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Test yourself: A back pain vignette by Pinnacol Sr. Medical Director Tom Denberg, MD

Back pain is the most common type of injury in workers’ compensation. General principles related to

November 22, 2017
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Back pain is the most common type of injury in workers’ compensation. General principles related to the effective management of this condition are applicable to most types of injuries. Below is a fictional case study designed to assess both your knowledge of back pain management and care coordination in general. Please read the vignette carefully in order to identify as many problematic aspects of the case as you can.  

Injury and initial treatment
A 46-year-old female restaurant worker develops acute nonradicular back pain while she is lifting a box of cleaning supplies onto a high shelf. She is seen in urgent care, where the treating provider notes that she has a fifth-grade education, has been smoking 1.5 packs of cigarettes per day for 30 years, drinks a “moderate” amount of alcohol, and recently went through a divorce. She is referred to an occupational medicine physician for ongoing care. A week later, after determining the patient has no neurological red flags, the physician orders an MRI, which shows a “small” L5-S1 central disc protrusion. The physician also refers the patient for physical therapy and to a physiatrist for an epidural injection and refills her muscle relaxant and NSAID prescriptions.

Complications/ongoing treatment
A month later, when the patient fails to realize a benefit from these interventions, the physiatrist refers her to a pain medicine physician who prescribes Nucynta, an opioid analgesic. With neither improvement nor worsening of symptoms six weeks later, the physiatrist refers her to an orthopedic surgeon for an opinion. The orthopedic surgeon orders a second MRI, which is read in a different imaging center by a different radiologist, who comments on a “moderate” left central L5-S1 protrusion.

After comparing the two MRI dictations, the surgeon informs the patient that her disc problem has worsened and that, although discectomy is an option, surgery provides no guarantee of benefit and that she should discuss this option with her primary care provider. The patient sees her occupational medicine physician a week later and announces that she has decided to proceed with surgery. She then undergoes surgery, yet again she fails to realize any improvement.

Ultimately, after being off work for almost nine months since the date of her injury, she is declared at MMI and given an impairment rating. She disagrees with the rating and engages the services of an attorney.

Test yourself
This fictional but realistic vignette raises a host of issues. While physicians always need to independently exercise their best clinical judgment, the vignette helps to illustrate important principles related to the care of an injured worker with back pain. Many of these principles are delineated in the DOWC Medical Treatment Guidelines (MTGs) by means of evidence statements derived from the peer-reviewed literature, and others are based on well-established norms related to how physicians can best communicate and coordinate care.

Before reading further, how many distinct areas of concern can you identify in the clinical management of this patient? (Identifying one or two items means that there is significant room for improvement; three to four means that there is opportunity to enhance your knowledge; five to six is very good; and seven or more is superior.)

  1. Psychosocial risk factors - The patient has significant psychosocial risk factors, including limited formal education; noteworthy, ongoing tobacco and alcohol use; and a recent divorce. None of her providers sought to better characterize and address these issues before she underwent surgery, and none referred her for a psychological evaluation as is recommended by the DOWC low back pain medical treatment guideline (2014 LBP MTG). A formal psychological or psychosocial evaluation should be performed on patients not making expected progress within six to 12 weeks following injury (Page 40) and should be done to predict the likelihood of success when contemplating surgery (Page 93).
  2. Imaging - Despite the absence of red flags, the occupational medicine physician ordered an MRI only a week from the date of injury. Absent specific indications, high-tech imaging should only be obtained after at least six weeks of conservative therapy because early radiographic imaging without clear indications has been associated not only with significant, avoidable expense but also with prolonged care unassociated with any change in functional outcomes (Page 14).Separately, less than three months after the initial MRI, the surgeon ordered a second MRI. Because there had been no change in her symptoms, this second MRI was superfluous and added avoidable expense to her care.
  3. Conservative therapy; injections - Without an adequate trial of conservative therapy, the occupational medicine physician referred the patient for injections. There is strong evidence that epidural injections have no meaningful short- or long-term benefit for low back pain (Page 20). Second, because injections are invasive, one should first attempt noninvasive interventions (Page 21). When epidural injections are ultimately considered, they are most appropriate for radicular pain (which the patient did not have) after six to eight weeks of active, conservative therapy (Page 24).
  4. Opioids - The pain medicine physician prescribed a strong opioid even though the patient was drinking a “moderate” amount of alcohol and taking a muscle relaxant. One should use extreme caution when prescribing opioids with other central nervous system depressants because of the negative, potentiating effects on consciousness and respiration (2014 LBP MTG Pages 70-71 and the 2012 DOWC Chronic Pain Disorder MTG Page 78).
  5. Diagnostic study interpretations - There is no indication that the second radiologist or the surgeon compared the actual films from the two MRI studies. Instead, the surgeon simply compared radiologist dictations and, on the basis of noting that one radiologist identified a “small” L5-S1 disc protrusion while the second identified a “moderate” L5-S1 protrusion, informed the patient that her back condition had “worsened.” Without accounting for the subjective element associated with radiological interpretation or the clinical relevance of the MRI findings, and despite advising the patient that surgery might not help, the surgeon biased the patient toward having surgery. The patient was potentially at higher risk of a poor surgical outcome because of her smoking and alcohol use and possibly because of psychosocial factors (e.g., a recent divorce), but the surgeon did not research these issues or discuss them with the patient.
  6. Communication and coordination - The vignette does not describe an actual conversation between the surgeon and the referring provider. Rather than rely solely on written reports, it is important that referring providers and specialists have actual conversations, especially when highly invasive procedures are contemplated and there are doubts about a beneficial result. Also, as described, neither of the specialists documented a discussion of surgery’s pros and cons with the patient.
  7. Clearly identified authorized treating provider - Finally, it is unclear whether the authorizing treating provider (ATP) was the occupational medicine physician or the physiatrist. Frequently, clinical outcomes and patient satisfaction are significantly compromised when there is no single clearly identified provider who educates the patient, understands the full psychosocial and musculoskeletal details, and orchestrates referrals and informed decision-making with the patient.  

Ideally, the occupational medicine physician would have kept close tabs on the patient and asserted control at critical junctures. The occupational medicine provider should have stressed to the physiatrist that he or she (the occupational medicine physician) was the ATP, but the physiatrist should also have known this without being told. The physiatrist could have shared an opinion with the occupational medicine physician but should not have directly referred the patient to a surgeon. After – or ideally before – the surgery consult, the occupational medicine physician could have scheduled a long visit with the patient (which is reimbursed within Colorado’s workers’ compensation system) to carry out shared decision-making and perhaps get agreement about decreasing alcohol use and increasing exercise. This process might have revealed the patient’s fear of surgery. The patient might have been reticent to undergo surgery after learning its benefit is highly doubtful in the absence of neurological findings. Ultimately, she might have decided to pursue conservative treatment after receiving some additional guidance.  

Summary
This vignette illustrates several ways in which the MTGs can help both physicians and patients make reasonable decisions while highlighting the importance of effective communication and coordination of care.

What did you think of this exercise? Would you like us to create more like it? I’d love to hear from you at tom.denberg@pinnacol.com.

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