When the patient requests imaging, the physician advises him of the risks associated with imaging and the unlikely prospect that it will change management—despite the change in neurologic symptoms. After considering such evidence-based options as massage therapy, yoga, and spinal manipulation, they agree on a trial of PT. The patient’s current level of function is reviewed, and work limitations are set.
After 8 weeks of PT, the patient experiences an improvement in overall function, pain level, and weakness. His straight-leg-raise test—the physical exam finding with the most sensitivity for disc herniation—returns to normal, as does his patellar reflex. Although frustrated with the length of recovery time, he is appreciative of his physician and therapists.
Follow this physician’s lead: Be prudent with imaging. Many primary care physicians caring for a patient like this one would consider imaging studies to assess the worsening signs and symptoms. The evidence, however, does not clearly support that decision. Given the potential harm of testing and varying benefit in outcomes, the ACP/APS offers different recommendations on imaging and other diagnostic tests, depending on the category of LBP. Prompt evaluation with advanced imaging (MRI or CT) is recommended for severe or progressive neurologic deficits, and with suspicion of a serious underlying condition, such as vertebral infection, cauda equine syndrome, or cancer with spinal cord compression, given that delayed treatment may lead to poor outcomes (ACP/APS recommendation; SOR: B).1
For many patients with herniated lumbar discs, symptoms can improve within 4 weeks.9,10 Thus, there is no compelling evidence that routine imaging changes treatment decisions or outcomes.11 For patients with persistent symptoms of radiculopathy or spinal stenosis who have not responded to conservative therapy, invasive procedures (surgery or epidural injections) become potential treatment options, and thus imaging with MRI (preferred) or CT may be warranted.
CASE 2
Patient with chronic LBP
A 48-year-old man new to the practice comes in complaining of persistent pain in the lower back, which he ranks at 6 on a scale of 1 to 10. Approximately 5 years ago he underwent an L4-L5 laminectomy/fusion for herniated nucleus pulposus. The surgery relieved shooting pains down his left leg, but he has since had progressive problems with lumbar pain and stiffness. Two courses of PT and a series of facet joint injections over the years have provided only temporary relief. The patient had been followed by a pain management clinic, but was discharged after exhausting his insurance benefit. A recent MRI ordered by the pain management clinic showed mild to moderate degenerative changes in L2 to S1 with a healed fusion.
The reason for his visit this day is to request a refill of his hydrocodone, initiated by the pain clinic. He is worried that he will not get better and is afraid of injuring himself and has, as a result, been avoiding activities. He denies depressive symptoms except for decreased self-worth and pain-related sleep disturbance. He says that he was once more vigorous and felt competent, but is now passive and feels helpless about his pain. He is concerned that his physical capabilities will worsen even more and asks if there are any other therapies that might be helpful.
No easy answers. Patients with chronic LBP—pain lasting for longer than 2 months—present unique challenges. They have often seen several clinicians, including pain management specialists, have undergone repeated imaging, and are frustrated by their persistent symptoms. Many have had 1 or more surgeries, and most have tried numerous medications to gain relief.
This patient is seeking a refill of his opioid. Before agreeing to such a request, weigh the risks and benefits of opioids and the potential benefits of alternative therapies (SOR: B).1 Although the chronic use of opioids is an option for a select group of patients with chronic LBP,12 these agents can be expensive, lead to habituation and addiction, be easily redirected for monetary gain, and have untoward side effects. Evidence does not show that long-term opioid use improves functioning in patients with chronic LBP.
Nonpharmacologic therapies that have proven beneficial for such patients include acupuncture, cognitive-behavioral therapy, PT, exercise therapy (defined as any supervised or formal exercise program), and therapeutic massage (SOR: B).1 It would be preferable to start a therapeutic plan incorporating 1 or more of these modalities, based on a patient’s psychosocial history, insurance status, and preferences. Suggesting these therapies with guarded optimism can lead to a decreased need for opioids and increased functioning.