The North American Spine Society (NASS) announced its participation in the Choosing Wisely® campaign during its 2013 annual meeting and released a list of five specific tests and treatments that are commonly ordered but may not always be necessary in spine care. Choosing Wisely is an initiative of the ABIM Foundation, to support and engage physicians in being better stewards of finite health care resources.
NASS joins more than 50 medical societies, including the AAOS, in identifying evidence-based recommendations that can support conversations between patients and physicians about the most appropriate care based on the patient’s individual circumstances. The NASS recommendations and rationales are as follows:
- Don’t recommend advanced imaging (eg, MRI) of the spine within the first 6 weeks in patients with non-specific acute low back pain in the absence of red flags.
Support statement: In the absence of red flags, advanced imaging within the first 6 weeks has not been found to improve outcomes, but does increase costs. Red flags include, but are not limited to, the following: trauma history, unintentional weight loss, immunosuppression, history of cancer, intravenous drug use, steroid use, osteoporosis, age older than 50, focal neurologic deficit, and progression of symptoms.
- Don’t perform elective spinal injections without imaging guidance, unless contraindicated.
Support statement: Elective spinal injections, such as epidural steroid injections, should be performed under imaging guidance using fluoroscopy or CT with contrast enhancement (unless contraindicated) to ensure correct placement of the needle and to maximize diagnostic accuracy and therapeutic efficacy. Failure to use appropriate imaging may result in inappropriate placement of the medication, thereby decreasing the efficacy of the procedure and increasing the need for additional care.
- Don’t use bone morphogenetic protein (rhBMP) for routine anterior cervical spine fusion surgery.
Support statement: Bone morphogenetic protein is a compound that stimulates bone formation and healing. Life-threatening complications have been reported in the routine use of recombinant human rhBMP in anterior cervical spine fusion surgery, due to swelling of the soft tissues. This may lead to difficulty swallowing or pressure on the airway.
- Don’t use electromyography (EMG) and nerve conduction studies (NCS) to determine the cause of axial lumbar, thoracic, or cervical spine pain.
Support statement: EMG and NCS are measures of nerve and muscle function. They may be indicated when there is concern for a neurologic injury or disorder, such as the presence of leg or arm pain, numbness, or weakness associated with compression of a spinal nerve. As spinal nerve injury is not a cause of neck, mid back, or low back pain, EMG/NCS have not been found to be helpful in diagnosing the underlying causes of axial lumbar, thoracic, and cervical spine pain.
- Don’t recommend bed rest for more than 48 hours when treating low back pain.
Support statement: In patients with low back pain, bed rest exceeding 48 hours in duration has not been shown to be of benefit.
A collaborative effort
To create this list, NASS appointed a multidisciplinary task force to identify five areas in which to make recommendations. Based on the scientific evidence, existing clinical practice recommendations, and expert opinion, the task force collaboratively drafted a list of nine recommendations that was subsequently submitted to the NASS board of directors for review and ranking. After further refinement, the final list was approved by the NASS board of directors.
“Because back pain is so prevalent and debilitating, desperate patients flock to their spine specialists’ offices armed with advice and anecdotes from well-meaning family, friends, and online sources,” said F. Todd Wetzel, MD, who chaired the NASS Choosing Wisely task force. “We hope this list of recommendations will help spine care providers and their patients cut through the confusion about some of these issues and make informed care decisions together.”
To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit www.ChoosingWisely.org
Adapted from a press release by Nicolle Heller, media relations, NASS.