Have we been over treating chronic low back pain? Muscle and joint complaints are one of the most common reasons for visits to a doctor. Of these types of complaints, back pain is the most common. Approximately 25% of US adults reported back pain during the past three months. This percentage has not changed for decades. I suspect Schuylkill County is no different.
The Costs Of Treating Chronic Low Back Pain
Because back pain is so common, there have been an increasing number of tests and treatments to try to help the problem. This includes spinal injections, surgical procedures, implantable devices, and medications. Each of these may be helpful for some patients. The problem is that the use of these tests and treatments appears to be expanding beyond published guidelines. This is driven by doctors’ professional concern for the patient, and marketing by the manufacturers.
These are some of the increases for Medicare expenditures for treating chronic low back pain:
629% increase for epidural steroid injections
423% increase in expenditures for opioids/narcotics for back pain
307% increase in the number of lumbar MRIs
231% increase in low back joint injections
220% increase in spinal fusion surgery rates
These numbers are quite startling. But guess what, none of this has improved patient outcomes or disability rates. Let’s look at each of one individually.
Epidural Steroid Injections
· Epidural corticosteroid injections may offer temporary relief of sciatica. Both European and American guidelines based on review of the literature conclude that they do not reduce the rate of subsequent surgery. For patients with just back pain, there is no evidence of a benefit from spinal injections. This increased 600% plus from 1995 to 2005. I personally believe that this number is much higher since 2005. (See article What You Need to Know About Steroid Shots in the Spine (Epidurals)
Opioids/Narcotics for Back Pain
- Prescription opioids/narcotics are addicting medications. There use is steadily increasing for musculoskeletal conditions. Deaths related to prescription opioids/narcotics are greater than the combined total involving cocaine and heroin. Unlike end-of-life cancer patients, patients taking opioids for back pain can do so for decades. More than half of the prescriptions for opioids/narcotics are for back pain! As a result, prescription opioids/narcotics constitute a major portion of those with addiction problems.
- Oddly enough, opioid/narcotic use may increase your sensitivity to pain.
- Furthermore, chronic use of opioid drugs may also cause hypogonadism, reduced testosterone levels, diminished libido, and erectile dysfunction. One can only conclude that the benefit of opioid/narcotic drugs in clinical practice for long-term management for treating chronic low back pain is questionable. Today, in 2015, we have seen the government launch programs to stop the prescribing of narcotics, especially for the treating chronic low back pain.
Low Back Imaging: MRI and CT scans
- Did you know that spinal surgery rates are highest where spinal imaging rates are highest? Are the spinal surgeons driving the imaging rates or are the imaging rates driving the surgery? No one wants to say.
- It is estimated that 33 to 66% of spinal imaging is inappropriate.
- One of the biggest problems with inappropriate spinal imaging is that it may reveal findings that are irrelevant but alarming.
- Did you know that “positive findings” such as a herniated disc are common in people without back pain? More than 60% of herniated discs found on MRIs are not causing back pain!
- “Positive findings” such as a herniated disc result in more surgery and higher costs, but the patients’ post surgical outcomes were no better. This includes subsequent pain, function, quality of life, or overall improvement.
Low Back Joint Injections
- Facet joint injections with steroids seem no more effective than saline injections.
Spinal Fusion Surgery
- New and “improved” fusion techniques and devices, such as implants, increase the risk of nerve injury, blood loss, overall complications and repeat surgery. They do not result in improved disability rates.
All of the above strategies may be acceptable if there were substantial improvements in patient outcomes, but they are not. If fact, statics indicates that disability from musculoskeletal disorders is rising, not falling. To put it in simple terms, the high tech techniques for treating chronic low back pain produce worse results than doing nothing at all!
There are no “magic bullets” for chronic back pain and expecting a cure from a drug, injection, or operation is generally wishful thinking.
Chronic back pain, like diabetes or asthma, is a condition that can be treated but rarely cured. Its management is up to you and your health care providers. Chiropractic physicians and physical therapist generally provide these services. There was no finding of overtreatment by Chiropractic physicans or physical therapists.
There are three excellent management options for chronic back pain. See What Did 629 Chronic Back Pain Sufferers Find Out? and LOW BACK PAIN: PATIENTS REPORT WHAT WORKED.
This article is based upon Overtreating Chronic Back Pain:Time to Back Off? that appeared in The Journal of the American Board of Family Medicine Volume 22, Number 1, January 2009.
What to know more…
Doctors’ Choice Physical Medicine & Rehab
Dr. David Novatnak
Glee Pascual, Physical Therapist
Pottsville Schuylkill County PA