A C P C O L O R A D O 2 0 1 4 C H A P T E R M E E T I N G

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JASON FRIEDRICH MD PM&R, SPORTS MEDICINE, PAIN MEDICINE

KAISER PERMANENTE- COLORADO DEPARTMENT OF NEUROSURGERY

Back Pain: Value Driven Workup and Treatment

Disclosures

None

Questions For Today

1. What are the evidence based indicators (timing, red flags, clinical findings) for imaging, both plain films and MRI, in low back pain?

2. What is the evidence for epidural steroid injections in LBP?

3. Are different types of injections more effective for LBP?

Less Is More

Application of “Less Is More” to Low Back Pain Srinivas, Deyo, Berger

Arch Intern Med 2012;172(13):1016-1020

Indicators for Imaging- Why Care?

Conscientious spine imaging = #1 on National Physicians Alliance top 5 primary care activities for “Promoting Good Stewardship in Clinical Practice”

“Don’t do imaging for low back pain within the first 6 weeks unless red flags are present”

Indicators for Imaging- Why Care?

Overused and expensive Lumbar MR imaging up 307% between 1994-2005 (yet increased

spine related disability between 1997 and 2005)1,2 Avoiding imaging in first 6 weeks has potential cost savings of

$300 million/year for plain films and MRI combined1 Questionable benefit Poorly correlated with symptoms and outcomes2,3

Many “abnormalities” found in asymptomatic patients4,5,6 Harmful “patient labeling”, chasing incidental findings, radiation, higher

surgical rates, higher cost to the patient1

Worse outcomes, more disability and decreased sense of well-being1, 2, 7

Indicators for Imaging

Most importantly Will It Change Management?

Not:

Will it alleviate anxiety?7 Will it save me some time?

Will it protect me from litigation? Will it improve my patient satisfaction scores?

Adapted from ACP/APS guidelines8

in Roudsari B, Jarvik JG. Lumbar Spine MRI for Low Back Pain: Indications and Yield. AJR. 2010:195;552.

Possible cx Hx/PE (RED FLAGS) Imaging Additional Studies

Cancer (0.7%)

H/O CA w/ new LBP MRI ESR

Unexplained wt loss Fail to improve after 1 mo Age>50

X-rays

Multiple risks present Xrays or MRI

Vertebral Infection (0.01%)

Fever with new LBP IV drug use Recent Infection

MRI ESR and/or CRP

Cauda Equina Syndrome (0.04%)

Urinary retention Motor deficits mult. levels Fecal incontinence Saddle anesthesia

MRI None

Severe/Progressive neurological deficit

Progressive motor weakness MRI Consider EMG/NCS

Chou 20078

Red Flag Conditions

Specific causes (non-red flag conditions)

Hx/Exam Imaging Additional Studies

Vertebral compression Fracture (4%)

Steroid use Osteoporosis Older age

X-ray None

Ankylosing Spondylitis (0.3-5%)

AM stiffness Improves with exercise Alternating buttock pain Second half of night pain Younger age

X-rays (AP pelvis or SI joint)

ESR and/or CRP (+/- HLA B27)

Herniated Disc/Lumbar radiculopathy

Back pain with leg pain in specific nerve root distribution +SLR or +CSLR

None None

Sxs present > 1 month (and not improving)

MRI +/- EMG/NCS

Spinal Stenosis Radiating leg pain Older age Pseudoclaudication

None None

Sxs present > 1 month (and not improving)

MRI +/- EMG/NCS Chou 20078

Indicators for Imaging: Red Flags

Almost all have identifiable risk factor Metastatic cancer8, 9

History of cancer (+LR=14.7) Unexplained weight loss (+LR=2.7) Failure to improve after 1 mo (+LR=3.0) Age > 50 (+LR= 2.7)

Infection: fever, IV drug use, recent infection, immunosupression Cauda equina syndrome: urinary retention (90% sensitivity; if no

retention, then probability of CES is 1/10000), saddle anesthesia, LE weakness, gait abnormality

Compression fracture: trauma, older age, steroid use, contusion/abrasion (combination reduced false positives)10

Inflammatory disease: younger age, morning stiffness, improvement with exercise, alternating buttock pain, awakening due to back pain during second half of night8

Yellow Flags?11

Risk Factors for Chronicity/Disability Should not by itself guide decision for imaging Depression/Mood issues Social issues/poor support network/poor coping Work-related issues/litigation/seeking disability Sleep disturbance Fear-avoidance/Kinesiophobia Deconditioning Family history of disability/chronic pain Early Imaging1,2,7,11

Indications for Imaging: Clinical Findings

Goal: Identify red flags and evaluate for “severe or progressive neurologic deficits”

Exam should include L4, L5, and S1 dermatomes, myotomes, and lower limb DTRs

Above approach thought to capture 99% of serious spinal pathology11

Indications for Imaging: Summary

1. Will it change management? 2.MD role in LBP = rule out the rare things that can

kill or paralyze, then reassure and activate 3.Evidence does not support imaging with a goal of

chasing down “pain generators” or alleviating anxiety

4.Early imaging is harmful 5. Little guidance on imaging in chronic LBP3

• N=283 • Patients from prospective RCT: Sciatica Trial (surgery vs

prolonged conservative care) • Favorable outcome = complete or nearly complete

disappearance of symptoms at 1 year • Includes both surgical and non-surgical patients

At 1 year: MRI findings

Disc herniation

Nerve Root Compression

Scar Tissue

Favorable outcome

35% 24% 86%

Unfavorable outcome

33% 26% 75%

Epidural Steroid Injections12,13,14

Axial low back pain without radiculopathy, spinal

stenosis, failed back surgery syndrome Sparse/inconclusive evidence, but show no clear benefit

(above placebo).

LBP with radiculopathy Lots of studies

Variable short-term benefit; may not be better than epidural saline Best study indicates TFESI significantly better than IMST,

TFLA, TFNS, IMNS for radicular pain due to HNP (NNT = 2-3 for >50% improvement at 1 month, NNT=4-6 for 3 mo, 4-9 at 6 mo, 5-14 at 12 mo)15

Very strict inclusion criteria

Epidural Steroid Injections

Friedly 200816 Large veteran population Mixed diagnoses: HNP, radiculopathy, spinal stenosis, DDD,

other LBP syndromes No decrease in opioid use

No conclusions on return to work13

Epidural Steroid Injections

No clinical practice guideline (0/18) recommends ESIs for lower back pain without neurological involvement11,12

Other Injections for LBP

Soft-tissue Facet-Specific Interventions Disc-Specific Interventions Spinal cord stimulator

Axial pain not currently an indication No RCTs Low quality studies with mixed results

Soft-tissue Injections for LBP

Insufficient or poor evidence to support efficacy or make recommendation11, 12

-6/18 CPGs recommend against soft-tissue injections -2/18 support use (Belgium) -10/18 cite insufficient evidence (including ACP)

Soft-tissue Injections IM steroid (no good data; not proven better than placebo) Prolotherapy (no better than saline or local anesthetic control

injections)12 TPIs (with local anesthetic superior to placebo at 2 weeks only;

adding steroid does not improve efficacy; likely no better than acupressure)12

Dry Needling (probably as good as a TPI)12 Botox (mixed/sparse/low quality evidence)17

Facet Joint-Specific Injections

IA facet injections11,12 6/18 CPGs recommend

against; 2/18 for; 10/18 insufficient evidence (including ACP/APS)

Best study underway and yet to be published

Medial Branch Blocks11,12 Role is more diagnostic than

therapeutic No placebo controlled trials

for therapeutic effect ACP/APS: Insufficient

evidence

Radiofrequency Ablation11,12 Mixed results/difficult to

interpret Minimal benefit beyond sham12 or

lumbar facet injections18 ACP/APS: Insufficient evidence Landmark trial was observational

(N=15)19: 2 differential diagnostic medial

branch blocks minimum of 80% relief on each),

and precise technique utilized 60% achieved >90% improvement

for 12 months No other study has achieved such

favorable results

Other Injections for LBP

Disc Specific Interventions Intradiscal injection IDET Nucleolysis

No intradiscal procedure has consistently proven better than placebo ACP recommends against intradiscal steroid

injection and poor evidence to evaluate IDET or nucleolysis12

Other Injections for LBP: Summary

1. Epidural steroid injections are NOT indicated for axial lower back pain

2. NO interventional treatment has consistently proven better than placebo for axial low back pain

3. As of now, it is not clear that identifying a specific “pain generator” and targeting that with an intervention really improves outcomes on a population level

Closing Remarks

“Less Is More” when it comes to low back pain Avoid “poor standards of care” “Don’t do imaging for low back pain within the first 6 weeks

unless red flags are present”

No interventional treatment has consistently proven

better than placebo for axial low back pain i.e. very high NNT on population level Some limited success with interventions in difficult to identify

subpopulations of low back pain

Closing Remarks

Role of MD in low back pain Rule out red flags (things that kill/paralyze) Identify factors that may affect treatment response

Inflammatory disease Yellow flags (of chronicity/disability)19

Error on side of reassurance, encourage movement, and getting back to ordinary activities as normal as possible20

Fear–avoidance beliefs predict disability better than pain levels or underlying diagnosis21

The END

http://www.wsib.on.ca/files/Content/DownloadableFileTheBackBook/BackBookEnglish.pdf

International anti-disability propaganda

• NPR morning edition 1/13/2014: Pain In the Back? Exercise May Help You Learn Not to Feel It

References

1. Srinivas SV, Deyo RA, et al. Application of “Less is More” to Low Back Pain. Arch Intern Med. 2012;172(13):1016-20

2. Chou R, Qaseem A, et al. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care from the American College of Physicians. Ann Intern Med. 2011;154:181-89

3. El Barzouhi A et al. Magnetic Resonance Imaging in Follow-up assessment of Sciatica. NEJM. 2013;368(11):999-1007

4. Boden SD, Davis DO, et al. Abnormal MR scans of the lumbar spine in asymptomatic subjects. A prospective invesitgation. J Bone Jt Surg. 1990;72:403-8

5. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137:586-97

6. Jensen MC, Brant-Zawadzki MN, et al. MRI of the lumbar spine in people without low back pain. NEJM. 1994;331:69-73.

7. Webster BS, Bauer AZ, et al. Iatrogenic Consequences of Early MRI in Acute, Work-related, Disabling Low back Pain. Spine. 2013;38(22):1939-46.

References 8. Chou R, Qaseem A, et al. Diagnosis and treatment of low back pain: A

joint clinical practice guideline from the American College of Physicians and ther American Pain Society. Ann Intern Med. 2007;147:478-491

9. Henschke N, Maher CG, et al. Red flags to screen for malignancy in patients with low back pain (Review). Cochrane Collaboration. 2013; 2

10. Williams CM, Henschke N, et al. Red flags to screen for vertebral fracture in patients presenting with low back pain (Review). Cochrane Collaboration. 2013;1

11. Dagenais S, Tricco AC, et al. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine. 2010;10:514-29

12. Chou R, Atlas SJ, et al. Nonsurgical interventional therapies for low back pain. A review of the evidence for an American Pain Society Clinical Practice Guideline. Spine. 2009;34(10):1078-93

13. Friedrich JM, Harrast MA. Lumbar epidural steroid injections: indications, contraindications, risks, and benefits. Curr Sports Med Rep. 2010;9(1):43-9

14. Staal J, de Bie R, et al. Injection therapy for subacute and chronic low back pain. Cochrane Database Syst Rev. 2008: CD001824

References

15. Ghahreman A, Ferch R. The efficacy of transforaminal injection of steroids for the treatment of radicular pain. Pain Medicine. 2010;11:1149-68

16. Friedly J, Nishio I, et al. The relationship between repeated epidural steroid injections and subsequent opioid use and lumbar surgery. Arch Phys. Med. Rehabil. 2008;89:1011-5.

17. Waseem Z, Boulius C, et al. Botulinum toxin injections for low-back pain and sciatica. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD008257.

18. Lakemeier S, Lind M, et al. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double blind trial. Anesth Analg. 2013;117:228-35.

19. Dreyfuss P, Halbrook B, et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine. 2000;25(10):1270-7.

20. The Back Book, 5th impression 2008. 21. Zale EL, Lange KL, et al. The relationship between pain-related fear and

disability: a meta-analysis. J. Pain. 2013;14(10):1019-30