Back injuries — one of the most common injuries in workers compensation — are getting a treatment do-over as doctors, payers and other experts urge injured workers to wait on surgery and opt for conservative care first.

Ohio — a monopoly workers comp state — has gone even further by instituting a rule that mandates a set time period for conservative care before surgery becomes an option. While early referral results point to potentially positive outcomes in terms of the number of back surgery procedures performed in the state, the possible dangers of delaying surgical treatments remain uncertain, experts say.

“The physicians and surgeons are realizing that just because someone has back pain, surgery is not the answer,” said Andrea Buhl, Jersey City, New Jersey-based senior vice president of clinically integrated medical programs for Sedgwick Claims Management Services Inc. “More and more, physicians are looking at the big picture. Surgery could make it worse.”

The Burr Ridge, Illinois-based North American Spine Society calls back pain second among the most common reasons for visiting a doctor, after the common cold. In workers compensation, experts say back injuries can be found across all lines of work, from manufacturing and heavy lifting to sit-all-day clerical jobs.

Researchers with the Cambridge, Massachusetts-based Workers Compensation Research Institute estimate that back injuries are present in roughly one-fifth of all claims. While the source of pain can be an acute injury, such as one that occurs while lifting a heavy object, experts say most injuries are degenerative in nature.

Traditionally, it is invasive diagnostics that are at the heart of the number of workers comp claims with back pain or injury — almost anyone over the age of 40 will have some degeneration of the spine, according to Mike Farrand, Radnor, Pennsylvania-based senior principal in the integrated casualty consulting practice with Willis Towers Watson PLC.

“The philosophy has been on the imaging piece… there are studies that show a lot of people have herniation in backs,” he said. “To get those diagnostics early on, it becomes the focus of the claim.”

“Back surgery in general can be very complicated and it’s hard to pinpoint diagnostically where the pain is coming from,” said Ms. Buhl. “And people manifest pain in different ways… the diagnostic tools are not 100% effective.”

“While (lumbar) fusion surgeries can be successful, many are not,” Evelina Radeva, a Cambridge, Massachusetts-based policy analyst with WCRI, said during a webinar in November on the status of inpatient care for such complicated surgeries. 

WCRI research found that 10 of the 18 states it studied saw decreases of up to 9.3% between 2013 and 2017 of injured workers who underwent surgery to correct back disc problems.

“The benefits of back surgery are highly contested,” she added.

Conservative care has different meanings for different doctors and payers, and treatment can run the gamut, from limiting imaging and diagnostics at the onset of the claim, to physical therapy, cold therapy, rest, acupuncture and more.

“Spine specialists in general have been urging a more conservative approach first to see if we can get patients better without surgery,” said Dr. Terrence Welsh, Columbus, Ohiobased chief medical officer for the Ohio Bureau of Workers’ Compensation, which provides workers compensation insurance for all employers in Ohio.

In January, Ohio introduced its “lumbar fusion rule” mandating 60 days of conservative care before the authorization of lumbar fusion surgery, a common surgery that aims to correct back pain by limiting movement between vertebrae. The rule describes conservative care as including “physical therapy, chiropractic care and rest, anti-inflammatories, ice and other non-surgical treatments.” 

“We knew that there are a certain percentage of surgeries that are unsuccessful and that’s the point of our rule,” said Dr. Welsh, adding that the aim is to “reduce the number of failed back surgeries” in its system.

Such adverse outcomes following the popular fusion surgery included “chronic opioid dependence, increased disability and high rates of failed back syndrome, as well as additional surgery and new psychiatric co-morbidities,” according to a statement from the Ohio BWC.

The BWC quoted a study from the journal Orthopedics that found nearly 77% of fusion patients did not return to work within two years. The state does not have figures on the outcome of the new rule, Dr. Welsh said.

Meanwhile, King of Prussia, Pennsylvania-based MedRisk Inc. in its 2018 industry trends report revealed that it has seen a 6 percentage point drop in the number of post-surgical referrals for lower back pain in Ohio between 2017 and 2018 and “a rise in non-surgical (physical therapy) referrals” there.

“The data suggests that Ohio’s ruling is making an impact,” its report states.

Whether there is danger in delaying surgery remains unclear, and several experts declined to comment because of the controversy in appropriate treatment for injured workers.

Dr. Robert Beatty, a neurosurgeon in Overland Park, Kansas, wrote in an email to Business Insurance that “waiting criteria for treating anything ignores the fact that every case is different.”

“Waiting for 60 days might work most of the time but there will be cases who very well might develop permanent neurologic changes such as weakness or loss of bowel or bladder function,” he wrote.