Questions & Answers features staff members of Rockhill Orthopaedics, the Kansas City Spine Center, and the Health and Rehabilitation Pavilion. Here, we interview David A. Tillema, M.D., orthopaedic surgeon with the Spine Center.

When you see a new workers' comp patient with acute back pain, how do you proceed with diagnosis and treatment?
The first part of the work-up is a very thorough history and physical. This is then followed by routine x-rays if indicated. Most of the time we can get a good idea what is wrong with the patient's back on the basis of this information. The most important part of our evaluation, and that, which is frequently overlooked, is the history and physical. The treatment depends on what we think is wrong with the patient. Frequently physical therapy is indicated for the patient with acute back pain. More than 95% of patients with acute back pain will get better with time and therapy.

How long does this approach last?
Most patients will show improvement within two or three weeks. If the pain persists we might extend the therapy for another week or two, however, we do not keep the therapy going indefinitely. If physical therapy doesn't help them within several weeks, it isn't going to.

What is the next step if physical therapy doesn't help?
If physical therapy doesn't help, it is then important to reevaluate the patient to see if there are other reasons for the persistent discomfort. We want to rule out any change in the patient's findings and make sure he or she has not developed a herniated disc or symptoms of nerve root impingement. However, if the patient does not show any definite signs of organic problems we then need to look at other factors. This is the point where we also look at psychological factors to see if there are any other extenuating circumstances which are delaying the patient's recovery. It is well known that job dissatisfaction, unpleasant social situations or, or other psychological factors can delay recovery. It is very important to look into these factors if the patient has not gotten better in six weeks time frame. We know that the longer the individual is off work the harder it is to get him better and the harder it is to get him to return to work.

At what point do you order a CAT scan or an MRI?
Usually a CAT scan or an MRI are not ordered in a patient with acute discomfort unless you really have true signs of nerve root impingement. If the patient has not responded to physical therapy then it is time to reevaluate to see whether these tests are indicated. We do not usually order a CAT scan or an MRI unless we have a high suspicion of a herniated disc.

Why don't you order these tests right away in order to find out?
There are several reasons and one is cost. These tests are very expensive and we do our best to hold costs down. Another is that there is a high percentage of false positives. Several studies have shown that CAT scans and MRIs done in patients with absolutely no back findings will show up to 30 to 40 percent of abnormal findings. We therefore don't like to do the test unless they are needed to make further decisions on which way to go with treatment.

What do you do when the patient or the patient's attorney or insurance carrier wants a CAT scan or an MRI when you don't feel it is necessary?
This presents a real problem for us. We are frequently put in the position of where the patient or perhaps the patient's attorney have the idea that the work up is not complete unless you have either a CAT scan or an MRI and that you aren't treating the patient properly unless you get these tests. The physician, therefore, has to make a judgement based on clinical necessity for these x-rays.