Back Pain Spending Up, Relief Down

[PMR2008]

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Interesting article. It had a quote from Dr. Sherman.

Any comments from the seniors would be appreciated.

http://www.washingtonpost.com/wp-dyn/content/article/2008/02/12/AR2008021201807.html

"Spine problems are the most common reason why people of middle age have pain and disability, and we need to continue to search for better solutions because, although we have come up with newer techniques of treatments, we still have a large percentage of the of population with spine problems who are still disabled," added Dr. Andrew Sherman, head of medical rehabilitation at the Spine Institute at the University of Miami Miller School of Medicine.( http://rehabmed.med.miami.edu/x12.xml?id=35376 )

 

[lobelsteve]

Spine Surgeons making money of fusion, Pain docs making money off of SCS, ESI's without clinical basis, FP docs doingblind SIJ and Facet blocks.

Its about the money- docs should be ashamed.

 

[dc2md]

Pain docs making money off of SCS, ESI's without clinical basis

steve, give us an example of a ESI or SCS being given for a patient without clinical basis. what's a good clinical basis for ESI? radicular symptoms? evidence of foraminal stenosis on MRI? EMG/NCV findings in a nerve root distribution?
thanks,
chris

 

[ampaphb]

Steve's larger point, I believe, was that there are docs in all fields who perform procedures outside of what are reasonable indications.

Now the flip side is to never push the envelope, and that is also excessively cautious, IMHO, but in general, I still naively believe there are more reasonable interventionists than thieves out there.

Now that being said, I also think that the residents who get done with residency, and join someone who tells them "don't worry about a fellowship, I will train you to do these procedures" ends up with a very limited array of tools to work with. In my area, and I would venture to guess it is not solely in New Orleans, there are lots of guys who start with an interlaminar or a caudal, not because it is the logical thing to do necessarily, given the patient's presenting symptoms, but rather, because it is one of the few things they know how to do.

 

[lobelsteve]

Steve's larger point, I believe, was that there are docs in all fields who perform procedures outside of what are reasonable indications.

Now the flip side is to never push the envelope, and that is also excessively cautious, IMHO, but in general, I still naively believe there are more reasonable interventionists than thieves out there.

Now that being said, I also think that the residents who get done with residency, and join someone who tells them "don't worry about a fellowship, I will train you to do these procedures" ends up with a very limited array of tools to work with. In my area, and I would venture to guess it is not solely in New Orleans, there are lots of guys who start with an interlaminar or a caudal, not because it is the logical thing to do necessarily, given the patient's presenting symptoms, but rather, because it is one of the few things they know how to do.

Perfectly stated!

I'd only add that it is just a few who will spoil it for all of us. In SC, there were two recently graduated fellows who were aggrssive interventionalists. One patient had 25 procedures in 60 days, then referred to a Pain Specialist because nothing worked and they did not want to try medications, only injections. (Z- I'll PM you the details).

 

[dc2md]

One patient had 25 procedures in 60 days, then referred to a Pain Specialist because nothing worked and they did not want to try medications, only injections

wow! 😱 that's incredible. without breaking any HIPAA laws or calling-out the actually doc, can you tell us a little more? was it 25 procedures on separate days? a ton of multi-level lidocaine trials?
and as an aside, what do insurance companies say about that type of practice? do they (in general) reimburse per trial level or just for the actual steroid injection?

-chris

 

[drusso]

Perfectly stated!

I'd only add that it is just a few who will spoil it for all of us. In SC, there were two recently graduated fellows who were aggrssive interventionalists. One patient had 25 procedures in 60 days, then referred to a Pain Specialist because nothing worked and they did not want to try medications, only injections. (Z- I'll PM you the details).

"Aggressive Interventionalists?" = "Feral Practitioners?"

Again, raises the question about the difference between the specialties of Pain Medicine and "Interventional Spine."

 

[rehab_sports_dr]

> Again, raises the question about the difference between the specialties of Pain Medicine and "Interventional Spine."


Not sure what to make of this statement ....

In the geographic regions where I've worked, the docs who have been, IMO, most inappropriately aggressive with the needle would probably classify themselves as Pain docs

Regardless of what one calls oneself, I don't think that aggression and self-interest are a function of what one calls oneself.

The problem, obviously, is that the financial incentive system is far out of line with optimal care guidelines. People in general respond to incentives, and physicians are no different.

There is an interesting article by Weinstein et al that looked at increasing frequency and expenditures for spine care. It is likely that basis of Andy Sherman's comments, which is that expenses are increasing, without a significant improvement in outcomes.

This is probably true for all approaches to spine management- not just surgery and injections, but physical therapy, chiropractic care, accupuncture, etc.

Unfortunately, there is just an enormous lack of outcome data to help stratify appropriate treatment approaches for different patients

I do think that, by far, the biggest issue here is spine surgery. There is just far more money involved than for the other aspects. Even if a spine injectionist wanted to be dirty, there is just not enough money going around to be reach the same level of unethical activity as the surgeons can.

Again, there are many wonderful, altruist, and incredibly ethical spine surgeons out there. But, as an example, there is the recent NY Times article about a group of surgeons being investors for a company that makes spine hardware, and then referring patients for surgeries requiring that kind of hardware. While physiatrists have financial conflicts of interest, it is usually not on that order f magnitude.

I do think, though, that we have to better self-regulate those areas where we do have financial conflict of interest. Our patients deserve it, and if we don't self-regulate, other groups will do it for us.

 

[truthseeker]

"Unfortunately, there is just an enormous lack of outcome data to help stratify appropriate treatment approaches for different patients"

The problem here is that it is difficult to stratify the appropriate treatment approaches when the diagnosis of LBP is so terribly multifactorial. What is the cause off the symptoms.


There is logic and research for and against SIJ assessment validity, for and against validity of diagnosis of discogenic pain, for and against the validity of the diagnosis of "other sources" of LBP and the odd thing is that many of our patients have more than one of these sources of pain. So the research that is done, the diagnostic criteria are too vague and do not account for comorbidities. For example, if a patient has known facet arthropathy, diagnosed by injection, but also have annular tears at corresponding levels diagnosed by MR, what type of treatment do they get?
What study to they become a part of?

I think first, we need to standardize language. Then, we need to ask the right clinical questions rather than artificially creating subgroups of patients that don't really exist. Meaning the guy with only one factor that creates his pain. If they have an annular tear, chances are they have poor lifting mechanics, tight hip muscles, leg length discrepancy, weak abdominals or a mixture of the above. You can't treat the annular tear without addressing the cause of it.

 

[rehab_sports_dr]

I strongly agree with you- low back pain is multifactorial. It is also heterogenous, with multiple different pain sources, often in combination. It also is confounded by other pathologies, especially psychosocial, but certainly with other pathologies along the kinetic chain

I am not sure whether LBP is any more multifactorial and heterogenous, however, than other diagnoses like hypertension or brain injury

I think spine care could benefit from a "model systems" type approach. I agree with you that a big issue is a language issue. For example, z-joint pain has a million different names. PASSOR has taken a position statement to encourage the use of z-joint pain, but many still call it things like facet joint pain, lumbar spondylosis, or just lumbago. The inconsistency in description certainly makes it hard to have consistency in treatment.

All that said, we need to do a better job of documenting what we are doing and what are our outcomes.

For example, if we have patient with suspected radiculopathy, we should be standardized on how we made that diagnosis (muscle stretch reflexes, myotomal weakness, dermatomal pain pattern, whether they were able to centralize their symptoms, etc.), have a consistent treatment protocol, and a consistent mechanism for determining whether our treatment protocol worked. While other factors are likely at play, and will contribute "noise" to our analysis, we need to start by doing the analysis in the first place.

There are some studies, but there is definitely a paucity of quality Level 1 studies.

 

[lobelsteve]

I think spine care could benefit from a "model systems" type approach.

I agree with you that a big issue is a language issue. For example, z-joint pain has a million different names. PASSOR has taken a position statement to encourage the use of z-joint pain, but many still call it things like facet joint pain, lumbar spondylosis, or just lumbago. The inconsistency in description certainly makes it hard to have consistency in treatment.


For example, if we have patient with suspected radiculopathy, we should be standardized on how we made that diagnosis (muscle stretch reflexes, myotomal weakness, dermatomal pain pattern, whether they were able to centralize their symptoms, etc.), have a consistent treatment protocol, and a consistent mechanism for determining whether our treatment protocol worked. While other factors are likely at play, and will contribute "noise" to our analysis, we need to start by doing the analysis in the first place.

I see problems: when you cookbook it, you don't need a doctor anymore- a nurse can handle the protocol.

As far as the terminology: ICD9 has handled that for us. Instead of facet or Z-joint, or whatever, it should be called what medicare calls it: spondylosis without myelopathy. I would then further clssify it based on anterior, middle, or posterior column. 721.3 Lumbar spondylosis without myelopathy (posterior)

 

[truthseeker]

I think spine care could benefit from a "model systems" type approach.

I agree with you that a big issue is a language issue. For example, z-joint pain has a million different names. PASSOR has taken a position statement to encourage the use of z-joint pain, but many still call it things like facet joint pain, lumbar spondylosis, or just lumbago. The inconsistency in description certainly makes it hard to have consistency in treatment.


For example, if we have patient with suspected radiculopathy, we should be standardized on how we made that diagnosis (muscle stretch reflexes, myotomal weakness, dermatomal pain pattern, whether they were able to centralize their symptoms, etc.), have a consistent treatment protocol, and a consistent mechanism for determining whether our treatment protocol worked. While other factors are likely at play, and will contribute "noise" to our analysis, we need to start by doing the analysis in the first place.

I see problems: when you cookbook it, you don't need a doctor anymore- a nurse can handle the protocol.

As far as the terminology: ICD9 has handled that for us. Instead of facet or Z-joint, or whatever, it should be called what medicare calls it: spondylosis without myelopathy. I would then further clssify it based on anterior, middle, or posterior column. 721.3 Lumbar spondylosis without myelopathy (posterior)

I don't think what he meant was to cookbook it, I would be against that as well. What I at least was talking about was that when studies are typically done, they pidgeon-hole diagnoses. They do not account for multifactorial LBP but conclude that McKenzie treatment approach is the best, or that a brochure is as good as a PT teaching exercises, or that chiropractic is cost effective, or whatever. The researchers tend to make precise standard-of-care recommendations that have far-reaching effects but do so, in my opinion, invalidly by grouping LBP sub groups together that should not be grouped together.

My point earlier about language was probably poorly expressed. Although I do have problems with different names for the same anatomy, what I meant to write was that, clinically, with LBP it seems to be difficult for some to get to the root of the problem. I don't know how many of my patients come in with poor diagnoses from their PCP. physiatrists are generally very good at it, neurosurgeons often if it is not surgical, they just don't get it. Orthopedists sometimes get it, but more than likely lump all back pain into 847.2 - LBP. Disk injuries are treated very differently than z-joint pain, which are treated very differently than SIJ dysfunction.

I guess I am rambling.

 

[Disciple]

For example, if we have patient with suspected radiculopathy, we should be standardized on how we made that diagnosis (muscle stretch reflexes, myotomal weakness, dermatomal pain pattern, whether they were able to centralize their symptoms, etc.), have a consistent treatment protocol, and a consistent mechanism for determining whether our treatment protocol worked. While other factors are likely at play, and will contribute "noise" to our analysis, we need to start by doing the analysis in the first place.

What about "radiculopathy" vs. "radiculitis", i.e. nerve root irritation due to inflammatory mediators not severe enough to cause a conduction block?

Should we not treat these patients?

 

[Disciple]

"Aggressive Interventionalists?" = "Feral Practitioners?"

Again, raises the question about the difference between the specialties of Pain Medicine and "Interventional Spine."

I think this has less to do with how one classifies themselves and more to do with the individual skills a practicioner possesses or lacks.

For example, an "interventional spine" specialist who knows nothing about medications, can perform a cursory physical exam based predominantly on pain provocation maneuvers and who knows a few basic interventional techniques learned in fellowship after an inpt heavy PM&R residency.

vs

A pain doc who comes from a non or lightly multidisciplinary based fellowship, light on clinic, physical diagnosis and present day interventional techniqes.

Both are on the less desirable end of the spectrum.

What it really comes down to is the immaturity of the field and non-standardization of training.

Things are improving, but we need to give it some time.