Page 15 - Delaware Medical Journal - January 2016
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SCIENTIFIC ARTICLE
TABLE 2: Classification of Low Back Pain by Categories and Examples of Causes
MECHANICAL
NON-MECHANICAL
VISCERAL
Musculoskeletal strain • Ligament
• Muscle
• Fascia
Herniated disk Disckogenic pain Facet degeneration Spinal stenosis Spondylolisthesis Spondylolitholysis Scoliosis
Fracture
Neoplasm Infection
• Osteomyelitis
• Epidural abscess • Shingles
Inflammatory arthritis
• Ankylosing spondylitis • Psoriatic arthritis
Sickle cell anemia
Pelvic organ disease
• Prostatitis
• Endometriosis
• Chronic pelvic inflammatory disease
Renal disease
• Nephrolithiasis
• Pyelonephritis
• Perinephric abscess
Vascular disease
• Aortic anurysm
Gastrointestinal disease • Pancreatitis
• Cholecystitis
• Ulcer
published a piece in the New England Journal of Medicine calling
their patients. Building on this, Choosing Wisely was launched in 2012 with “Top Five” lists from nine specialties.6 Of the 45 tests and treatments selected, 24 were directly related to diagnostic imaging. This suggests a common perception among professional societies
and many branches of medicine that imaging is overused. And yet, standard practice data demonstrates that LBP guidelines evoke the strongest debate regarding best practice. Lee attributes this partially to the fact that there are various guidelines by different professional institutes.7 Such guidance is fragmented and uncoordinated with respect to pain, causing confusion for both patients and clinicians. Furthermore, Morden also noted that in the Choosing Wisely campaign, in general, participating societies generally named other specialties’ services as low-value.8 The same study shows that imaging is listed at 29 percent of all services as low-value by the top 25 participants of the Choosing Wisely initiative. As part of this initiative, on the surface, it seems that physicians are willing to make recommendations to improve health care value against their vary widely in their potential impact on care and spending. This further adds to the debate and controversy regarding best practice.
BACKGROUND
LBP causes tend to be multi-factorial but can be broken down into 3 subsets: mechanical, non-mechanical, and visceral disease. (See Table 2
Manusov9
(97 percent) fall into the musculoskeletal/mechanical causes.9 The majority of these cases are self-limiting and will not require any thorough history and physical, is often imaging to rule out more concerning causes. Physicians perform tests such as computed tomography (CT) scans, magnetic resonance imaging (MRI), and X-rays for LBP to determine the presence of serious underlying conditions, such as cancer or spinal infection. One problem with irrelevant but alarming. Routine imaging can subject patients to relevant that lead to further downstream testing, spinal injections, and in some cases, surgery. Studies have shown that asymptomatic patients — those without LBP — still have abnormalities on imaging of their low backs. Thirty-six percent of asymptomatic 60 year olds had a herniated disc on imaging and more than 90 percent had a degenerated or bulging disc, yet remained symptom free.10,11
specialty societies developed recommendations and guidelines 12 These guidelines imaging within one year of acute LBP.13 Most of these were plain radiographs. Of those who had imaging, 60 percent of them had imaging on the same day as the index diagnosis of pain, and 80 percent within 1 month of the diagnosis. Medicare review
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