Primary Care Doctors Outperform Surgeons in Back Pain Management

SAN DIEGO—Primary care physicians (PCPs) are more familiar with clinical management guidelines for low back pain than orthopedic surgeons, according to results of an Israeli survey presented at the American Academy of Orthopedic Surgeons annual meeting.

Charles Milgrom, MD, associate professor of surgery at Hadassah Hospital, Hebrew University, Jerusalem, Israel, and colleagues analyzed questionnaires about the treatment of acute, uncomplicated low back pain that were completed by 140 PCPs and 243 orthopedic surgeons.

Clinical guidelines for the management of acute low back pain, which are very similar to the evidence-based guidelines issued by the US Public Health Service, are sent to most physicians throughout Israel.

Respondents were asked which drug treatment is preferable for patients with low back pain: paracetamol (known as acetaminophen in the United States), conventional nonsteroidal antiinflammatory drugs (NSAIDs), cyclooxygenase (COX)-2 inhibitors, or opioids. More than 1 answer was permitted. Compared with 89.1% of PCPs who correctly answered “paracetamol” and “conventional NSAIDs,” only 45.7% of orthopedists said so.

Physicians were also asked which imaging studies they would recommend to patients presenting with acute low back pain. Their choices included x-ray of the lumbar spine, ultrasound of the kidneys, computed tomography of the lumbar spine, bone scan, magnetic resonance imaging, or none. More than twice as many PCPs as orthopedists correctly answered that no radiographic study was necessary (88.6% vs 35.1%, respectively).

Finally, the surveyed physicians were asked which treatments they would recommend: manipulation, bed rest, encouragement and explanation, or physical therapy. The responses showed that:

• 43.4% of PCPs and 49.4% of orthopedic surgeons correctly said that manipulation is not recommended

• 53.6% of PCPs and 33% of surgeons correctly answered that bed rest is not recommended

• 71% of PCPs and 54.2% of surgeons marked the correct answer, “explanation and encouragement.”

Overall, the mean score on the questionnaire (maximum possible 100 points) was 69.9 points for PCPs and 45.5 points for orthopedists (P <.001).

Dr Milgrom said that this study shows that both PCPs and orthopedic surgeons have &#8220;deficiencies&#8221; in their knowledge about the management of acute low back pain but that PCPs are nonetheless much better acquainted with current guidelines.

He added that the gap between the 2 groups is probably due to the fact that the curriculum for orthopedists in training is more focused on the surgical than the nonsurgical management of low back pain.

About 40% to 60% of adults in Western countries report having experienced an episode of low back pain within the previous month.