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Chronic Low Back Pain:When is imaging need?
Y. Raja Rampersaud, MD, FRCS(C)Associate Professor, Divisions of Orthopaedic and Neurosurgery,
Spinal Program, Toronto Western Hospital,University Health Network,
University of Toronto, Canada
27th Annual ORAN IMAGING Review, Sept 30-Oct 3, 2012University Health Network
Toronto Western Spine Program
Disclosures
• Co-chair steering / advisory committee or Ontario MOHLTC– Low Back Pain Initiative– Clinical Lead, Interprofessional Spine
Assessment and Education Clinics (ISAEC – Pilot project)
University Health Network Toronto Western Spine Program
Objectives
• Understand the drivers for spinal imaging for low back pain from a primary care provider perspective.
• Recognize the impact of appropriate and inappropriate use of spinal imaging.
• Describe the clinical indications for spinal imaging in chronic low back pain.
Question #1• Have you ever had low back pain lasting
more then one day?a) Never
b) Yes but never limits me
c) Yes, limits me and typically last less then 6 weeks
d) Yes limits me and typically last more then 6 weeks
e) Yes limits me and typically last more then 12 weeks
Question # 2
• For those who have had LBP, have you had any imaging?a) No
b) Plain x-ray
c) CT
d) MRI
e) b,c and/or d
Typical Case
• 45 y.o. male with 16 weeks history of LBP (first significant episode)– Spontaneous onset
– No Red-Flags
– No neurologic complaints
– No neurologic findings
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Question # 3
• Should this patient have imaging?a) No, only if symptoms are manageable
b) No, regardless
c) Plain x-ray
d) CT
e) MRI
Question # 4
• Should this patient have imaging if his LBP is associated with leg pain?a) No, only if symptoms are manageable
b) No, regardless
c) Plain x-ray
d) CT
e) MRI
Question # 5
• Should this patient have imaging if his LBP is associated with neurological symptoms?a) No, only if symptoms are manageable
b) No, regardless
c) Plain x-ray
d) CT
e) MRI
University Health Network Toronto Western Spine Program
Low Back Pain
• 70-80% of the population experiences low back pain at some point in time
• One of commonest causes of missed work days
• One of the commonest reasons to see a physician
Y. Raja Rampersaud MD. FRCSC.
University Health Network Toronto Western Spine Program
Investigations
• Why do we get investigations?– Aid in diagnosis
– Patient request / reassurance
– Medicolegal
• Increased utilization of spine MRI– > 1000% increase in Ontario
Laupacis, A, R. Przybysz and M.A. Keller. 2005. “CT and MRI Scanning.” In: J.V. Tu, S.P. Pinfold, P. McColgan and A. Laupacis, eds., Access to Health Services in Ontario: ICES Atlas. Toronto, ON: Institute for Clinical Evaluative Sciences. You, J.J., I. Purdy, D.M. Rothwell, R. Przybysz, J. Fang and A. Laupacis. 2008. “Indications for and Results of Outpatient Computed Tomography and Magnetic Resonance Imaging in Ontario.” Canadian Association of Radiologists Journal 59(3): 135-43.You, J.J., W. Levinson and A. Laupacis. 2009. “Attitudes of Family Physicians, Specialists and Radiologist about the Use of Computed Tomography and Magnetic Resonance Imaging in Ontario.” Healthcare Policy 12(1): 54-65.
University Health Network Toronto Western Spine Program
• 90% of MRIs for LBP are abnormal
• < 2% of CTs for Headache are abnormal
• Value of a negative test is nearly non-existent for LBP
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University Health Network Toronto Western Spine Program
• Modality of choice in evaluation of most spinal disorders.o Incidental “abnormal” findings common
within asymptomatic individuals.o 57-80% abnormalities for those over the age of 60
o Poor correlation with patient symptoms, therapeutic decision-making and patient outcome.
Modic & Ross. Radiology. 2007; 245(1): 43-61.
Boden et al. JBJS. 1990; 72(3): 403-8.
Beattie et al, Spine 2000; 25(7): 81-28.
MRI and the Lumbar Spine
University Health Network Toronto Western Spine Program
MRI Symptom Correlation
University Health Network Toronto Western Spine Program
00.51
1.52
2.53
3.54
4.55
Surgical Population Non‐surgical Population
Number of MRI A
bnorm
alities Per
Patient
Figure 1. A comparison of the total amount of intervertebral disk abnormalities on MRI between the surgical & non‐surgical
populations.
University Health Network Toronto Western Spine Program
Type of Abnormalities
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
DegenerativeDisc Disease
DiskHerniation
SpinalStenosis
Instability Deformity PreviousSurgery
Prevalence Rate
Figure 2. The prevalence rate for different types of structural abnormalities present on MRI for surgical and non‐surgical individuals.
Surgical Population
Stenosis: OR = 1.6 (surgical)
Spondylolisthesis: OR = 2.8 (surgical)
* p < 0.01
University Health Network Toronto Western Spine Program
Current Problems with LBP
• Messaging is inconsistent with nature of LBP
• Societal perception and expectation regarding LBP pain (pain in general)
• “Medicalization” of LBP
– Too much focus on the Bio – Psycho - Social
• Fragmented and Episodic models of care
University Health Network Toronto Western Spine Program
Clinical Practice Guidelines (CPGs)
LBP- CPGs– Numerous / Helpful
– Favourable natural history
– biopsychosocial approach to professional and self-management
Koes BW, Van Tulder M, Ostelo R, Burton A, Waddell G. Clinical guidelines for the management of low back pain in primary care. An international comparison. Spine. 2001;26:2504–14.
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University Health Network Toronto Western Spine Program
Current Messaging
• Reassure – Most (80-90%) back pain is benign
– Don’t worry, most LBP goes away
• Keep active
• Keep working
University Health Network Toronto Western Spine Program
What does benign mean?
• Doc: It won’t kill you… Patient: It will go away…
University Health Network Toronto Western Spine Program
What typically happens to LBP?
0
1
2
3
4
5
6
7
8
9
Course A
Course A
Time
Pain
University Health Network Toronto Western Spine Program
Does it go away?• Population survey:
– Resolution -27%• Recurrence in 6mths – 29%
– Persistent – 40%
– Younger more likely to resolve
– Mostly mild!
University Health Network Toronto Western Spine Program
Does it go away?
• Typical course of LBP: Health Care Level– First episode: only 65% last <3mths
– Recurrence in the majority
– Severity can increase with recurrences
University Health Network Toronto Western Spine Program
This message does not get delivered and if so it is after the fact.
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University Health Network Toronto Western Spine Program
What typically happens to LBP?
0
1
2
3
4
5
6
7
8
9
10
Course A
Course B
Time
Pain
University Health Network Toronto Western Spine Program
What do Canadian’s think of LBP?
• Generally pessimistic view of LBP– Makes everything worse
– Will eventually stop one from working
– Will become progressively worse with age
University Health Network Toronto Western Spine Program
Case
• 45 y.o. male with 20 week history of persistent LBP
• “Doc, you told me it would get better”… “I feel worse, I tried but I can’t work, I can’t sleep”…”there has to be something really bad going on!”
• Why is it not going away like YOU TOLD ME?
University Health Network Toronto Western Spine Program
Y. Raja Rampersaud MD. FRCSC.
Non-Specific?
One-size fits alldoes not work!
Stratified approach is best!
University Health Network Toronto Western Spine Program
Not a homogenous problem• “Non-specific low back pain” is treated as a
homogenous entity
Y. Raja Rampersaud MD. FRCSC. University Health Network Toronto Western Spine Program
Our current approach is wrong
• Over 90% of back pain is caused by minor altered mechanics.
• Mechanical pain is pain• related to movement
• related to position
• related to a physical structure
• It means there is a sore thing in the back.
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University Health Network Toronto Western Spine Program
We just can’t agree on which sore thing!
We can agree it is a sore thing.
University Health Network Toronto Western Spine Program
“Medicalization”
• Patient not improving
• We are trained to investigate, make a diagnosis, and manage typically based on what is available in your tool box…
…so that is what we do.
Y. Raja Rampersaud MD. FRCSC.
University Health Network Toronto Western Spine Program
What do patients want?
• Imaging test to tell them what is wrong
• Funded physiotherapy
• Note for work activity restrictions
Y. Raja Rampersaud MD. FRCSC. University Health Network Toronto Western Spine Program
When to get Imaging?• Imaging
– American College of Radiology (ACR) and Canadian Association of Radiologist (CAR) old guidelines:
– LBP – > 6 weeks • MRI test of choice
University Health Network Toronto Western Spine Program
2005 Guidelines:
University Health Network Toronto Western Spine Program
2005 Guidelines:
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University Health Network Toronto Western Spine Program
2005 Guidelines:
University Health Network Toronto Western Spine Program
Investigations
• 45 yo male with 9 mths of LBP, getting some occasional leg pain– Diffuse degenerative disc
disease
– L5-S1 herniated disc impinging on the S1 nerve root
• Now what?
Y. Raja Rampersaud MD. FRCSC.
University Health Network Toronto Western Spine Program
• Descriptive MRI reports are often “concerning”– “large disc herniation”– “indentation of the cauda equina”– “severe diffuse degenerative disc”…etc
MRI and Spine
University Health Network Toronto Western Spine Program
Patient Perspective
• 45 y.o. male now at 9mths of LBP– “Holy crap, all that is going on in my
back, no wonder why it hurts so much”
– Can it be fixed?
– I have to see a Specialist!
Y. Raja Rampersaud MD. FRCSC.
…and so on!
University Health Network Toronto Western Spine Program
Fragmented and Episodic Care
• One flare at a time
• No one provider can take full ownership of LBP
• Interprofessional silo’s– Inconsistent and contradictory diagnoses and care
• System challenges– Wait-times / Cost / Big Business in the private sector
– Insurance company / WSIB want to know what the “sore thing is” and won’t pay until that information is provided (Pain is not an acceptable diagnosis)
Y. Raja Rampersaud MD. FRCSC. University Health Network Toronto Western Spine Program
Fragmented and Episodic Care
• Perfect storm for maladaptive pain behaviours, coping, and cognitive processes!
Y. Raja Rampersaud MD. FRCSC.
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University Health Network Toronto Western Spine Program
43Y. Raja Rampersaud MD. FRCSC. University Health Network Toronto Western Spine Program
Chronic LBP
• Current care does not work
• 20-30% chronic pain – 70-80% resources!
Y. Raja Rampersaud MD. FRCSC.
Initial Pain Pain Disorder
• We have to do better!
University Health Network Toronto Western Spine Program
Steps• Change the messaging regarding LBP
– Chronic / Recurring Condition
• Integrated care models– Clinical expertise
– Self-management
– Appropriateness• Right care at the right time and in the right
amount.
• Sustainable University Health Network
Toronto Western Spine Program
Alberta LBP Guidelines – Nov 2011
http://www.topalbertadoctors.org/cpgs.php
University Health Network Toronto Western Spine Program
http://www.topalbertadoctors.org/cpgs.php
University Health Network Toronto Western Spine Program
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University Health Network Toronto Western Spine Program
Sustainability
• Patient needs:• immediate pain relief
• reassurance
• a clear or realistic prognosis
• a clear plan
• Accountability– All stake holders!
University Health Network Toronto Western Spine Program
Cost-Effectiveness Analysis of aReduction in Diagnostic Imaging in
Degenerative Spinal Disorders
Joanne S. M. Kim, MSc, PhDJoyce Z. Dong, MScStacey Brener, MScPeter Coyte, MA, PhDY. Raja Rampersaud, MD, FRCSC
Healthcare Policy,2011;7(2):e105
University Health Network Toronto Western Spine Program
Study Objectives
• Determine cost implications of eliminating umbrella use of CT/MRI from a health care perspective
• Reduce unnecessary use of advanced imaging thereby improving its efficiency
University Health Network Toronto Western Spine Program
Usual care (some CT/all MRI)
vs. triage program (no CT/some MRI)
Outcome:number of surgical candidates identified
MRIs used for diagnosis
Incremental cost components:CTs, MRIs, X-rays, and consultations
Cost-effectiveness analysis:Use of natural units and resource utilization
Study Design
University Health Network Toronto Western Spine Program
2,046 patients with MRI seen over 31mths
Condition Diagnosis # Patients # Surgical # Non-surgical
Lumbar disc herniation/sciatica/radiculopathy MRI 623 486 137
Lumbar spinal stenosis/claudication MRI 228 196 32
Degenerative spondylolisthesis X-ray 87 80 7
Isthmic spondylolisthesis X-ray 103 91 12
Cervical radiculopathy/herniated nucleus pulposus MRI 139 86 53
Cervical myelopathy/stenosis MRI 26 21 5
Axial back pain/DDD*/stenosis/facet osteoarthritis CA* 470 114 356
Axial neck pain/DDD*/spondylosis CA* 58 5 53
Coronal deformity/scoliosis X-ray 50 22 28
Sagittal deformity/kyphosis X-ray 19 13 6
Tumour/infection MRI 18 11 7
Inflammatory/rheumatoid arthritis/ankylosing spondylitis MRI 11 7 4
Myofascial/multifactorial/chronic/regional pain syndrome CA* 134 5 129
Miscellaneous MRI 80 24 56
Total NA 2,046 1,162 884
*CA, clinical assessment.University Health Network
Toronto Western Spine Program
Decision Tree
PCP, primary care provider; SS, spine surgeon; APP, advance practice physiotherapist.
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University Health Network Toronto Western Spine Program
Outcome and Cost AnalysesSavings Costs
CTs MRIs SS Consult Post Care X-rays APP Consult
Quantities 869 1,841 662 N/A 1,914 5,576
Prices (2009 CAD)* $532 $899 $76.30 N/A $91.58 $31.87
Costs (Q x P) $462,308 $1,655,059 $50,511 $216,021 $126,747 $177,707
Cost Difference $2,007,977 in savings for study duration of 31 months ($775,224 per year )
•Cost Savings of $775K / year ($2M / 31 mths)
•Triage program is more effective and cheaper.
•It is dominating.
*from OCCI and OHIP SoBUniversity Health Network
Toronto Western Spine Program
Sensitivity Analysis:
NO pre assessment CT or X-ray
MRI = $84
University Health Network Toronto Western Spine Program
# Surgeries
per Year # Surgeons
# Ortho
Surgeons
# Neuro
Surgeons
25-49 11 6 5
50-74 12 7 5
75-99 8 4 4
>100 31 17 14
Triage program would save Ontario$24,234,929 per year
Provincial Implications
University Health Network Toronto Western Spine Program
Funding
• Integrated and Sustainable Model of Care
Y. Raja Rampersaud MD. FRCSC.
Y. Raja Rampersaud MD. FRCSC.
Prevent Modify
Self Manage
Stratified Shared Care.
University Health Network Toronto Western Spine Program
When to get Imaging?• Imaging
– MRI not needed if manageable• X-ray / CT will rule out most surgical disorders
– # / spondylolisthesis / deformity…etc
– Leg pain• Unmanageable, Progressive • MRI /CT
– If functionally significant neurological findings, suspicion of tumor, infection etc (i.e. red flags)
• MRI
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University Health Network Toronto Western Spine Program
Key Messages
• Unless it is going to change your management, it does not need to be ordered.
• In the absence of RED FLAGS, neurological findings, or leg symptoms (failing conservative management) MRI is scanning is of limited value.
University Health Network Toronto Western Spine Program
Typical Case
• 45 y.o. male with 16 weeks history of LBP (first significant episode)– Spontaneous onset
– No Red-Flags
– No neurologic complaints
– No neurologic findings
University Health Network Toronto Western Spine Program
Question # 3
• Should this patient have imaging?a) No, only if symptoms are manageable
b) No, regardless
c) Plain x-ray
d) CT
e) MRI
University Health Network Toronto Western Spine Program
Question # 4
• Should this patient have imaging if his LBP is associated with leg pain?a) No, only if symptoms are manageable
b) No, regardless
c) Plain x-ray
d) CT
e) MRI
University Health Network Toronto Western Spine Program
Question # 5
• Should this patient have imaging if his LBP is associated with neurological symptoms?a) No, only if symptoms are manageable
b) No, regardless
c) Plain x-ray
d) CT
e) MRI