Superdoc (9) - Back pain and investigations


An investigation won't tell us what we usually need to know about back pain - so why do we often jump so quickly into it?

It’s tough to surprise someone in my line of work. We Superdocs have seen a thing or two. Each passing hour on the job can bring a changing location, disaster, medical emergency, distressed feline … the list continues.

Mostly these are the events that make work super-interesting and keep me on my super-toes; but there are a few I’d like to see a little less of. Back pain investigation is one.

As doctors we rarely see any patient who’s had back pain for more than a short period who hasn’t had some type of investigation of the spine.

Let’s look at why we investigate and what the consequences are.

People who have back pain can potentially have something serious wrong with their back: a cancer that’s spread to the spine or some other tumour or growth, or even possibly an infection; but, this is extremely rare.

None-the-less, doctors don’t want to miss something that’s potentially dangerous and treatable.

Unfortunately, a number of studies have shown that the chance of picking up a serious back problem by doing an investigation is extremely low. If the person is losing weight, has a history of cancer or has some other serious symptom such as night sweats, then it is important to do an appropriate investigation. However, what commonly occurs is people with uncomplicated back pain have lots of tests. They might have an x-ray to start followed by a CT scan, and if referral to a specialist is arranged an MRI scan is almost a given.

Patients in the compensation system often have multiple investigations, and it’s not uncommon to see them arrive at clinics with a 5-kilogram bag of various scans. Perhaps they’ve had back problems for a few years and start to get soreness in the neck, so a neck scan is done too. They ask the doctor to check how their problem is going so a repeat back MRI is performed.

“So, what’s the problem with this?” you might say.

Well, the first issue - and the least important – is the expense. In that 5-kilo bag of scans is about $4000’s worth of investigations.

Wouldn’t it be great to see that patient getting value for money? There are better ways of spending the money that would improve their health outcomes.

The next issue is that it causes all sorts of confusion. Employers or claim staff might consider that there is some meaning if the person does or doesn’t have an abnormal scan. Perhaps if the case goes to court, lawyers and judges consider there is some relevance or meaning from the scan results.

The last and most important issue is the patient. They wait for the scan results expecting there will be some clear answer to their problem, and that at last there’ll be clarity about the diagnosis and what treatment should fix their problem. Worse is the patient who has a normal scan. They’re often left bewildered, and sometimes feel more confused when the scan doesn’t show a specific abnormality.

More than all of the above, scans often make a simple situation complex.

A scan doesn’t tell what kind of treatment should be provided; it doesn’t tell whether the person’s going to do well; it doesn’t tell us how long the back problem is going to stay around and it doesn’t tell us the cause of the pain. Further, it doesn’t tell us anything about the person’s work capacity or work abilities, or the duties that should be provided to help them continue in the workplace.

Radiologists also contribute to the problem. If you have a blood test and a measure of your hemoglobin count, the pathology laboratory will report on the normal range. For example, if my hemoglobin is 13 the result will be returned to the doctor with “hemoglobin of 13”, and sitting next to it will be the figure for the normal range, for example “11.8 to 14.6”. The doctor immediately knows that the “13” is within the normal range and not to worry.

Radiologists on the other hand do not report on normal age-related changes in the spine. It would be useful to see radiologists’ reports on an MRI scan, showing disc-degenerative changes and recording if it’s seen on 60% of scans for this patient’s age.

Confronted by this, some radiologists suggest that it is the referring doctor’s job to understand the significance of radiology findings. I think that’s a cop-out. Radiology services earn significant incomes from the scans and it’s behoved on them to play their part in reducing unnecessary disability from scan results.

If somebody is going to have an operation for a disc prolapse they should have a scan; it’s important in determining at what level the surgery is performed. Other than that there is little value in spinal investigations.

One of the most famous back researchers, Dr Richard Deyo, studied patient expectations about medical investigation in the 1980s. He found that a two-minute explanation about the value and appropriateness of spinal investigations left patients satisfied and comfortable when scans weren’t performed. Yet the research hasn’t diminished our tendency to immediately order investigations.

I’ll often do an MRI scan of the back earlier rather than later simply because the patient is going to have it done by someone and I might as well get in first and give a good explanation about the results of the exam, lest it is done by someone who interprets degenerative changes as something significant.

If a person has a long-term back problem, in this day and age they are likely to get some type of scan. Better it is done earlier rather than later and the fundamental issue is that the person is given clear advice about what is significant and what is not. Lack of serious abnormalities is important to point out to foster the person’s understanding and confidence to return to activity.