Hrev_master [page 28] [Emergency Care Journal 2022; 18:10413] Emergency Care Journal 2022; volume 18:10413 Abstract Patients often present to the emergency department with non- specific complaints of lumbar back pain. Because of the nature of the emergency department, the lack of knowledge or time on the part of providers, and the high levels of quick decision making, unnecessary imaging studies are often ordered to provide care for the patient’s emotional and perceived physical needs. This narra- tive review will present a hypothetical typical standardized case of a patient presenting with lower back pain, examine the current evi- dence and recommendations from the major ruling bodies in inter- nal medicine, neurology, neurosurgery, and radiology, evaluate the major statements released by the Choosing Wisely campaign, and finally, present a new diagnostic decision tree for the management of lumbar back pain. Introduction One of the most common chief complaints in the emergency department is that of musculoskeletal pain.1,2 Of these complaints, non-specific lower back pain often receives either imaging studies or consultation of the internal medicine, neurological, or neurosur- gical services within the hospital system.1,2 Lumbar back pain is debilitating in nature and can affect activities of daily living due to the required integration of the musculature and skeletal structures during ambulation and simple postural positioning.3,4 Therefore, it is key that the clinician can balance the immediate desire to initiate action, regardless of if the action to help is actually beneficial, and the utility of that action for the betterment of the patient, especially Correspondence: Thomas C. Varkey, Department of Radiology, Dell Medical School, The University of Texas at Austin, 302 W Medlock Dr. APT #11, Phoenix, AZ, 85013 Cell Phone: 623.707.5338 E-mail: Tvarkey@utexas.edu Key words: Value-based care; evidence based imaging; emergency department; lumbar back pain; non-specific complaints. Acknowledgements: The Authorial team would like to acknowledge Dean Steve Smith and Dean Alejandro Moreno of the Medical Education Department at Dell Medical School for their constant encour- agement to see that the patient’s physical, financial, and emotional needs are seen first and foremost Contributions: KA, TCV: Conceptualization and critical revisions for accuracy and clarity; ECA, SK, FJ, JT: Critical revisions for accuracy and clarity. Conflict of interest: TCV is an Adjunct Professor at Grand Canyon University and receives payment for his teaching and grading, he is a faculty member with the National Multiple Sclerosis Society’s Monthly Fellows Difficult Case Discussion Webinar, and Thomas serves on the board of editors for ProClinS Cardiology and Current Medicine. The other authors declare no conflict of interest. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate: Not applicable. Informed consent: Not applicable. Received for publication: 16 February 2022. Revision received: 8 April 2022. Accepted for publication: 14 June 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10413 doi:10.4081/ecj.2022.10413 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. Evidence-based imaging for the management of lower back pain in the emergency department: A narrative review Kartik Akkihal,1,3 Edy C. Adams,1 Soman Khan,1 Faraz Jafri,1 Jorge Taboada,1 Thomas C. Varkey1,2,4,5 1Department of Radiology, Dell Medical School, The University of Texas at Austin, Austin, Texas; 2Department of Business Management, The Colangelo College of Business, Grand Canyon University, Phoenix, Arizona; 3Department of Kinesiology and Health Education, College of Education, University of Texas at Austin, Austin, Texas; 4Department of Educational Psychology, College of Education, University of Texas at Austin, Austin, Texas; 5Department of Neurology, The University of Arizona, Phoenix, Arizona, USA Highlights - Lumbar back pain is debilitating in nature and can affect activities of daily living. - No medical testing, imagining study, treatment, or intervention is without effect on the entire bodily system. - The major principle of value-based care is to utilize the lowest costing imaging study followed by more expensive imaging modalities if deemed necessary. - Only through knowing the patient and considering their specific needs, including physical, financial, and emotional needs, can one both provide quality care and avoid doing harm. Non -co mmerc ial us e o nly in the emergency department. Often, imaging studies are utilized by clinicians as their first step in a treatment plan, with jokes in the emergency department discussing a therapeutic CT scan as first line for patients presenting with non-specific pain. As is often stated within the value-based care literature, no medical testing, imagining study, treatment, or intervention is without effect on the entire bodily system.5 Furthermore, imaging studies can be expensive for the patient and should only be utilized when the findings can significantly alter the course of care.5 Finally, and most importantly, the patient trusts their clinician implicitly,6 requiring that the medical practitioner take this trust and responsibly to act towards the benefit of the patient.7 Therefore, it is key that the clinician is judicious when ordering testing and imaging studies to ensure that the patient’s safety, financial situation, and implicit trust in their doctor are held first and foremost.5-7 This article presents a hypothetical typical standardized case of a patient presenting with lower back pain, examines the current evidence and recommendations from the major ruling bodies in internal medicine, neurology, neurosurgery, and radiology, evaluates the major statements released by the Choosing Wisely campaign, and finally, presents a new diagnostic decision tree for the management of lower back pain. Materials and Methods This paper followed clear methods in the development of a narrative review looking at the major associations and organization involved in providing recommendation for the betterment of the patient. On top of consulting the major organizations including, but not limited to, the American Radiological Association, the American Association of Family Practitioners, the Radiological Society of North America, the European Society of Radiology, the American College of Physicians, the American Neurological Association, and the American Academy of Neurology, the team looked at the major papers which have come out on the topics of the evaluation and treatment of lumbar back pain, imaging for patients with non-specific lumbar back pain, and value based care from the period of 1998 to 2022. Papers were found utilizing key search terms of “Lumbar Back Pain”, “Value Based Care”, and “Imaging” on search engines including Google, PubMed, and the Cochrane Library. Papers were excluded based on availability in the English language, status of peer review, public access, general- izability to the general patient population, and age before 1998. Case presentation This case is a hypothetical, typical patient who presents to an emergency department with complaints of non-specific lumbar back pain. The patient is a 45-year-old right-handed Caucasian male with no pertinent past medical history, who presents to the emergency department with the chief complaint of non-specific lower back pain. The patient states that his back pain began rough- ly five (5) weeks ago while he was lifting a large box at work. The pain continues to bother him throughout the day and persists at night. It becomes worse when standing up, sitting up, or when lift- ing objects. He states that the pain is constant, does not become better or worse throughout the day, is dull and achy, and can extend down his right leg. He says that the use of over-the-counter pain relievers, such as acetaminophen or ibuprofen, helps a little, but that the pain continues to bother him even despite taking the max- imum recommended dosage. He has tried stretching exercises and foam rolling techniques, but neither of these seem to help him. Upon further questioning, the patient states that he does not have numbness or tingling in any region of his body and that he is not experiencing any urinary or fecal incontinence. On physical exam- ination, the patient ambulates normally with subjective pain and demonstrates 5/5 strength in the hip flexors, hip extensors, hip abductors, and hip adductors. The patient has a normal sensation to light touch and pinpoint in the bilateral lower extremities. Finally, the patient has a normal anal wink reflex, normal patellar reflex, and normal down going Babinski. The remainder of the physical examination is within normal limits. The current recommendations Because of the nuances associated with lower back pain, the different ruling bodies in neurology, neurosurgery, and internal medicine strongly recommend that the provider first obtain a thor- ough history and physical exam to assess the likelihood of serious spinal pathology. An effective history can identify any major “red flag” symptoms, which require further work up.8 These red flag symptoms include: immunocompromised state (chronic liver dis- ease, chronic kidney disease, or medically induced immunosup- pression), history of recent intravenous drug use, history of cancer, anticoagulant use, major trauma in children or young adults, minor trauma in older patients (>50 years of age), rheumatologic disease, symptoms of spinal cord compression (saddle anesthesia, urinary or bowel incontinence or retention, perineal sensory loss, or anal sphincter laxity), any systemic symptoms (fever, rigors, or weight loss), and finally severe or progressive neurological deficits.8 If the patient experiences any of these symptoms or falls into any of these categories, further evaluation with imaging is highly recom- Mini Review Table 1. Symptomatic categorical break down of lumbar back pain as a presenting symptom with recommended imaging or treatment modalities.9-15 Major Group Minor Group Imaging or therapy Lumbar Back Pain Only Simple Back Pain (<50, No signs of systemic disease, Conservative Therapy (NSAIDs and Hot/Cold compresses) 93% of all cases no history of cancer, no neurological deficits) for 6 weeks Complex Back Pain (>50 or Signs of systemic disease Obtain CRP or ESR, if greater than normal obtain plain film radiography or History of cancer or Neurological deficits) Lumbar Pain with Radiculopathy (Without bladder or bowel involvement) Conservative Management (NSAIDs and Hot/Cold compresses) for 6 weeks Associated Radicular Pain unless there is progression of Neurological deficits 4% of all cases Urgent Situation Urgent Neurosurgical consultation and CT or MRI Possible Stenosis Tolerable pain without Neurological Deficits Symptomatic Treatment alone 3% of all cases Intolerable pain or Neurological Deficits MRI, CT, or EMG [Emergency Care Journal 2022; 18:10413] [page 29] Non -co mmerc ial us e o nly mended.8 Of note, there is a lack of high-quality evidence for the diagnostic accuracy of red flag tests and there is no consensus on which red flags are most useful to identify serious spinal pathology or how they should be used in the clinical setting.8 Therefore, it is recommended to use medical history in conjunction with the patient’s determinants of health and physical exam when making diagnostic decisions. Once a proper medical history has been obtained, the provider is encouraged to perform a physical examination with sensory, muscular strength, and reflex testing of the lower extremities and observation of ambulation. These physical examination maneuvers within the context of the patient’s history can help to demonstrate which pathologies are more or less likely.9 Per data collected from several different peer reviewed studies, patients usually fall into one of three major symptomatic categories: Lumbar Back Pain Only, Lumbar Back Pain with Associated Radicular Pain, and Potential Lumbar Stenosis.9-15 Subcategories for each of these can be found in Table 1. Choosing Wisely campaign According to the Choosing Wisely campaign, a national organi- zation focused on reducing unnecessary testing within medicine, the use of any imaging modalities on lower back pain without the aforementioned red flags is greatly discouraged within the first six weeks of the initial incidence of back pain.16-19 Choosing Wisely also recommends the utilization of either heat or cold packs as first line treatment and includes NSAIDs as potential first line treatment of lower back pain in their patient resources.18,19 The Choosing Wisely campaign, which also studied the effectiveness of evidence- based imaging for the management of lower back pain, concluded that patients with uncomplicated low back pain who received imag- ing studies often had worse outcomes than those who were only Mini Review Figure 1. CT: computerized tomography; MRI: magnetic resonance imaging. This algorithm was based on recommendations of general principles from both the Radiological Society of North America and the European Society of Radiology.20,21 [page 30] [Emergency Care Journal 2022; 18:10413] Non -co mmerc ial us e o nly treated with conservative management such as over-the-counter pain medication, heat, and physical exercise.16-19 Cost to the patient As detailed in a recent case report by Sui et al.,5 the cost of ion- izing imaging studies which are necessary to observe the muscu- loskeletal causes of back pain can range from a few hundred dol- lars to a few thousand dollars. The authors further state that the major principle of value-based care is to utilize the lowest costing imaging study followed by more expensive imaging modalities if deemed necessary, a generalized decision tree for all imaging stud- ies is included here for the benefit of the readers (Figure 1).5 Therefore, in the case of the standardized patient in the case pre- sentation, it is the highest recommendation of the authors to delay the use of imaging studies until at least six weeks have passed and to recommend the use of ice to minimize inflammation and heat to reduce pain and relax the muscles. If the patient’s symptoms had worsened, if the symptoms were debilitating, or if red flag symp- toms (as listed above) became known to the team, then imaging studies to rule in or out diagnoses become necessary. If deemed necessary after the six-week window has passed, an imaging study can be used to see if there are signs of disease, which can be mod- ified with the use of either medical or surgical action. Clinical pearls for the emergency room Due to either a lack of medical knowledge or lack of access to routine care, patients will often present with non-emergent com- plaints to the emergency department at their local hospital, leaving emergency physicians to decide whether to order an imaging study.2 By understanding the overarching concepts presented in this article, it is the hope of the authors that emergency physicians will feel more comfortable making educated decisions on whether Mini Review Figure 2. ESR: Erythrocyte Sediment Rate, CRP: C-Reactive Protein CT: computerized tomography; MRI: magnetic resonance imaging. EMG: Electromyography. Detailed here is a diagnostic decision tree based on data from several peer reviewed studies and literature reviews.9-15 [Emergency Care Journal 2022; 18:10413] [page 31] Non -co mmerc ial us e o nly to order testing. To improve efficiency and provide a standardized approach, we have created a new diagnostic tree with regards to the most common causes of lower back pain (Figure 2). Patient-centered care While clearly identifying risks and benefits before ordering a test or intervention is an important part of value-based care, this practice may not always include considerations of the patient’s own fears and concerns. Although it may be clear to the physician that imaging a case of low-back pain will not be beneficial, patients may feel frustrated or dismissed if they do not receive these studies. In this case, the peer reviewed literature recommends that the clinician clearly explain their reasoning and thought process, provide reas- surance and information for when to re-present for care, and give the patient resources for education.22 The astute clinician can and will encourage the patient to follow up with their PCP to receive referrals for physical therapy, exercise programs, and prescriptions for medications such as steroids, muscle relaxers, or high dose NSAIDs.23,24 It is also important to educate patients on stretching techniques to do at home, write doctor’s note for work absence, and stress the importance of “team lifting” heavy objects and the use of proper lifting techniques.17,23 Through taking these actions, the physician will both provide for the emotional needs of the patient and ensure that the patient receives the best care possible.22,28,29 Conclusions In the emergency department, patients often present with non- specific complaints of back pain.1,2 Through proper evaluation and utilization of the history and physical examination, the astute clin- ician will be able to differentiate between those patients who require imaging studies to evaluate for potential interventions and those for whom conservative management will suffice. Following in the vein of Sir William Osler’s “Great Physician,” only through knowing the patient and considering their specific needs, including physical, financial, and emotional needs, can one both provide quality care and avoid doing harm, as is required by the Oath of Hippocrates. References 1. Wu A, March L, Zheng X, et al. Global low back pain preva- lence and years lived with disability from 1990 to 2017: esti- mates from the Global Burden of Disease Study 2017. Ann Transl Med 2020;8:299. 2. Idil H, Kilic TY, Toker İ, et al. Non-urgent adult patients in the emergency department: Causes and patient characteristics. Turkish J Emerg Med 2018;18:71–4. 3. Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014;73:968–74. 4. Hartvingsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet 2015;386:2145-91. 5. Siu VJ, Varkey T, Khan UN, et al. Lend Me a Hand: A Value- Based Care Case Study on Pan Plexopathy of Unknown Origin. Cureus 2021;13:e20354. 6. Kao AC, Green DC, Davis NA, et al. Patients' trust in their physicians: effects of choice, continuity, and payment method. J General Intern Med 1998;13:681–6. 7. Classen DC, Kilbridge PM. The roles and responsibility of physicians to improve patient safety within health care deliv- ery systems. Acad Med 2002;77:963-72. 8. Finucane LM, Downie A, Mercer C, et al. International frame- work for red flags for potential serious spinal pathologies. J Orth Sports Phys Ther 2020;50:350-72. 9. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001;344:363-70. 10. Joines JD, McNutt RA, Carey TS, et al. Finding cancer in pri- mary care outpatients with low back pain: a comparison of diagnostic strategies. J General Intern Med 2001;16:14–23. 11. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med 2002;137:586-97. 12. Sandhu HS, Sanchez-Caso LP, Parvataneni HK, et al. Association between findings of provocative discography and vertebral endplate signal changes as seen on MRI. J Spinal Disord 2000;13:438-43. 13. Pui MH, Husen YA. Value of magnetic resonance myelography in the diagnosis of disc herniation and spinal stenosis. Australas Radiol 2000;44:281-4. 14. Chou R, Qaseem A, Snow V, et al Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-91. 15. Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging prac- tice guidelines for musculoskeletal complaints in adults -an evidence-based approach part 3: spinal disorders. J Manipulative Physiol Ther 2008;31:33-88. 16. Reed SJ, Pearsons S. Choosing wisely® recommendation anal- ysis: Prioritizing opportunities for reducing inappropriate care. Imaging for nonspecific low back pain. 2019. Accessed February 9, 2022. Available from: https://www.choosingwise- ly.org/wp-content/uploads/2015/05/ICER_Low-Back-Pain.pdf 17. Foundation, A. B. I. M. ACEP - Lumbar Spine Imaging in the ED: Choosing wisely. Choosing Wisely | Promoting conversa- tions between providers and patients. 2015, November 9. Retrieved February 9, 2022. Available from: https://www.choosingwisely.org/clinician-lists/acep-lumbar- spine-imaging-in-the-ed/ 18. Foundation, A. B. I. M. Imaging tests for back pain: Choosing wisely. Choosing Wisely | Promoting conversations between providers and patients. 2018, October 31. Retrieved February 9, 2022. Available from: https://www.choosingwisely. org/patient-resources/imaging-tests-for-back-pain/ 19. Foundation, A. B. I. M. Low back pain: Choosing wisely. Choosing Wisely | Promoting conversations between providers and patients. 2019, June 21. Retrieved February 9, 2022. Available from: https://www.choosingwisely.org/patient- resources/low-back-pain/ 20. Brady AP, Bello JA, Derchi LE, et al. Radiology in the era of value-based healthcare: A multi-society expert statement from the ACR, CAR, ESR, IS3R, RANZCR, and RSNA. Can Assoc Radiol J 2021;72:208-14. 21. European Society of Radiology (ESR). ESR concept paper on value-based radiology. Insights Imaging 2017;8:447–54. 22. Epstein RM, Street RL, Jr. The values and value of patient-cen- tered care. Ann Fam Med 2011;9:100–3. 23. Khalil TM, Asfour SS, Martinez LM, et al. Stretching in the rehabilitation of low-back pain patients. Spine (Phila Pa 1976) 1992;17:311-7. 24. Rainville J, Hartigan C, Martinez E, et al. Exercise as a treat- ment for chronic low back pain. Spine J 2004;4:106-15. 25. Kamal KC, Alexandru DO, Kamal D, et al. Managing low Mini Review [page 32] [Emergency Care Journal 2022; 18:10413] Non -co mmerc ial us e o nly back pain in primary care. Curr Health Sci J 2020;46:396-404. 26. Visser S, van der Molen HF, Kuijer PP, et al. Evaluation of team lifting on work demands, workload and workers' evalua- tion: an observational field study. Appl Ergon 2014;45:1597- 602. 27. Faber G, Visser S, van der Molen HF, et al. Does team lifting increase the variability in peak lumbar compression in iron- workers? Work 2012;41:4171-3. 28. Hudon C, Fortin M, Haggerty JL, et al. Measuring patients' perceptions of patient-centered care: a systematic review of tools for family medicine. Ann Fam Med 2011;9:155–64. 29. Epstein RM, Franks P, Fiscella K, et al. Measuring patient-cen- tered communication in patient-physician consultations: Theoretical and practical issues. Soc Sci Med 2005;61:1516- 28. Mini Review [Emergency Care Journal 2022; 18:10413] [page 33] Non -co mmerc ial us e o nly