence to promote conversations between providers and patients to help patients choose care that is supported by evidence, free from harm and truly necessary.”    

Twice you’ve been warned now…