Back Pain: Test or Treat?

People with arthritis-related back pain might find relief more quickly — and their route to back pain relief might cost as much as $10,000 less — if physicians were to ignore current guidelines for diagnosing the cause of the pain and instead start treatment immediately. Arthritis-related back pain accounts for about 15 percent of lower back pain. These findings, which were published this month in the journal Anesthesiology, point to quicker, more effective, and less costly relief for back pain. The study was led by Stephen P. Cohen, M.D., an associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine

Arthritis-related back pain is often treated with a non-invasive procedure called radiofrequency denervation, which stops arthritic joints from sending pain signals to the brain. Radiofrequency denervation is the second most common procedure in pain clinics across the United States. The relief can last many months and sometimes years, but the procedure often must be repeated when pain returns.

Generally, radiofrequency denervation isn’t used until the cause of the back pain is accurately located in the spinal column — a feat that’s more easily said than done. It’s difficult to accurately diagnose arthritis-related back pain, because findings on diagnostic imaging tests like MRIs or X-rays often don’t match the degree of pain a person experiences. So people with back pain often have to undergo a series of temporary nerve blocks, which serve to prove that the arthritis is indeed causing their back pain, before doctors will recommend radiofrequency denervation.

But Cohen’s team suggests that the if arthritis is the suspected cause of the back pain, it might actually be more prudent to skip the diagnostic nerve blocks and start treatment. According to Cohen, “If we just do the radiofrequency procedure first, we’re going to help more people and we’re going to save a lot of money.”

Cohen and colleagues studied 151 patients at several hospitals whose back pain fit the criteria for arthritic back pain. Patients were randomized to one of three groups: Group 0 received radiofrequency denervation based on clinical findings without nerve blocks; group 1 underwent the radiofrequency treatment only after a positive response to a single diagnostic block; and group 2 only got the treatment if they had positive responses to two diagnostic blocks.

One-third of the patients in group 0 experienced significant pain relief lasting at least three months. Only 16 percent of group 1 and 22 percent of group 2 improved. Those in group 0 were treated immediately, visited a clinic just once, and did not miss any extra days of work for repeated diagnostic tests. The costs per successful treatment in groups 0, 1 and 2 were $6,286, $17,142 and $15,241, respectively.

Here’s the key to Cohen’s proposal: radiofrequency denervation is as safe as giving a diagnostic block and usually provides pain relief after only one procedure. Although people whose back pain is not caused by arthritis aren’t likely to benefit from radiofrequency denervation, they’re not likely to be harmed, either. In fact, radiofrequency denervation is about as risky as the nerve blocks themselves.

Cohen’s findings are, no doubt, of critical importance for people with arthritis-related back pain. But they also speaks volumes about strategies to control the cost of health care. How many other low-risk procedure are there that aren’t performed until repeated diagnostic testing has been performed?

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