Most spinal pathology is initially assessed by primary care and emergency department providers. Hence, it is crucial for these providers to recognize emergent vs nonemergent conditions and subsequently provide the established standard of care. When the situation is a spinal emergency, one in which the spinal cord or exiting nerve roots are at increased risk of permanent damage, the consequences of mismanagement can be dire. Failure to promptly recognize and adequately treat these injuries can have a devastating and potentially permanent impact on the long-term neurological function of patients.1 Yet, even with non-emergent pathologies, failure to provide adequate care can result in suboptimal patient outcomes and unnecessary resource use.
Unfortunately, for those who infrequently treat such conditions, spinal pathologies can sometimes be difficult to diagnose, secondary to confounding comorbidities and the nonspecific nature of many symptoms.2–4 Many of these first-line providers include those who work in internal medicine, family medicine, emergency care, and neurology.5–7 Although previous studies have detailed the appropriate steps providers should follow to effectively recognize and manage emergent and nonemergent spinal pathology, an assessment of provider knowledge on the subject has not yet been completed.6,8 In this investigation, a pilot survey was administered to internal medicine, family medicine, emergency care, and neurology providers to ascertain different specialties' understanding of spinal management. The purpose was to establish whether there is a need for supplemental departmental training to improve provider knowledge and awareness.
Materials and Methods
Recruitment and Questionnaire Design
The authors conducted a cross-sectional evaluation of primary care, emergency care, and neurology providers at Rhode Island Hospital using an anonymous internet-based questionnaire. An email containing a link to the questionnaire was sent to providers' email addresses by head faculty members in the following departments: internal medicine, family medicine, emergency medicine, and neurology. Participants were eligible for inclusion if they worked as a physician, physician assistant, or nurse practitioner within one of the aforementioned departments. The study population was limited to primary care, emergency care, and neurology providers because they are often the first point of contact for patients experiencing symptoms underlying common atraumatic spinal pathologies and rare spinal emergencies. Because orthopedic surgeons and neurosurgeons initiate a downstream level of care relative to first-line providers, they were not sampled in this study.
The multiple-choice questionnaire, designed to take 10 minutes to complete, consisted of 3 sections: (1) demographic information, (2) clinical questions testing knowledge, and (3) comfort recognizing cases of spinal emergency. Regarding the knowledge-based questions, each scenario was specifically designed to assess first-line providers' clinical judgment regarding the identification of both emergent and nonemergent commonly encountered spinal pathologies along with the appropriate subsequent management. Question 1 was intended to assess the first-line providers' ability to recognize and provide appropriate nonurgent treatment for lumbar radiculopathy. Question 2 assessed the ability to recognize cauda equina syndrome and provide the appropriate urgent initial workup. Question 3 was intended to assess the ability to recognize and order appropriate urgent imaging for an epidural abscess. Question 4 returned to cauda equina syndrome and evaluated the first-line providers' ability to recognize its nature for emergent surgical treatment. Finally, question 5 assessed the ability of first-line providers to recognize cervical myelopathy and the nonurgent nature with which to obtain imaging.
Questions were developed by all authors, including a fellowship-trained spine surgeon (A.H.D.). After initial development, the questionnaire was piloted among 3 attending orthopedic spine surgeons for clarity, intent, and accuracy. The final questionnaire was sent to participants' email addresses as a link using the Lifespan REDCap Portal System, an anonymous data collection tool maintained by the Lifespan Biostatistics Core.9 Questionnaire data were collected from June 2017 through November 2017. The institutional review boards of Rhode Island Hospital and the Miriam Hospital approved the study protocol.
The main outcome measures were bivariate analyses and interdepartmental differences in management of spinal pathology, familiarity, and preparedness for the diagnosis of spinal emergencies.
Survey results were exported from the Lifespan REDCap Portal System and analyzed using SAS version 9.4 (SAS Institute, Cary, North Carolina) and R version 3.4.3 (R Foundation for Statistical Computing, Vienna, Austria). Descriptive statistics were generated. Bivariate analyses used chi-square, Fisher's exact, and Kruskal–Wallis tests, as appropriate. Tests of interdepartmental differences used Fisher's exact test. Statistical significance was defined as P<.0012, per the Bonferroni correction for 41 comparisons.
Descriptive Statistics and Survey Responses
A total of 143 pilot questionnaires were completed and collected. Participant completion rate was 100% because the electronic survey required all questions to be answered prior to submission. Departmental distribution of participants included the following: internal medicine (21.7%, n=31), family medicine (9.1%, n=13), emergency medicine (48.3%, n=69), and neurology (21.0%, n=30). The most commonly reported provider occupation was physician (88.1%, n=126), followed by physician assistant (6.3%, n=9) and nurse practitioner (5.6%, n=8). Level of training was evenly spread among the participants, including postgraduate year 1/2 (25.9%, n=37), postgraduate year 3/4/5 (19.6%, n=28), attending providers with less than 6 years of experience (25.9%, n=37), and attending providers with 6 or more years of experience (28.7%, n=41) (Table 1).
Overall, the majority of providers worked in an academic-based practice setting (91.6%, n=131). Most participants used past training experiences (85.3%, n=122) and internet sources (70.6%, n=101) to obtain information about spinal emergencies. In the past 3 months, medical providers had commonly seen cases of sciatica (88.1%, n=126), sensorimotor loss in the lower extremities (79.0%, n=113), and bowel/bladder dysfunction (66.4%, n=95). When asked about their preparation to communicate risk and identify spinal emergencies, a minority of first-line providers reported being “very prepared” (35.7% [n=51] and 35.0% [n=50], respectively); the majority of providers merely felt “somewhat prepared” to handle spinal emergencies (Table 1).
Regarding the knowledge-based questions, the question assessing identification and treatment of lumbar radiculopathy (question 1) was answered correctly by 72.0% (n=103) of participants. Most other respondents (27.3%, n=39) advocated for excessive diagnostic imaging. All respondents (100%, n=143) correctly classified a case of cauda equina syndrome (question 2), with most individuals (73.4%, n=105) electing to treat the condition aggressively within a 12-hour surgical time frame (question 4). It was found that 73.4% (n=105) of health care providers appropriately recognized an epidural abscess and identified its proper initial management (question 3). Other participants (26.6%, n=38) either did not recognize the patient as having an epidural abscess or did not properly proceed with the correct imaging for the pathology. Only 18.2% (n=26) of respondents recognized the appropriate nonurgent nature of obtaining imaging for cervical myelopathy (question 5). The majority of respondents (62.2%, n=89) chose to aggressively manage cervical myelopathy with an emergent magnetic resonance image (MRI) of the cervical spine.
Significant differences in percent correct by department type were observed for the management of lumbar radiculopathy (question 1, P<.0001), epidural abscess (question 3, P=.0002), and cervical myelopathy (question 5, P<.0001). In addition, occupation and level of practice/training were not significantly associated with answers to any knowledge-based questions or total correct responses in the survey (Table 2).
Interdepartmental Differences for Select Questions
Pairwise comparisons of percentage correct by department type were conducted for questions 1, 3, and 5 (those exhibiting significant associations with department type overall). Emergency medicine providers performed markedly better than members of internal medicine and neurology on initial management of lumbar radiculopathy (P=.0007 and P<.0001, respectively). When compared with emergency medicine, family medicine respondents performed poorer on managing epidural abscess (P<.0001). Neurology providers demonstrated more appropriate responses on outpatient management of cervical myelopathy compared with emergency medicine members (P<.0001) (Table 3).
P Values for Pairwise Comparisons of Interdepartmental Differences
This investigation assessed the proficiency with which different first-line provider specialties recognize and evaluate common spinal pathologies. The authors hypothesized that department type and level of practice/training would be associated with varying levels of proficiencies.
The bivariate analyses demonstrated an association between department type and proficiency with the initial management of lumbar radiculopathy, detection of epidural abscess, and management of cervical myelopathy; there were no associations regarding proficiency and level of practice/training. This suggests that variations in how spinal emergencies are handled may be predominately secondary to interspecialty differences.
Regarding the knowledge-based questions, although the question assessing the identification and proper management of lumbar radiculopathy was answered correctly by a majority of respondents, more than one-fourth of providers elected to inappropriately order an MRI, bypassing a course of initial conservative management. Lumbar radiculopathy, without red-flag symptoms, is typically treated conservatively with pain control among other modalities prior to obtaining advanced imaging or surgical consultation.10,11 A study conducted by de Schepper et al12 suggested that MRIs being ordered by general practitioners for back pain and radiculopathy only satisfied international guidelines 55% of the time, indicating a need for global education initiative.
Pairwise comparisons of interdepartmental differences in provider knowledge demonstrated that emergency medicine providers more appropriately handled lumbar radiculopathy relative to internal medicine and neurology. This demonstrates that emergency medicine providers are likely not improperly using emergency department resources in obtaining urgent MRIs; however, it highlights the low comparative threshold internal medicine and neurology providers have in obtaining advanced imaging prior to a trial of conservative treatment.12 This disparity may be in part due to differences in location of the patient throughout management (emergency department or on the hospital wards) and time frame of interacting with patients (initial patient encounter vs consultation).
The question assessing the proper identification of an epidural abscess and subsequent need to order an MRI with gadolinium was answered incorrectly by nearly one-fourth of respondents. It is possible that these providers did not recognize the patient as having an epidural abscess, or they did indeed recognize the pathology but did not properly proceed with the correct imaging. The relatively poor performance of the family medicine respondents regarding epidural abscesses may potentially be attributed to the more outpatient focused nature of the specialty, limiting their exposure to this pathology. However, spinal epidural abscess is a commonly missed diagnosis, and rapid identification is necessary for optimizing outcomes.8 Thus, educational initiatives focused on family medicine practitioners and training regarding epidural abscess may be appropriate.
The question assessing the recognition of cervical myelopathy and need to obtain nonurgent advanced imaging was answered correctly by only a marginal number of respondents, illustrating that the majority of providers either are unable to recognize cervical myelopathy or feel that the condition requires an urgent workup. Even neurology, who performed the best, managed to answer the question appropriately only 50% of the time. Nonetheless, neurology demonstrated a markedly greater ability to appropriately oversee the treatment of cervical myelopathy relative to emergency medicine. Similarly, although the values did not reach significance, internal medicine and family medicine also performed poorly on this question. The rationale for neurology performing better may be attributed to increased familiarity with the condition secondary to increased prevalence in outpatient clinics. The poor performance all around may be secondary to difficulties providers may have differentiating cervical myelopathy from more serious or urgent pathologies (eg, stroke and tumors).13
The second question assessed recognition of cauda equina syndrome as a surgical emergency and the appropriate initial management, whereas the fourth question assessed first-line provider knowledge of when a decompression should be performed. Although all providers (100% in question 2) accurately recognized the presentation of cauda equina syndrome, most providers (73.4% in question 4) chose to have these patients undergo surgical decompression as soon as possible (within 12 hours). The general consensus is that cauda equina syndrome needs to be surgically treated within a 48-hour time frame, but only level III evidence supports this claim.14 Thus, the difference between the equivocally accepted and most readily selected surgical time frame in the current study may be attributed to the general idea that biological systems tend to deteriorate in a continuous rather than stepwise manner.14 Therefore, in acute cauda equina syndrome, surgical intervention as soon as possible is probably best for clinical outcomes.
In all, it is clear from this study that many providers do not appropriately order advanced imaging per international guidelines or understand the urgency with which imaging is needed for myelopathy or radiculopathy. This highlights a potential suboptimal use of valuable resources.15–17 The disparity regarding the relatively lower threshold for primary care providers to obtain advanced imaging compared with emergency department providers underscores the relative scrutiny primary care providers have recently experienced for unnecessary referral of lumbosacral radiculopathy for surgical assessment and MRI.18 Increased use of advanced imaging has been shown to increase length of stay, costs, and precocious surgical intervention.11,12,19,20 Given that neurology providers also displayed a propensity to aggressively manage lumbar radiculopathy, future studies should investigate reasons behind referral tendencies. Although MRI is eventually necessary to evaluate cervical myelopathy, the overuse of emergent MRI can deplete emergency department resources that could otherwise be available for more acute patient conditions.19,20
Given that epidural abscess is classified as one of the true spinal emergencies, the likelihood of a patient presenting with underlying grave pathology in the emergency department is higher than in a primary care setting.20 This idea is consistent with the observation that family medicine providers underperformed in the appropriate recognition of an epidural abscess and the next step in its management.
Overall, despite the variation among respondents, the authors found that the majority of providers felt only “somewhat prepared” to communicate risk and identify possible cases of spinal emergency. Because the majority of respondents reported using medical school/residency training as a main source of information for spinal emergency knowledge, this raises important questions regarding how to best implement strategies to further spine education across a variety of specialties during their training years. In addition, given the popularity of using internet sources for information about spinal emergency management (Table 1), it will be crucial to address limitations in the validity and quality of readily available online information.
This investigation had several potential limitations. Because survey participation was skewed toward physician providers and emergency department providers, there is a possibility of response bias, although bivariate analyses showed comparable performance for knowledge-based questions across occupation type. The method of distribution of this study also made it difficult to quantify the actual response rate because it is unknown how many providers had access to or received the survey-containing emails. Additionally, providers who self-selected to participate may have had greater knowledge about spinal pathology or were more comfortable with managing spinal conditions, so this study may have overestimated provider knowledge and preparedness. Although the sample size was representative of membership in an academic level I trauma center, it may not represent all US providers in the fields of emergency medicine, primary care, and neurology. Additional studies will need to sample providers from other clinical settings, such as private-practice groups and community health care facilities, to reach a more established consensus regarding whether these interspecialty differences exist outside of the academic environment. In addition, the authors cannot know whether providers would act in real practice as they indicated in the study's hypothetical scenarios. Future studies should investigate specific training differences regarding spinal emergency management decisions and the clinical consequences of compromised routine protocol due to either misplaced concerns or lack of spinal emergency preparedness.
Disparities exist between the first-line provider specialties regarding identifying emergent and nonemergent spinal conditions as well as providing appropriate management. Fewer than half of the respondents felt “very prepared” to handle spinal emergencies. To optimize resource use and improve patient care, further educational initiatives should be undertaken to improve first-line provider knowledge regarding spinal emergencies.
- Stokes OM, Arnold FJL. Spinal emergencies. Surgery. 2012;30(3):122–128. doi:10.1016/j.mpsur.2011.12.003 [CrossRef]
- Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev. 2000;23(4):175–204. doi:10.1007/PL00011954 [CrossRef] PMID:11153548
- Todd NV. Causes and outcomes of cauda equina syndrome in medico-legal practice: a single neurosurgical experience of 40 consecutive cases. Br J Neurosurg. 2011;25(4):503–508. doi:10.3109/02688697.2010.550344 [CrossRef] PMID:21513452
- Balasubramanian K, Kalsi P, Greenough CG, Kuskoor Seetharam MP. Reliability of clinical assessment in diagnosing cauda equina syndrome. Br J Neurosurg. 2010;24(4):383–386. doi:10.3109/02688697.2010.505987 [CrossRef] PMID:20726746
- Corwell BN. The emergency department evaluation, management, and treatment of back pain. Emerg Med Clin North Am. 2010;28(4):811–839. doi:10.1016/j.emc.2010.06.001 [CrossRef] PMID:20971393
- Arce D, Sass P, Abul-Khoudoud H. Recognizing spinal cord emergencies. Am Fam Physician. 2001;64(4):631–638. PMID:11529262
- Petri R, Gimbel R. Evaluation of the patient with spinal trauma and back pain: an evidence based approach. Emerg Med Clin North Am. 1999;17(1):25–39, vii–viii. doi:10.1016/S0733-8627(05)70045-6 [CrossRef] PMID:10101339
- Chao D, Nanda A. Spinal epidural abscess: a diagnostic challenge. Am Fam Physician. 2002;65(7):1341–1346. PMID:11996416
- Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381. doi:10.1016/j.jbi.2008.08.010 [CrossRef] PMID:18929686
- Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin. 2007;25(2):387–405. doi:10.1016/j.ncl.2007.01.008 [CrossRef] PMID:17445735
- Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for evaluation of low back pain. Radiol Clin North Am. 2012;50(4):569–585. doi:10.1016/j.rcl.2012.04.005 [CrossRef] PMID:22643385
- de Schepper EI, Koes BW, Veldhuizen EF, Oei EH, Bierma-Zeinstra SM, Luijsterburg PA. Prevalence of spinal pathology in patients presenting for lumbar MRI as referred from general practice. Fam Pract. 2016;33(1):51–56. doi:10.1093/fampra/cmv097 [CrossRef] PMID:26659653
- Kim HJ, Tetreault LA, Massicotte EM, et al. Differential diagnosis for cervical spondylotic myelopathy: literature review. Spine. 2013;38(22)(suppl 1):S78–S88. doi:10.1097/BRS.0b013e3182a7eb06 [CrossRef] PMID:23962997
- Chau AM, Xu LL, Pelzer NR, Gragnaniello C. Timing of surgical intervention in cauda equina syndrome: a systematic critical review. World Neurosurg. 2014;81(3–4):640–650. doi:10.1016/j.wneu.2013.11.007 [CrossRef] PMID:24240024
- Alentado VJ, Lubelski D, Steinmetz MP, Benzel EC, Mroz TE. Optimal duration of conservative management prior to surgery for cervical and lumbar radiculopathy: a literature review. Global Spine J. 2014;4(4):279–286. doi:10.1055/s-0034-1387807 [CrossRef] PMID:25396110
- Childress MA. Spine conditions: cervical spine conditions. FP Essent. 2017;461:11–14. PMID:29019639
- Iversen T, Solberg TK, Romner B, et al. Accuracy of physical examination for chronic lumbar radiculopathy. BMC Musculoskelet Disord. 2013;14(1):206. doi:10.1186/1471-2474-14-206 [CrossRef] PMID:23837886
- Haswell K, Gilmour JM, Moore BJ. Lumbosacral radiculopathy referral decision-making and primary care management: a case report. Man Ther. 2015;20(2):353–357. doi:10.1016/j.math.2014.07.010 [CrossRef] PMID:25096717
- Dick EA, Varma D, Kashef E, Curtis J. Use of advanced imaging techniques during visits to emergency departments: implications, costs, patient benefits/risks. Br J Radiol. 2016;89(1061):20150819. doi:10.1259/bjr.20150819 [CrossRef] PMID:26693970
- Singleton J, Edlow JA. Acute Nontraumatic back pain: risk stratification, emergency department management, and review of serious pathologies. Emerg Med Clin North Am. 2016;34(4):743–757. doi:10.1016/j.emc.2016.06.015 [CrossRef] PMID:27741986
| Emergency medicine||69||48.3|
| Family medicine||13||9.1|
| Internal medicine||31||21.7|
| Nurse practitioner||8||5.6|
| Physician assistant||9||6.3|
|Level of practice/training|
| Postgraduate year 1/2||37||25.9|
| Postgraduate year 3/4/5||28||19.6|
| 0–5 years in practice||37||25.9|
| 6+ years in practice||41||28.7|
| Academic medical center–based practice||131||91.6|
| Community clinic or community health care practice||4||2.8|
| Large-group private practice (≥4 providers)||6||4.2|
| Small-group private practice (<4 providers)||1||0.7|
|Source of information|
| Medical journals||69||48.3|
| Professional organization (eg, American College of Physicians, American Medical Association)||33||23.1|
| Medical school/residency training||122||85.3|
|Patient type seen (3 mo)|
| Bladder/bowel dysfunction||95||66.4|
| Cervical myelopathy||61||42.7|
| Sensorimotor loss in the lower extremities||113||79.0|
| Saddle-type anesthesia||37||25.9|
|Preparation to communicate risk of spinal emergencies|
| Not at all prepared||17||11.9|
| Somewhat prepared||75||52.5|
| Very prepared||51||35.7|
|Preparation to identify spinal emergencies|
| Not at all prepared||11||7.7|
| Somewhat prepared||82||57.3|
| Very prepared||50||35.0|
|Variable||Question 1||Question 2||Question 3||Question 4||Question 5||Total Correct|
| Emergency medicine||89.9||100.0||81.2||17.4||5.8||2.9|
| Family medicine||76.9||100.0||23.1||15.4||15.4||2.3|
| Internal medicine||58.1||100.0||77.4||45.2||16.1||3.0|
| Nurse practitioner||87.5||100.0||37.5||25.0||12.5||2.6|
| Physician assistant||88.9||100.0||66.7||22.2||11.1||2.9|
|Level of practice/training|
| Postgraduate year 1/2||67.6||100.0||67.6||32.4||27.0||2.9|
| Postgraduate year 3/4/5||57.1||100.0||71.4||35.7||17.9||2.8|
| 0–5 years in practice||75.7||100.0||67.6||24.3||16.2||2.8|
| 6+ years in practice||82.9||100.0||85.4||14.6||12.2||3.0|
P Valuesa for Pairwise Comparisons of Interdepartmental Differences
|Question/Provider||Emergency Medicine||Family Medicine||Internal Medicine|
| Family medicine||.1918||-||-|
| Internal medicine||.0007||.3137||-|
| Family medicine||<.0001||-||-|
| Internal medicine||.7876||.0016||-|
| Family medicine||.2404||-||-|
| Internal medicine||.1308||1.0000||-|