NASS Releases "Choosing Wisely" List: What Tests Are Necessary for Patients With Back Pain?

During its 2013 annual meeting, the North American Spine Society (NASS) released a list of five specific tests and treatments commonly ordered by physicians for patients with back pain, but which the organization deems seldom necessary. The list is part of NASS’ “Choosing Wisely” program, an initiative of the American Board of Internal Medicine (ABIM) Foundation that aims to “promote conversations between physicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary.” The list identifies evidence-based recommendations that can support conversations between patients and physicians about the most appropriate care based on the patient’s individual circumstances.

“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, M.D., NASS Choosing Wisely task force chair and professor and vice chair for the department of orthopedic surgery and sports medicine and professor of neurosurgery at Temple University School of Medicine in Philadelphia, Pa. “We hope this list of recommendations will help spine care providers and their patients cut through the noise and make informed care decisions together.”

The list, titled “Five Things Physicians and Patients Should Question,” is as follows:

1. Don’t recommend advanced imaging (e.g., MRI) of the spine within the first six weeks in patients with non-specific acute low back pain in the absence of red flags;
2. Don’t perform elective spinal injections without imaging guidance, unless contraindicated;
3. Don’t use bone morphogenetic protein (BMP) for routine anterior cervical spine fusion surgery;
4. Don’t use electromyography (EMG) and nerve conduction studies (NCS) to determine the cause of axial lumbar, thoracic or cervical spine pain; and
5. Don’t recommend bed rest for more than 48 hours when treating low back pain.

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 which 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.

“The North American Spine Society has shown tremendous leadership by releasing its list of tests and procedures that may be commonly performed in spine care, but aren’t always necessary,” said Richard J. Baron, M.D., president and CEO of the ABIM Foundation. “The content of this list and all of the others developed through this effort are helping physicians and patients across the country engage in conversations about what evidence-based care they need, and what we can do to reduce waste and overuse in our health care system.”

According to NASS, more than 50 national and state medical specialty societies, regional health collaboratives and consumer partners have joined the campaign to encourage conversations about appropriate care, including Consumer Reports, which is developing patient-friendly materials based on the society lists. With the release of these new lists, the campaign will have covered more than 250 tests and procedures that the specialty society partners say may be overused or unnecessary, and that physicians and patients should discuss.

Other lists that Choosing Wisely has compiled include a list to determine whether a bone density test is necessary or not and when an imaging test for lower back-pain is necessary.