Page 16 - Delaware Medical Journal - January 2016

SCIENTIFIC ARTICLE
from 2009 showed that nearly one-third of patients with lumbar pain had imaging within 28 days, without trying conservative treatment first.13
In 1998, the total cost for LBP expenses in the US was estimated as $90 billion. Medicare data from 1996 through 2004 showed increases in epidural steroid injections (629 percent), opioid prescriptions (423 percent), and spinal fusions (220 percent), all adding to health care dollars. More recent analysis found that the annual total direct
and indirect costs of back pain are estimated to exceed
$100 billion, with increased use of medical imaging contributing significantly to these costs.14 Individuals with back pain incurred 60 percent higher health care costs per capita than those without back pain.15 There was also a
307 percent increase in lumbar MRIs done over that time frame, indicating a correlation between imaging and costly procedures.1 A study concluded that among older adults with low back pain without radiculopathy, patients who received early radiographs incurred a 1-year total payment of $1,380 more than those without radiographs.16 Additionally,
those who received early MRI/CTs incurred a 1-year total payment of $1,430 higher than those without the MRI and CT scans. One-year outcomes from both groups did not show clinical differences. Imaging is a large part of driving up costs of LBP, not only from the direct cost of the study but the downstream effects such as further testing, referrals, invasive procedures, and surgeries. Furthermore, rising spine care expenditures for medical imaging are not linked to a corresponding improvement in patient outcomes.
Acute LBP is unique in that it has an extraordinary high prevalence and high cost in the general population, yet it
is largely self-resolving. Clinical guidelines state that LBP can be adequately managed without imaging and instead refer to physical examination, medical history, initial pain management (as needed), and physical therapy as the best first course of action.17 Randomized control trials show that routine imaging of the lumbar spine in patients presenting with LBP without red flag symptoms does not improve their outcome compared with patients receiving usual clinical care without imaging.2 The data on the natural history of mechanical/musculoskeletal back pain suggest that the majority of such patients, even those with radicular symptoms, will have rapid improvements in their pain within weeks of onset.18
DISCUSSION
Imaging studies are often misleading and are considered to be of less value than performing a detailed history and physical exam.
Over-reliance on imaging is not only a poor use of medical resources, it increases unnecessary radiation exposure, causes unnecessary follow up testing, and is not associated with improvement in symptoms. Less obviously, it can label a patient with a disease which has been shown to have negative psychologic outcomes. Rather than self-resolving back pain as a physiological self-correction, it becomes a medical diagnosis of lumbago as a pathologic condition.
There is no evidence at this time that “labeling” a patient with

regarding their pain. In a randomized control study, patients with acute onset LBP all received MRIs of the lumbar were in the disclosure group and were told they had benign degenerative disc disease had a diminished sense of well- being as compared to those in the non-disclosure group.3 When interviewing physicians on the reasons for the overuse of imaging in these cases they listed many reasons including patient preference and demand, patients being unaware of associated risks of unnecessary imaging, and a lack of time to engage patients in these conversations.19 These results suggest patients except perhaps a satisfaction with their health care.
Despite the fact that the vast majority of individuals will respond to conservative treatment, more extreme treatment measures are becoming increasingly common.20 As noted previously there has been an exponential increase in prescription of opioids, spinal corticosteroid injections, and spine surgery as MRI for LBP has increased, indicating a correlation between more enhanced imaging and increased intervention. These additional interventions are additional health care dollars with questionable results as disability from musculoskeletal disorders appears to be rising, not falling, along with these increased intervention.20
The American Academy of Family Physicians (AAFP) lists 15 recommendations in association with Choosing Wisely ranging from antibiotic overuse, to unnecessary induction of labor, to unnecessary imaging. The recommendation for imaging in LBP is as stated below:
(bowel or bladder dysfunction, saddle parasthesia), fever, sudden back pain with spinal tenderness (especially in patients with a history of osteoporosis, cancer, or steroid use), trauma or serious underlying conditions (e.g., cancer
or osteomyelitis).
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Del Med J | January 2016 | Vol. 88 | No. 1