oct 3 - 1400 - rampersaud - chronic lower back...

9/11/2012

1

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

9/11/2012

2

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


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.


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.


• 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

9/11/2012

3


• 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


MRI Symptom Correlation


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.


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


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


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.

9/11/2012

4


Current Messaging

• Reassure – Most (80-90%) back pain is benign

– Don’t worry, most LBP goes away

• Keep active

• Keep working


What does benign mean?

• Doc: It won’t kill you… Patient: It will go away…


What typically happens to LBP?

0

1

2

3

4

5

6

7

8

9

Course A

Course A

Time

Pain


Does it go away?• Population survey:

– Resolution -27%• Recurrence in 6mths – 29%

– Persistent – 40%

– Younger more likely to resolve

– Mostly mild!


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


This message does not get delivered and if so it is after the fact.

9/11/2012

5


What typically happens to LBP?

0

1

2

3

4

5

6

7

8

9

10

Course A

Course B

Time

Pain


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


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?



Non-Specific?

One-size fits alldoes not work!

Stratified approach is best!


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.

9/11/2012

6


We just can’t agree on which sore thing!

We can agree it is a sore thing.


“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.



What do patients want?

• Imaging test to tell them what is wrong

• Funded physiotherapy

• Note for work activity restrictions


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


2005 Guidelines:


2005 Guidelines:

9/11/2012

7


2005 Guidelines:


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?



• Descriptive MRI reports are often “concerning”– “large disc herniation”– “indentation of the cauda equina”– “severe diffuse degenerative disc”…etc

MRI and Spine


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!


…and so on!


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)


Fragmented and Episodic Care

• Perfect storm for maladaptive pain behaviours, coping, and cognitive processes!


9/11/2012

8


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!


Initial Pain Pain Disorder

• We have to do better!


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


Alberta LBP Guidelines – Nov 2011

http://www.topalbertadoctors.org/cpgs.php


http://www.topalbertadoctors.org/cpgs.php


9/11/2012

9


Sustainability

• Patient needs:• immediate pain relief

• reassurance

• a clear or realistic prognosis

• a clear plan

• Accountability– All stake holders!


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


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


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


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


Decision Tree

PCP, primary care provider; SS, spine surgeon; APP, advance practice physiotherapist.

9/11/2012

10


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


Sensitivity Analysis:

NO pre assessment CT or X-ray

MRI = $84


# 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


Funding

• Integrated and Sustainable Model of Care



Prevent Modify

Self Manage

Stratified Shared Care.


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

9/11/2012

11


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.


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


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

oct 3 - 1400 - rampersaud - chronic lower back...

Documents