Chronic low back pain: work-up and treatment
By Alan Scarrow, MD, JD, Chairman, St. John's Neurosurgery

Recently at St. John’s there has been a significant amount of effort made toward improving the care of patients with spine related symptoms. 

This group of patients have experienced a significant increase in the cost of their care with annual increases (measured in dollars per member per month for patients with Mercy Health Plans benefits) exceeding 12 percent. This has prompted a group of physicians and administrators involved in the care of spine patients at St. John’s to form a Spine Task Force (STF) whose purpose is to identify underlying causes for this increase in cost and ameliorate them with "best practice" solutions. One of the most significant issues the STF has identified thus far is the work up, imaging and treatment of patients with chronic low back pain.

Low back pain (LBP) is the second most common reason to visit a physician in the United States. It is the most common cause of disability in Americans under the age of 45 with the resulting loss in productivity from LBP estimated to be as much as $75 billion per year. Although these patients often present with severe pain that is accompanied by a complicated history such as physical and psychological stress, the fortunate truth is that the vast majority of patients with LBP will have their symptoms resolve in six weeks or less. Eighty to 90 percent of patients with LBP will improve with time.  Best practice recommendations for these patients would include a short course (< six weeks) of one or more of the following: non-steroidal anti-inflammatory drugs (NSAIDs), narcotics, cox-2 inhibitors, physical therapy or antidepressants (in patients with symptoms of depression).  Imaging for patients with acute LBP is not recommended because of its low utility. No more than 8 percent of patients with LBP will have identifiable pathology on their imaging study.

While the expectation for a patient with acute LBP heavily favors recovery in six weeks or less, there is still a significant group of patients who fail to improve. In this situation consultation with a spine specialist such as a neurologist, physiatrist or pain management physician is appropriate. During this evaluation the specialist will try and discern an underlying anatomic cause for the patient’s symptoms. A wide variety of tissues may be implicated in the cause of LBP including muscles, tendon, ligaments, disc, facet joints, periosteum, meninges, or blood vessels making accurate diagnosis difficult.  At this time an imaging study of the spine may aid in the diagnosis. By far the most beneficial imaging study in these patients is a magnetic resonance image (MRI) as it provides the best detail of soft tissue and neural structures in the spine. Computed tomography (CT) scans of the spine offer limited insight into the cause of LBP because of its inability to view those tissues.

In a few of the patients reaching this level of the work up, underlying pathologies such as compression fractures, stenosis, herniated discs, spondylolisthesis or even tumors may be revealed by the MRI.  Yet a large number of these patients will still not be found to have an identifiable anatomic cause of their symptoms. Careful thought must go into the next step of treatment for these patients particularly in regard to continuing with conservative treatment of moving towards surgery.

There are three Class I studies (prospective, randomized trials) comparing surgical versus conservative management for severe chronic LBP.  The first study looked at 294 adult patients with severe LBP for > two years without significant leg pain or degenerative changes on MRI and an absence of spondylolisthesis, spinal stenosis, fracture, infection, tumor, or disc herniation. Group 1 received surgery while Group 2 received non-surgical treatment in the form of physical therapy, education, TENS units, acupuncture, injections, cognitive therapy and coping strategies. At two-year follow up, Group 1 had significant improvement over Group 2 as measured by improved back and leg pain, disability, and depression scores. Seventy-five percent of Group 1 stated they would repeat their treatment while only 53 percent of Group 2 participants said the same thing.

The second Class I study looked at this same group of patients but broke down the surgical patients in Group 1 into four subgroups based on the type of surgery that was performed. Group 1a had an "onlay" fusion where bone from the patient’s hip was placed over the transverse processes of the spine, group 1b had onlay fusion plus pedicle screws, group 1c had onlay fusion plus pedicle screws and anterior interbody fusion, and group 1d had onlay fusion plus pedicle screws and posterior interbody fusion. All four groups had a decrease in back pain, improved disability and depression but an increase in pain between years 1 and 2 following surgery. Fusion rates (the presence of a bony union between levels of the spine), often associated with "success" in lumbar spine surgery were 72 percent in group 1a, 87 percent in group 1b and 91 percent in groups 1c and d yet there was no difference between the groups in overall satisfaction or outcome.

The third Class study looked at the overall direct health care costs for 289 patients with > two years of severe LBP as measured by hospital care, office visits, drugs, home services, productivity losses (work loss), and support costs (travel, shopping, housekeeping). Patients were randomized to one of three surgical groups (Group 1 - onlay fusion, Group 2 - onlay fusion plus pedicle screws, or Group 3 - onlay fusion plus pedicle screws and interbody fusion) or nonsurgical treatment (Group 4) and followed for two years. Direct health care costs were twice as high for the surgical group (Group 3 > Group 2 > Group 1) with Group 4 having higher costs for office visits and drugs.  Patients in the surgical groups had an increased rate of return to work and significant improvement in back pain and Oswestry disability scores but no significant difference in production losses or sick time off in comparison to the nonsurgical group. There were no significant differences between the surgical groups in this regard.  The overall costs to society (health care plus productivity losses) were approximately $10,000 more for each surgical patient. Based on this data, the authors of the study estimated that in order to get 10 patients with severe LBP back to work, 30 surgeries would need to be performed versus 63 nonsurgical treatments.

In summary, patients with LBP can be divided into groups with acute symptoms and those with more chronic symptoms. Patients with acute LBP can be managed conservatively for approximately six weeks with NSAIDs, narcotics, cox-2 inhibitors, physical therapy or antidepressants. Referral to a spine specialist and obtaining imaging studies, preferably MRI, should be done after that initial period. A work-up by a spine specialist will attempt to identify an anatomic source of the patient’s symptoms and be treated accordingly. 

For patients without an identifiable anatomic source of pain, surgical treatment should be considered. In these cases, Class I evidence suggests that particular thought should be given to the specific type of surgery to be performed, the costs associated with each surgery and the expectations for returning to a productive life.

To refer a spine patient to Dr. Scarrow, please call his office at 417-820-5150 or e-mail him at ascarrow@sprg.mercy.net.

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