Outpatient Back Pain Treatments: Not What the Doctor Should Order

Summary and Comment |
August 20, 2013

Outpatient Back Pain Treatments: Not What the Doctor Should Order

  1. Jaime Toro, MD

Treatment of back and neck pain increasingly relies on strategies that run counter to published guidelines.

  1. Jaime Toro, MD

Back pain treatment is costly and often includes overuse of imaging and referral to specialists. The total health costs for low back and neck pain increased 65% from 1997 to 2005 (from a mean of US$4795 per person to US$6096; JAMA 2008; 299:656).

To examine trends in outpatient treatment of back pain, researchers used data from federal surveys in 2-year increments between 1999 and 2010. Guideline-concordant use of NSAIDs or acetaminophen dropped from 37% to 25%, while guideline-discordant use of narcotics increased from 19% to 29%. Referrals for physical therapy remained unchanged at 20%, while referrals to other physicians for injections or surgery doubled, from 7% to 14%. Use of magnetic resonance imaging or computed tomography increased from 7% to 11%.


Most people arriving at their doctor's office with complaints of low back pain will get better within 4 weeks and will not need referrals to other physicians or imaging. If the back pain remains severe after 3 months, or there is an acute neurological compromise or other “red flags” including history of malignant neoplasm, then imaging might be advised. According to guidelines, imaging should be ordered only if there is a high degree of suspicion of a severe or specific condition, such as cauda equina syndrome or vertebral infection, or severe and progressive neurological deficits, such as motor weakness (Ann Intern Med 2011; 154:181). There is no question that we are over-imaging patients with neck and low-back pain. A large number of people when scanned have abnormal images like bulging disks, disk protrusion, nerve root compression, disk extrusion, and moderate-to-severe central stenosis (Spine 2005; 30:1541). Without clinical symptoms, this information is not that relevant. The danger is that some of these common findings might nonetheless make physicians feel obliged to do something about them.

With health care costs increasing, using guidelines in the management of back pain represents an area of potential cost savings and improvement in quality of care.

Editor Disclosures at Time of Publication

  • Disclosures for Jaime Toro, MD at time of publication Editorial boards Multiple Sclerosis and Related Disorders


Reader Comments (6)

Pat Creighton

I see one major flaw in this study. It doesn't clarify whether the "back pain" being addressed with acetaminophen is muscular or other sources. Should this not be making a difference?

Ghislain Levesque

I personally think that the recommandations are becoming ever more confusing.On one side some proponents would recommend ANSAIDS for pain relief while others see in it a
hurdle to healing and propose such expensive treatment as PRP.Are we then left with acetaminophen and narcotics?

May Hong, M.D. Physician, Family Medicine/General Practice

In the state I practice, patients who are having difficulty with work due to back pain must contend with employers who will fire them unless they are shown to have something causing them to have pain. Since MRI will often disclose incidental disc disease, it helps them keep their jobs for awhile before they get fired and then file for disability.

Paul H. Goodley, M.D. Physician, Orthopedics, Israel

Low back pain is common. My brief contribution focused on the fundamental failure of using appropriate clinical techniques to better diagnose painful conditions so they may be treated early. The necessary mindset shift back to fundamentals is an essential.

Paul H. Goodley, M.D.

Hussein El-Hassan.MD.FRCS Physician, Surgery, Specialized, Beirut-Lebanon

Patients with low back pain and radicular involvement should have a CT or MRI done. This is in my opinion a red flag.

Frank McDonnell MD Physician, Anesthesiology, Deaconess hospital Evansville indiana

35 year's less than 3% referred back neck pain better in 4 weeks. 100% referred, to PT , narcotics required , with NSAID 90% imaging dependant on clinical findings, 50% medicare , with scoliosis, kyphosis, , collapse ,obese , deconditioned, Palliation, mobility medication blocks , only RX , Above criteria not realistic

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