Australian and New Zealand Association of Neurologists: tests, treatments and procedures clinicians and consumers should question

1 Don’t perform imaging of the carotid arteries for simple faints

Syncope is common, with a lifetime prevalence of 40%. Carotid imaging studies such as carotid duplex are commonly performed in patients presenting with syncope. When symptomatic, occlusive carotid artery disease causes focal neurologic symptoms such as weakness, altered sensation or speech, and not syncope. In addition, studies demonstrate that even elderly patients with syncope are unlikely to have carotid occlusive disease. Therefore, performing carotid imaging studies in patients with syncope increases cost without adding benefit. Furthermore, carotid imaging may identify incidental asymptomatic occlusive carotid artery disease that may be inappropriately assumed to be the cause of the syncope. This can delay the identification of the true cause of syncope and may subject the patient to additional risk-associated procedures such as catheter angiography, carotid endarterectomy (CEA), or carotid stenting.

Supporting evidence

Kadian-Dodov D, Papolos A, Olin JW. Diagnostic utility of carotid artery duplex ultrasonography in the evaluation of syncope: a good test ordered for the wrong reason. Eur Heart J Cardiovasc Imaging 2015;16(6):621-5.
Maung AA, Kaplan LJ, Schuster KM, et al. Routine or protocol evaluation of trauma patients with suspected syncope is unnecessary. J Trauma 2011;70(2):428-32.
Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF Scientific Statement on the Evaluation of Syncope. J Am Coll Cardiol 2006;47:473-84.

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2 Don’t perform imaging of the brain for non-acute primary headache disorders

Headache is a common disorder with many potential causes. The primary headache disorders, which include migraine and tension headaches, account for the majority of headaches. Secondary headaches, which are those with underlying pathology (e.g., tumour, aneurysm, or giant cell arteritis) are far less common. Most patients presenting with headache will not have a serious underlying condition. Neuroimaging is not usually warranted for patients with recurrent migraine or tension headaches and a normal neurological examination. The likelihood of significant intracranial lesions on CT or MRI in this group ranges from 0.3% to 0.4%. Headache worsened by Valsalva maneuver, headache causing awakening from sleep, new headache in the older population, or progressively worsening headache may indicate a higher likelihood of finding significant abnormalities on CT or MRI as does the presence of abnormal neurological signs on examination.

Supporting evidence

Morey SS. Headache Consortium releases guidelines for use of CT or MRI in migraine work-up. Am Fam Physician 2000;62(7):1699-701.
Medical Advisory Secretariat. Neuroimaging for the evaluation of chronic headaches: an evidence-based analysis. Ont Health Technol Assess Ser 2010;10(26):1–57.

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3 Don’t perform epidural steroid injections to treat patients with low back pain who do not have radicular symptoms in the legs originating from the nerve roots

Lumbar epidural steroid injections may provide limited short term benefit (less than 3-6 months) for patients with an acute lumbar radiculopathy causing back pain and symptoms in the legs (Level C evidence). When there is low back pain alone, the outcomes of epidural steroid injections are poor. Although serious adverse events are rare, catastrophic events can occur and any symptom relief from the injection is typically brief. The inconsequential benefits of epidural steroid injections for low back pain without radicular symptoms do not outweigh its risks, no matter how small they may be.

Supporting evidence

Choi HJ, Hahn S, Kim CH, et al. Epidural steroid injection therapy for low back pain: a meta-analysis. Int J Technol Assess Health Care 2013;29(3):244-53.
Quaraishi NA. Transforaminal injection of corticosteroids for lumbar radiculopathy: systematic review and meta-analysis. Eur Spine J 2012;21(2):214-9.
Staal JB, de Bie R, de Vet HCW, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev 2008;16:(3).

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4 Don’t use opioids for the treatment of migraine, except in rare circumstances

Migraine is the most frequent cause of headache seen in the medical office, urgent care, or emergency department. Almost all patients should receive migraine-specific medications or non-opioid analgesics because these medications are the most effective migraine treatments. However, many patients continue to receive opioids for migraine treatment. Use of opioids increases the risk of headache and chronic migraine arising from medication overuse. The per capita cost of headache and chronic migraine arising from medication overuse is 3 times that of episodic migraine. When medical conditions such as cardiovascular disease or pregnancy preclude use of migraine-specific treatments, or when migraine-specific treatments fail, opioids are sometimes considered for rescue therapy. In these circumstances, use should be limited to 9 days per month or less to avoid medication overuse headache, and doctors should continue to focus on preventive and behavioural aspects of migraine care. In addition, long-term follow-up is needed to prevent treatment complications.

Supporting evidence

Bigal ME, Serrano D, Buse D, et al . Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008;48(8):1157-68.
Evers S, Afra J, Frese A, et al. European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force. Eur J Neurol [Online] 2009;16(9):968-81.
Tepper SJ. Opioids should not be used in migraine. Headache 2012;52; S1:30-4.

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5 Don’t routinely recommend surgery for a narrowed carotid artery (>50% stenosis) that has not caused symptoms

Best medical therapy is generally the appropriate management of patients with asymptomatic carotid stenosis. Medical treatment has improved since trials comparing carotid endarterectomy (CEA) plus best medical treatment with best medical treatment in asymptomatic carotid stenosis were conducted. There is evidence that the annual stroke rate in patients with asymptomatic carotid stenosis receiving best medical treatment has fallen to ≤1% annually. The effectiveness of CEA compared with current best medical therapy is not established. Additionally, randomised trials suggested equivocal benefit in women and patients aged >75. It may be reasonable to consider CEA for highly selected patient aged <75 years with >70% stenosis of the internal carotid artery. Where the perioperative risk of stroke, death and myocardial infarction is <3% and the patient is estimated to have a life expectancy of more than 3 to 5 years, consultation with a physician with expertise in stroke care is recommended prior to surgery.

Supporting evidence

MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004;363:1491-502.
Lanzino G, Rabinstein AA, Brown RD. Treatment of carotid artery stenosis: medical therapy, surgery, or stenting? Mayo Clin Proc 2009;84(4):362–8.
Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke 2010; 41:e11-7.

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