North American Spine Society

Five Things Physicians and Patients Should Question

Released October 9, 2013; updated April 8, 2019

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    Don’t recommend imaging of the spine within the first 6 weeks of an acute episode of low back pain in the absence of red flags.

    Red flags include, but are not limited to: trauma history, unintentional weight loss, immunosuppression, history of cancer, intravenous drug use, steroid use, fracture, infection, deformity, osteoporosis or osteopenia, progressive paresthesias or weakness involving the pelvis and lower extremities, urinary retention, saddle anesthesia, age > 50, focal neurologic deficit, and progression of symptoms.

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    Don’t perform elective spinal injections without imaging guidance, unless contraindicated.

    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.

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    Don’t prescribe opioids for acute or chronic low back pain before a thorough evaluation, consideration of a trial of alternative medications and treatments, and discussion of the risks of opioid therapy.

    The use of opioids is not recommended without a thorough evaluation, consideration of alternative medications, treatments, review of all current medications and discussions of risks of opioid therapy and potential interactions with current medications for other conditions. Opioid prescriptions should be for a limited period with the lowest effective dose that provides meaningful pain relief and improved function with manageable side effects.

  4. 4

    Don’t use electromyography (EMG) and nerve conduction studies (NCS) to determine the cause of axial lumbar, thoracic or cervical spine pain.

    Electromyography and nerve conduction studies 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.

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These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

THIS CHOOSING WISELY DOCUMENT DOES NOT REPRESENT A “STANDARD OF CARE,” nor is it intended as a fixed treatment protocol. It is anticipated that there will be patients who will require less or more treatment than the average. It is also acknowledged that in atypical cases, treatment falling outside this recommendation list will sometimes be necessary. This document should not be seen as prescribing the type, frequency or duration of intervention. Treatment should be based on the individual patient’s need and physician’s professional judgment. This document is designed to function as a guide and should not be used as the sole reason for denial of treatment and services. This document is not intended to expand or restrict a health care provider’s scope of practice or to supersede applicable ethical standards or provisions of law, but to encourage discussion of these issues between physician and patient, encourage active patient participation in health care decision-making, and foster greater mutual understanding.

NASS is a multidisciplinary medical organization dedicated to fostering the highest quality, evidence-based and ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 7,500 members from several disciplines including orthopedic surgery, neurosurgery, physiatry, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals.

For more information, visit www.spine.org and find NASS on: Facebook and Twitter.

How This List Was Created

The North American Spine Society (NASS) appointed a multidisciplinary task force in 2012 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 identified a draft 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 reviewed and approved by the NASS Board of Directors and released in October 2013. In 2018, a multidisciplinary task force was established to review and revise the existing recommendations. The final revision list was reviewed and approved by the NASS Executive Committee.

NASS’ disclosure and conflict of interest policy can be found at: https://www.spine.org/Documents/WhoWeAre/DisclosurePolicy.pdf

Sources

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    Forseen S, Corey A. Clinical decision support and acute low back pain: evidence-based order sets. J Am Coll Radiol. 2012 Oct;9(10):704-12.

    Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018; doi: 10.1007/s00586-018-5673-2. [Epub ahead of print]

  2. NASS Evidence-Based Guideline: North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spinal stenosis. Burr Ridge (IL): North American Spine Society (NASS); 2011. 104 p.

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    NASS Evidence-Based Guideline: North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spinal stenosis. Burr Ridge (IL): North American Spine Society (NASS); 2011. 104 p.

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