'Selective' Imaging Recommended for Low Back Pain (CME/CE)

[Justin]

(MedPage Today) -- Diagnostic imaging is overused in routine treatment of low back pain for various reasons and should be reserved for patients with specific risk factors, according to a new guideline from the American College of Physicians...

'Selective' Imaging Recommended for Low Back Pain (CME/CE) (click here for the full article at MedPage Today)

[Hooch]

Factors that call for imaging studies include the following:

• Major risk factors for cancer, such as history of cancer combined with new onset of back pain
• Risk factors for spinal infections
• Severe neurologic deficits
• Signs or risk factors associated with cauda equina syndrome, such as new-onset urine retention or fecal incontinence

We don't image, 'just for pain'.

There should be another bullet point there -

• Pain for longer than 3 months duration.

It is beyond me why it so difficult for medical professionals to realise pain for what it is essentially is - tissue damage, that may be surgically rectifiable.

[Justin]

[/LIST]We don't image, 'just for pain'.

There should be another bullet point there -

• Pain for longer than 3 months duration.

It is beyond me why it so difficult for medical professionals to realise pain for what it is essentially is - tissue damage, that may be surgically rectifiable.

This is a gross oversimplification of an extremely challenging subject: pain. Yes, "tissue damage" causes pain; however, not all "tissue damage" is "surgically rectifiable" -- and pain is much more complicated than this. Also, "pain for longer than 3 months duration" means nothing without context and a full history and physical. Patients present with symptoms, then a differential of "what ifs" starts to formulate in a physicians mind--everything from the "horses" (the things we see all the time) to the "zebras" (the really rare stuff that must still be on the differential, even if it's only seen in 1 out of 2 million patients). Anyway, what I am trying to say is that physicians know what pain is, they are more concerned about the underlining reason for the pain (what is causing the pain) so that they can treat appropriately (ie medically or surgically).

[Hooch]

No, not all tissue damage is surgically rectifiable, and how do you ascertain this? Through the use of imaging.

At it's core, pain is tissue damage. That is how pain works, that is how the nervous system functions. That is not controversial. Syndrome diagnosis such as Fibro are indicative that medical science does not understand the mechanism of many of the pain causing diseases that are part of the human condition. The complications and co-morbidities such as 'central sensitisation' associated with chronic pain grow from this initial (often degenerative) tissue damage, not the other way around. I have never heard of anyone saying I got depressed then developed chronic pain as a secondary condition, for instance.

In my experience, and in the experience of many others, I have had my primary symptom of severe chronic pain dismissed by numerous members of the first line of the medical profession, and mine is not an isolated experience.

My statement is a simple one: If a patient presents with disruptive ongoing pain of more than 3 months duration, a full diagnostic work up is required, which for any competent medical professional includes imaging.

3 months is an appropriate time for any acute or non-degenerative injury to heal or settle.

This would go a long way to avoiding the current situation where people are thrown in the 'too hard' basket and left to suffer or become their own advocates because of the diffuse nature of their symptoms.

But this would require medical professionals to consider pain as important a symptom as non-subjective symptoms such as numbness, reflex etc. This would also have wide ranging implications for the way we perceive individuals with pain in our society, the role of pain in workplace injuries, the role of pain in securing social security. Not all of them positive, but it is a change that would be overwhelmingly for the best imo.

Surely as President of the Spine Patient Society you would support such a measure?

[Justin]

I have never heard of anyone saying I got depressed then developed chronic pain as a secondary condition, for instance.

Rule #1 in Medicine is never say never.

In my experience, and in the experience of many others, I have had my primary symptom of severe chronic pain dismissed by numerous members of the first line of the medical profession, and mine is not an isolated experience.

Unfortunately, chronic pain is dismissed or not "given the attention it deserves" -- I completely agree with you on this.

My statement is a simple one: If a patient presents with disruptive ongoing pain of more than 3 months duration, a full diagnostic work up is required, which for any competent medical professional includes imaging.

This is not necessarily true. If someone comes in with GERD and their symptoms shout GERD, I'm not going to waste money chasing things I know it's not. A "full diagnostic workup" costs a lot of money. Also, you have to put this "disruptive ongoing pain" in some sort of context. In medicine, you don't "fully workup" everyone that comes through the door with "disruptive ongoing pain for more than 3 months duration." One also has to rule out factitious disorder (Münchausen syndrome), as well as many other medical and psychiatric possibilities. Putting someone through a whole hosts of tests without knowing what you are doing and why you are doing it is an incredible waste of money. We follow recommended guidelines and we also follow evidence-based medicine.

3 months is an appropriate time for any acute or non-degenerative injury to heal or settle.

What are you basing the above statement on? It takes 6 months to a year for a simple cut on your hand to completely heal (the tissue remodeling that one cannot see, is still going on close a year later).

This would go a long way to avoiding the current situation where people are thrown in the 'too hard' basket and left to suffer or become their own advocates because of the diffuse nature of their symptoms.

What are you referring to when you mention "this?" (What would go a long way?)

But this would require medical professionals to consider pain as important a symptom as non-subjective symptoms such as numbness, reflex etc. This would also have wide ranging implications for the way we perceive individuals with pain in our society, the role of pain in workplace injuries, the role of pain in securing social security. Not all of them positive, but it is a change that would be overwhelmingly for the best imo.

Pain is, unfortunately, subjective. It's not a objective finding (a sign) on physical exam. I agree: if pain was an objective physical finding, it would be treated accordingly. However, pain is very unique, as you know.

Surely as President of the Spine Patient Society you would support such a measure?

What measure I am supporting here? This is a good discussion.

[Hooch]

God, a quoteathon, thay never work.

The essential element is this: Too often (all the time?) the physician interprets the nature and severity of the patients pain and treats it accordingly. This is a fallacy. As we all know, pain is a subjective, ethereal quantity; but it is only experienced by one person: the patient. The idea that another could somehow magically interpret the level or quality of this pain is ridiculous. Until the day some sort of pain thermometer is invented, it will remain ridiculous.

You have a situation where one person validates or invalidates anothers pain, and it's a recipe for disaster. How many times in these forums and in others (and in person) have you heard, 'the doctors thought I was crazy', 'I couldn't get the doctors to listen', 'they didn't take me seriously' etc. This can go on for years.Some people have had to go to pieces in front of a doctor in order for them to 'get' that their pain is very real and significant. Unfortunately this can just as easily lead to them being treated as having some sort of emotional problem.

A lot of this would be avoidable with some simple regulations regarding the presence of continued pain as a serious symptom. That doesn't mean the pain can be magically made to go away, it doesn't mean that anything can necessarily be done.. what it does mean is that the pain generator is identified and treated. This could be as simple as diagnosing a sprained ankle and saying let it go and heal.

Re. 3 months, maybe too short? Maybe not. If someone presents after 3 months and lets be clear and say significant ongoing pain, unless there is already a clear and accurate diagnosis of why they are in pain it needs to be gotten to the bottom of. For a good attentive doctor this is everyday practice.. unfortunately there are a lot of doctors out there who simple aren't attentive to their patients needs, and only attentive to obvious clinical signs. Yes, significant, ongoing pain is a diffuse statement, but a diffuse statement for a diffuse symptom pain. Maybe be a better system would be to clearly educate medical professionals that the only who can tell you how much pain the patient is in, is the patient? As it stands with medical technology, that's where it's at, end of story.

Re. Munchausens Syndrome.. are you really telling me you are going to diagnose someone with that through your dead keen eye? The only way you could diagnose someone with that is after full diagnositc work up excluding all the symptoms the patient presents with. Otherwise, they could just be, you know, crook, and seeking help but getting none. It's a syndrome diagnosis of exclusion of medical conditions.. I'm sure there have been a few hit with such a diagnosis in the past who are just unlucky enough to have presently undiagnosable conditions. I mean, seriously, how many Munchausens cases do you honestly expect to deal with in your career? It's that bloody rare you deal with it when it comes.

[Justin]

Re. Munchausens Syndrome.. are you really telling me you are going to diagnose someone with that through your dead keen eye? The only way you could diagnose someone with that is after full diagnositc work up excluding all the symptoms the patient presents with. Otherwise, they could just be, you know, crook, and seeking help but getting none. It's a syndrome diagnosis of exclusion of medical conditions..

You do realize that I am currently training to be a physician, right? There's no need to spell out how you work-up a patient; I do this everyday. Also, I never said that I was going to "diagnose someone with that (Münchausen syndrome) through your (my) dead keen eye" -- please don't put words in my mouth. I just saw and diagnosed (gasp!) a patient with Münchausen's last week.

Anyway, I thought we were having a good discussion, but I guess not. Take care.

[Cindylou]

Oh, gosh, I think this has been an excellent discussion and I have thoroughly enjoyed being able to participate in it just by reading both of your offerings and insights. So thank-you both. Chris, perhaps you weren't aware that Justin is training to be a physician? I was really hearing where you were coming from Chris, most definitely, and then Justin you had just very insightful responses....guess that's why you're going to medical school, not me! haha And I am almost wondering if just maybe there are a few more sicko's (munchausen) in the medical database than either Chris or I would ever imagine. Perhaps? Anyway, thanks again. CL

[KBear]

Oh, gosh, I think this has been an excellent discussion and I have thoroughly enjoyed being able to participate in it just by reading both of your offerings and insights. So thank-you both. Chris, perhaps you weren't aware that Justin is training to be a physician? I was really hearing where you were coming from Chris, most definitely, and then Justin you had just very insightful responses....guess that's why you're going to medical school, not me! haha And I am almost wondering if just maybe there are a few more sicko's (munchausen) in the medical database than either Chris or I would ever imagine. Perhaps? Anyway, thanks again. CL

Ditto, both had very good points. I think in some cases imaging may be overused, but in others it isn't used enough. I know I was one of the ones treated like a head case, so I'm pretty sensitive on the subject and probably really biased.

I seriously think I know someone with munchausen, won't go into in the public forum, but may be asking you some questions Justin and CL (isn't your background in social work?).

[Hooch]

I realise you're training to be a physician. Frankly I don't see the relevance.

My points stand and they haven't been addressed. Not that I care that much, I don't see how my initial response was provocative or controversial. It wasn't even addressed at you in particular.

I have no idea why you even brought Munchausen's syndrome up, it is quite obviously a diagnosis which requires an extensive analysis of a patient (yes, absolutely including expensive imaging), and isn't particularly relevant to the original article or the following discussion. That sort of diagnosis has serious implications for the patient in having any real medical conditions taken seriously in the future and isn't exactly handed out like candy at the beach. Total opposite end of the spectrum to what was being discussed.

The article explicitly states that imaging should not be performed on those with low back pain unless they demonstrate obvious clinical symptoms such as neurologic deficit. Those who have suffer from the debilitating pain of ddd are left high and dry as the primary sympton is pain, which a clinician is unable to objectively measure. They are left undiagnosed and uninformed of any possible surgical intervention. And in pain.

How much pain and suffering will be avoided by inserting a simple guideline in there which simply says that longstanding chronic low back pain requires diagnosis, which requires imaging as there is simply no other way to tell what is going on in there?

I find it hard to believe that any spine patient would disagree with my statements, we spend at least half out time on this forum whinging about this sort of thing. In that article, in black and white, is a medical professional saying don't image for pain.

To reduce the unnecessary expense and radiation exposure, clinicians should order imaging scans "only in selected, higher-risk patients who have severe or progressive neurologic deficits or are suspected of having a serious or specific underlying condition," they wrote in the Feb. 1 issue of Annals of Internal Medicine.

Do you see how it all rests on the physicians interpretation of the patients pain? It is plainly obvious why the system does not work, and the medical profession needs to readjust their attitude to the clinical presentation of pain.