Living in the Grey Zone: Back Pain

Thanks to all who participated and attended the Grey Zone: Acute Back Pain lecture last Tuesday.  I learned a lot, hope that you did as well.  As is often the case with grey zone lectures, we spend so much time talking with the panel that we miss some of the didactics at the end.  Here are some highlights that I wanted to be sure to cover.

99% of patients will acute back pain will get better, often without you doing much at all.  Gentle activity, NSAIDs, and time will take care of most.  If it goes on for two-week or so, add some formal PT. The activity is good, but PT will also use massage, heat, TENS and US to help get the muscles to relax.

Red flags aren’t all they are made out to be, but are definitely a clue to slow down your thinking about a patient with back pain.  You may not need to do more just because a patient has one red flag-  80% of patients will have at least one.

Yellow Lights mean “slow down and prepare to stop” according to my 5-year-old, and that is just what these should signs and symptoms should make you do.

  • Age >70
  • History of cancer, not active malignancy
  • IV drug use
  • Osteoporosis, use of steroids
  • Immunosuppression

On the other hand, the red lights should make you stop and seriously consider more imaging, consultation, or other workup. You may still be justified in delaying imaging if there are one of these present, but you need to be extra sure that it is the right thing to do.

  • Known metastatic cancer
  • Trauma
  • Recent spinal surgery
  • Bowel/Bladder incontinence
  • Fever (without another reason)
  • Weight loss (without another reason)
  • Saddle anesthesia, decreased rectal tone
  • Progressive motor or sensory loss

If you do need to do more workup, let your differential diagnosis be your guide as to what needs to happen.  Here are some suggestions:

  • Vertebral Fracture: either from osteoporosis or trauma.  Plain films are quite helpful, CT is important for traumatic fractures- will give a better idea of the extent of the fracture and the mechanism.
  • Metastatic disease: Plain films are a place to start.  MRI would be quick to follow if there are neurologic findings.  Bone scan may be useful in a high risk patient with a less clear picture.
  • Cauda Equina Syndrome: Think this if there is saddle anesthesia, bowel/bladder incontinence. MRI if you are concerned, with quick referral to NSGY.
  • Spinal Stenosis: Pseudoclaudication is the classic sx here: predictable pain with standing or walking, better with rest.  Vascular claudication gets better quickly with rest, pseudoclaudication takes 20-30 minutes or more. Plain films may show misalignment, but the MRI is going to clinch the diagnosis.
  • Epidural abcess: Unexplained fever and weight loss in a high risk patient: IV drugs, recent spinal surgery, recently septic, decubital ulcers all are all risks. MRI is the imaging test.

Here’s a great patient centered video about low back pain to bring these points home to your patients.

Link Roundup: what I learned on “The Twitter”

Did you know that saying “The Twitter” immediately ages you by 9 years? You know that I was only kidding, right…

Here are the highlights of ambulatory medicine from the last few weeks.  Follow @ihaterashes to get these in real time.

 

 

While you are following new people on twitter, check out @medicalaxioms.  This guy is smart, funny,and usually spot on.  Some highlights:

A few things came across my screen about overdiagnosis of breast cancer from BMJ and Annals of IM Just a reminder that raising awareness isn’t enough.  A ribbon doesn’t provide any information- that’s our job.

I’m starting to tweet Grand Rounds when I can.  #uabmgr.  Here’s what I learned in the great talk on The Gut Microbiome given by Martin Rodriguez and Casey Morrow

And finally, I feel the need to share a few articles making the rounds some of the frustration in clinical medicine these days: burnout in Washington Post, competing agendas in NYT (here on Danielle Ofri’s site) and irritation with EMRs in The Atlantic. I have mixed feelings about these things, I love my job and want all of you to become primary care physicians. But burnout is real, as are the administrative challenges of practice.  We need to be able to talk about it, and I am relying on all of you to help make it better!

USPSTF Recommendations: Lung Cancer Screening

So, guideline season is still upon us, and I wanted to bring up something that kind of flew under the radar: Lung Cancer Screening.

You may remember a paper (and GR at UAB) from a few years ago that showed a mortality benefit for low dose CT scanning in smokers. The National Lung Screening Trial (NLST) This is the main study that drove the USPSTF to recommend CT screening in many smokers.

The guidelines are here. Here’s the scoop:

55-80 year olds with at least a 30pack year smoking history, currently smoking or quit within the last 15 years should receive Annual low dose chest CT. As with most screening guidelines, stop when life expectancy is “substantially limited” by another health problem, or when patients have been smoke free for more than 15 years.  Based on the wording above, it seems reasonable to stop at 80, sooner if there are significant comorbidities. They give this a Grade B recommendation.

Interestingly, the guidelines vary somewhat from the study itself.  The NLST enrolled patients 55-74, yet the guidelines recommend screening through age 80.  The study utilized 3 annual CT scans, and mortality benefit was seen after just those three scans. USPSTF recommended annual screening from 55-80 (potentially 25 scans if you start at 55 and the patient keeps smoking without developing some other health problem).

So the benefit of screening is obvious patients live longer, less likely to die from lung cancer.  The NLST enrolled >50,000 patients, screened them for 3 years, and then followed for an average of 6.5 years.  Overall mortality was reduced by 6.7% and lung cancer specific mortality was reduced by 20%.  NNS to prevent one lung cancer death is 320. In comparison, annual FOBT testing reduces colon cancer mortality by 15-20%, and the NNS 1173.

What about the harms?  Well, 39% of those in the CT group of the NLST had a positive test, and the majority of those led to more testing.  More testing may be more imaging, or may be a biopsy.  96% of the positive tests in the CT group were eventually proven to be false positives.  1.5% of those with a positive test had at least one complication from further testing.

Is this practice changing?  Maybe.  I have tried to order a low dose CT on a patient in the last few years, heavy smoker who I felt was high risk.  His insurance wouldn’t pay for it, but did pay for the regular CT when I told them I was worried about his weight loss.  The affordable care act mandates that all grade A or B USPSTF screening guidelines are covered without out-of-pocket cost to the patient.  In that case, we should be able to order these now without much pushback from the insurers.

Here are a few related stories:

What do you think?  Is the mortality reduction worth the huge number of false positives? Will you start ordering low dose CTs on your smoking patients? Would love to hear your thoughts in the comments.