Cost of providing treatment for backache and the life span has increased over last 5 decades. Backache is more common among elderly patients. Cost of treatment includes the cost of investigations to evaluate and diagnose the etiology of back pain. Backache is most often related to work injury, auto accident, and degenerative diseases. Investigations are precise and valuable to diagnose the cause, so appropriate treatment is provided. All back pain may not need most expensive investigations or frequent repetition of such investigation. Most of the investigations are considered when symptoms are exaggerated or area of symptoms has changed. Clinical diagnosis is considered as subjective expert conclusion and not objective finding. Subjective clinical diagnosis is different when two physicians examine same patient. One may diagnose a lower back pain as lumbar disc bulge and another physician may diagnose same symptoms as lumbar disc herniation. The difference in subjective diagnosis is eliminated when objective test is available like MRI. Both physicians will conclude same diagnosis based on the findings of MRI image.
Why physicians often prefer to repeat MRI or any other investigation when symptom characters are changed? Question has multiple answers but most common reason is to see the objective evidence. Physicians are questioned by patient, insurance provider and legal communities regarding objective evidence of diagnosis. Patient wants the truth, insurance providers want to eliminate the added cost of investigation and legal community want to use the evidence to protect the interest of patient or third party. Investigation is the main source of debate and argument in legal issues. Investigations must be provided as objective evidence to protect patient and service provider like physician. The cost of providing medical treatment is increasing every year so does the quality of treatment and lifestyle.
How can the cost of investigation and treatment be contained? Preventing duplication of same investigation and avoiding unnecessary treatment can contain the cost. Similarly cost can be kept low if investigation is not repeated when symptom character or diagnosis is not changed. Investigations are repeated when patient decides to take second or third opinion. Consultant physicians often find it difficult to get the copy of past investigations. Difficulties are created by government guidelines like HIPPA violations, hospital or lab guidelines because of fear of HIPPA violation and guidelines of insurance providers. Insurance provider prefers to let the investigations be available to physician who is employed by insurance provider. Hospital or lab prefers to share investigation with physician who has hospital or lab privileges. Physician would not treat patient if objective evidence were not available.
Backache is caused by abnormalities of vertebral column, pinch nerve and autoimmune diseases. Diagnosis is important to conclude proper treatment. The lab and radiological studies performed to diagnose backache is as follows.
Tests to Diagnose Back Pain or Backache Include
- Erythrocyte Sedimentation Rate (ESR)– ESR is increased when backache is caused by rheumatoid arthritis (autoimmune disease) and infection (epidural abscess, discitis or osteomyelitis).1
- C-reactive Protein (CRP)– CRP is increased in patients with history of arthritis (osteoarthtis) or inflammation of joint disease (rheumatoid arthritis). Cytokins and related protein factors are elevated in early stages of rheumatoid disease. Cytokine factors are used as a marker to diagnose early stage of rheumatoid arthritis.1
- White Blood Cell Count: Increased in patients with history of epidural abscess, arthritis, osteomyelitis or infections.
- Rheumatoid Factors (RF)– RF is a protein molecule known as antibodies. Seventy to ninety percent of patients suffering with rheumatoid arthritis show presence of RF. RF test is often non-specific test, since RF is also present in patients suffering with other type of autoimmune disorders. Symptoms of Rheumatoid arthritis are less severe when RF is absent.
- Citrulline Modified Proteins (anti-CCP)-Specific antibodies produced in rheumatoid disease prior to symptoms and during symptoms binds to Citrulline. The test is specific. Test is always positive in rheumatoid shoulder joint arthritis despite RF being absent. Anti-CCP predicts severity of rheumatoid arthritis and disease (RD) and also subclinical RD.
- ANA Blood Test– ANA is a non-specific antibody test. Results are positive in all autoimmune disease.
- HLA-B27 Genetic Marker– Test is positive in inflammatory joint diseases like Psoriatic Hip Joint Disease, Ankylosing Spondylitis and Reiter’s Syndrome.
- Antineutrophil Cytoplasmic Antibodies (ANCA)– ANCA is an abnormal antibody seen in-patient with history of hip joint pain caused by Wegener’s granuloma. Blood examination for ANCA level is performed to rule out Wegener’s granuloma as a cause of hip joint pain.
- X-Ray: Assists in diagnosis of osteoporosis, fracture, dislocation, foraminal stenosis and degenerative disc disease.
- Computerized Tomography (CT) Scan: CT scan is an important apparatus for osteoporosis, fracture, dislocation, foraminal stenosis, degenerative disc disease, herniated disc and soft tissue injury (tendon, muscle tear).
- Magnetic Resonance Imaging (MRI): This is a frequently used investigation in diagnosis of backache. MRI is a reliable investigation tool in diagnosing osteoporosis, fracture, dislocation, foraminal stenosis, degenerative disc disease and herniated disc. Note: 40% of MRIs show bulging discs in asymptomatic patients. 20% cases with ruptured discs were never found on MRI.
- Myelogram: Myelogram was a most frequent study performed prior to surgery in the past. Myelogram has been conducted less often as MRI studies became more frequent. Myelogram is an x-ray study in which a radio-opaque dye is injected directly into the spinal canal. Myelogram provides more reliable information of spinal stenosis and foraminal stenosis.
- Ultrasound: Ultrasound provides information about blood clot or calcified stones. Ultrasound is used often to rule out arterial venous blood clots in lower legs.
- EMG: Electromyography studies are performed to evaluate the nerve damage and radiculopathy.
- Bone Scan: Measures calcium concentration in bones and helps in diagnosis of bone tumor, compression fracture and osteoporosis.
- Bone Densitometry: For detecting osteoporosis.
- Epidural or Cerebrospinal Fluid (CSF) Analysis– Epidural fluid or spinal (cerebrospinal) fluid is analyzed to diagnose epidural abscess, discitis, osteomyelitis or meningitis as a cause of back pain.
- Ultrasound– Ultrasound study of back is performed to diagnose epidural abscess or hematoma.2