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Hello and thank you for joining our CME presentation today. I'm Doctor David Bene E VP of Clinical Value Based Care for Health care Outcomes Performance Company, also known as HCO. Our topic for today is initial management of low back pain. Before we get started on the topic of the day as we do for all CM E events. Um I want to assure the audience that I have no financial or nonfinancial uh relationships to disclose as it relates to this topic and subsequent uh presentation as a reminder to those of you who have attended other CM topics we present presented in this series. Our objective is to improve the continuum of care for musculoskeletal patients by defining the role of primary care providers in musculoskeletal value based care. We also aim to provide diagnostic and management pearls to pcps and other providers uh referring to M SK specialists. So that providers who manage the initial presentation of many common M SK uh issues can better and more accurately diagnose and treat these conditions. In addition, we aim to help providers identify red flags and other clinical factors, necessitating urgent imaging or specialist referral at the end of today's session. We hope the audience will be able to determine which patients based on symptomatology and symptom timeline would benefit from an order for advanced imaging therapy and a specialist referral uh identify red flags that typically require an escalation of care. Uh Of note, it's not today's objective to provide an exhaustive discussion about low back pain or even touch on all aspects of low back pain as it relates to value based care. Uh stay tuned for more C MB events to cover other topics we don't uh discuss in today's talk. So today, in order to achieve those objectives, we'll briefly review the HCO specialty uh care network tip sheet. Uh Then we'll do a brief run through multiple important topics in the initial management of back pain starting with a background. And then we'll have a discussion about clinical appropriateness and timing of of referrals to specialists including uh pain and spine surgery, uh referrals. And then we'll discuss imaging referrals both for X rays and MRI S hop, PCO and HCO Specialty Care Network. Also abbreviate HSC and are committed to distributing information to our vast referral network including pcps and all other upstream uh providers to improve the continuum of care for M SK issues and to support uh value based patient care. Some of you may be more familiar than others in the movement of healthcare towards uh value based care, which is especially prevalent and increasing in spine uh care by definition, value based care programs incentivize health care providers to provide improved quality of care while reducing unnecessary costs. HCO specialty care network is a clinically integrated network uh which is a type of value based care program in Arizona, HSC N has a full population health program for a Medicare advantage population and was recently recognized by a top national accreditation organization U A for its commitment to clinical integration and high quality care. HSEN is actually the first specialty network in the country for which clinical integration designation was awarded. The HSN network comprises orthopedics, spine surgeons and pain providers and other musculoskeletal providers in Arizona who have joined forces to follow standardized evidence based clinical pathways. HSN also collaborates with other providers including yourselves who encounter MSK conditions with a goal of improving patient outcomes and experience. And as you're well aware and particularly for spine care, a lot of the initial management of M SK care occurs not at the specialist level uh but upstream including at uh PCP clinic uh visits and saying this, it's clear that a population health program clearly relies on PCPs to help reduce unnecessary M SK costs. As PCPs are the most common gatekeeper for M SK care. Before we dive into the topic of the day, it's important to mention that the information shared in this talk is evidence based and consensus driven with recommended practices designed to be implemented for patients with M SK uh conditions. But it should be said for all clinical programs, clinical discretion should be used when using these guidelines for patients, especially if they are concomitant, clinical factors or comorbid conditions that may alter their clinically appropriate treatment path as we have with all talks within the series. Uh, let's start with a review of the HSEN uh, tip sheet. Um, as I've said before too, we've sent this out to you, um, by mail, but if you don't have a copy and you'd like one, please feel free to email us and we'd be happy to send you one. The email um is HSEN at ho dot com. Uh This tip sheet is more specific to the older Medicare Medicare advantage population, but many tips here are relevant to a younger population as well. Today, we're focusing on uh low back pain. Um That's the first row of this tip sheet and it shares common treatment recommendations as neck pain as well. At least for initial management. The overall recommendations for low back pain and neck pain include conservative management and potentially outpatient therapy. But more to come on that in this talk. Um But uh uh the DM E including orthotics and advanced uh diagnostic imaging are clearly, I mean, are clin not clinically indicated, not surprisingly low back pain is a leading uh physical uh complaint, prompting physician visits as the second most expensive muscle skeleton condition in terms of overall health care expenditure. And despite the ubiquitous nature of back pain. There are fewer standardized pathways to address how to manage back pain, especially when sle car a specialist or pursue imaging understanding which patients require which services at what time is an important step in promoting better and more efficient patient care. While concurrently minimizing the utilization of unnecessary resources. As we discussed back pain, I just want to level set on some uh definitions. Uh They'll come up in this talk. Uh For many of this may is obviously a review. But for others, an important remind as we speak about axial pain is referring to pain that's isolated uh to the spine and paraspinal regions. Whereas radicular symptoms indicate the pain or paresthesias that are caused by spine or spine related uh pathology um that's radiating down um from the buttock or into the legs. Um most commonly into the legs with varying degrees uh depending on where the pathology in the spine uh exists and how severe it is. And before we get into um uh uh referring um uh uh tips, uh it's important to review red flags associated with low back pain in detail. Uh Here you see a list of red flags with symptoms um uh are acute, we suggest a spine, uh surgeon referral is appropriate. Um And these are in the setting of uh trauma including a fall from height, um suspicion for an infection, including those that are immuno compromised or immunosuppressed or have a history of recent or current IV drug use, suspicion of an infection. Uh, I'm sorry. Um, also there's suspicion for, uh, suspicion for malignancy, uh, especially in patients who have a history of active cancer with acute back pain or back pain associated with unintentional weight loss. Um, and then also atraumatic severe back pain and age population where this is, uh, where this would not be suspected, usually above the age of 65. I would suggest maybe, um, that's a little bit young for this consideration. Um, but also below the age of 20 probably the most prevalent situation outside of trauma for which consideration should be made. For a spine surgeon. Referral refers to an acute neurologic deficit, including loss of function of the limbs or new bowel bladder or sexual dysfunction. Also saddle anesthesia and progressive and profound weakness. Uh are also red flags before we get into considerations for which provider referred to II, want to provide some notes on referrals to a spine, interventional uh doctors and for context pain interventionalist, um or spine interventionists, uh can be rehab providers, uh, like, uh PM and R docs. They could be anesthesiologist and some family practice internists also, uh, who have done a fellowship in pain could be AAA spine provider as well. Uh Firstly, it's very important to pursue uh conservative measures prior to a pain. Uh, provide a referral including therapies and other modalities, steroid injections and other interventional spine procedures are not necessary for most patients with new onset uh back pain. And there are many treatment options that should be uh pursued first referrals to a pain provider should only occur when their symptoms severe enough to interfere with activities of daily living and or ability to work. Um and had, when conservative measures have failed. It's always important to be thoughtful about which patients referred to an interventionalist. Since all pain procedures carry risks and steroids are strong medications that have a negative impact on a patient's general health, especially in those with underlying chronic medical conditions such as hypertension and diabetes being referred inappropriately or too soon, too, too soon to a pain provider may result in unnecessary care and increased expense to the patient. In order to break this down a little further. I added some thoughts to consider um uh whether a pain provider or a spine surgeon referral is appropriate. Uh We start with acute symptoms and then we'll consider uh additional consi considerations. Uh when we refer a pain interventionist or spine surgeon based on a time frame and severity of symptoms for consideration. Uh Number one is the patient experiencing any red flags. Um If yes, if these are acute red flags or referral to a spine surgeon may be appropriate. And if not, if the red flag symptoms are um acute, less than six weeks, um in duration, uh, the patient may need an emergency uh uh care in the hospital, uh depending on the symptoms, especially if there's a rapid progressive neurologic weakness or back pain along with constitutional symptoms. This is obviously not the norm. This would be a rare, a rare patient that had uh uh red flags that were uh this acute. Um, if the red flags are symptoms that are more chronic in nature but are severe enough to impact activity. A pain provider, referral uh may be appropriate. Uh consideration. Number two when uh talking about uh uh referrals, I is the patient uh experienced radicular symptoms. If they've had radicular symptoms for at least six weeks duration, have failed other conservative care or not able to participate in active therapy or the symptoms are severe enough that it interferes with ADL S and our ability to work. Um And conservative measures have otherwise failed, then a pain provider or an interventionist referral um is appropriate at that point. Now, if the patient has not improved with the conservative and pain interventional procedures, a referral to a spine surgeon um may be appropriate and I should mention that as I have in other talks in the series referrals to a surgeon may not be necessary if the patient does not want to consider surgical management as part of their treatment plan or axial back pain for patients with pain over 12 weeks in duration and have not improved with at least six weeks of conservative care. A referral to a pain provider is the most appropriate course of action whereas axial back pain over 12 weeks in duration with no improvement or worsening, despite more than six weeks conservative care and an interventional procedure has already been performed a referral to a spine surgeon, um is then appropriate. And if all these considers for all of these considerations, the answer was no, neither. The patient didn't fit any of these categories. A referral to either a pain provider or a spine surgeon is not clinically appropriate at the time and want to continue continue conservative measures. Now, let's uh switch gears and discuss ordering of imaging uh for patients with back pain. Uh imaging for spine disease is uh commonly prescribed without consideration of the next steps in treatment based on results. It's important to be intentional about uh imaging uh and prescriptions for imaging with a solid plan in in place for managing um for management depending on the outcomes of the study being ordered. It's also pivotal to order a study if the results will reasonably impact the patient's plan of care to avoid subjecting the patient to unnecessary time spent and out of pocket cost when there's no clear clinical advantage. First start with uh x-rays, ordering x-rays is often a reflex for providers uh for anyone with back pain. But for most clinical scenarios and x rays are not necessary when considering whether an X ray for back pain is clinically necessary. It's important to remember the vast majority of spine pain is self limiting, meaning it will go away by itself without any intervention. Additionally, in many clinical situations, an xray will not result in new clinical information that would impact management of the patient care of patients care especially early in the disease process. When considering whether to order a spine X ray for your patient, considering the following questions. Uh Does the patient have symptoms or findings for which a spine specialist referral is considered like a suspicion or uh of a fracture or metastatic disease? Uh And will order an X ray um provide clinical value. Um uh I II, if, if no, if, if the answer is uh uh yes, that you know there, there may be a chance there's suspicion of fracture and metastatic disease or it may add clinical value then probably you to the point in which referring to a specialist to order uh further imaging uh may be appropriate. And for MRI S, uh when we review the data, we're seeing many more MRI S being ordered by pcps than we expected based on uh the clinical uh situation, an MRI order for back pain is only clinically appropriate in certain clinical scenarios. And in most cases, the test should be ordered by a specialist. MRI S can be used to delineate the appearance and extent of pathology um present that may be a cause of a patient's back pain or radicular uh pain issues. But if no surgery or procedure is going to be done imminently. Uh, Mris are, are typically not necessary for PCPs to order an MRI is simply, um, uh, not necessary and should not be ordered. The treatment plan will not be changed based on the results as I've mentioned previously, if the, but if the patient has had spine surgery in the past or a spine surgery, referral is imminent, it's recommended to defer us to a spine specialist for the desired imaging study. It may not be the exact study that you would consider ordering uh right off the bat and we don't want to repeat uh MRI unnecessarily. Uh and importantly, findings in MRI often do not correlate with pain and can lead to incidental findings of irrelevant concern and further testing and cost to the patient unnecessarily if the patient is doing e experiencing any acute red flags, um you may need to order a stat MRI. Um and you also may need to order an immediate referral to a spine surgeon for evaluation. Um If the red flag symptoms are acute or profound, the patient also may need emergency care at the hospital. But this is quite a rare uh situation. It's usually people wouldn't present to their PCP clinic. Uh for a a typical visit. This would be something more that we'd see in an emergency room uh setting as we do for all talks with this series, I wanna end this talk with some uh take home points. Um And again, uh we didn't cover everything. Uh It's not uh an exhaustive talk about the low back pain or low back pains that relates uh to value based care. So there'll be further talks um that uh discuss different topics um related to this. Uh But for what we discussed today for back pain, conservative treatment prior to specialist referral and diagnostic imaging is typically the most appropriate initial treatment. Conservative trial should last 6 to 12 weeks or more to avoid unnecessary referrals and testing. An MRI should typically be ordered by a specialist. Uh Thank you for joining us today for this presentation. We hope you enjoyed the talk and hope you join us again. Uh As soon as we explore other topics in MSK care. Thank you. Have a good day.