How emergency physicians approach low back pain: Choosing costly options

To determine ways in which emergency physicians approach the diagnosis and treatment of the common presenting complaint of low back pain, responses of emergency physicians to a questionnaire dealing with three hypothetical patients with different types of low back pain were taken from a stratified national random sample of eight medical specialties. For severe acute (with and without sciatica) or chronic low back pain, physicians were asked which tests and consultants they would use in pursuit of the diagnosis, and which treatments and specialty referrals they would recommend in each of the three scenarios. For diagnosis in the acute cases (pain less than 1 week), up to 22% of emergency physicians recommended computed tomography (CT scan) and 36% recommended magnetic resonance imaging (MRI). Specialist consultation would be sought for 61% of the acute sciatica patients, 32% of the acute nonsciatica patients, and 47% of the chronic patients. In approaching treatment, over 75% of emergency physicians would advise bedrest for an average of 3.5 to 4.5 days. Between 16% and 40% suggested physical therapy for the acute patients. Referrals to surgical specialists (orthopedist or neurosurgeon) were highest (81%) for acute sciatica, compared with 52% for chonic low back pain, and 41% for acute nonsciatic low back pain. In conclusion, given that most cases of acute low back pain resolve with minimal intervention, diagnostic imaging, laboratory testing, and early specialist consultation favored by many emergency physicians would add little except expense to understanding its etiology. For treatment, emergency physician recommendations for bedrest were longer than necessary and, for physical therapy, of no proven benefit. The tendency to refer acute cases to orthopedists and neurosurgeons could set the stage for unnecessary operative intervention. Simpler, less costly, and more reassuring approaches to emergency department patients with low back pain should be considered.