Letter: Back Pain and Accesses to Emergency Departments During COVID-19 Lockdown in Italy

To the Editor:

Degenerative spine disease represents a frequent cause of questionable accesses to Emergency Departments (EDs) in Italy. Since emergency medicine can ensure a completely free-of-charge and prompt care, many patients with nonurgent pain syndromes improperly access EDs to skip waiting lists for the ordinary—and often congested—assistance for instrumental diagnostic services, outpatient consultations, and hospitalizations for surgical procedures.

The tragic occurrence of the COVID-19 pandemic has unmasked this phenomenon, well-known among physicians, but poorly translated into scientific evidence and thus never fully considered as a matter of public discussion. Because of the lockdown and the global awareness of the risks of the contagion, indeed, a drastic reduction in probably improper ED accesses has been observed.

The following data have been collected from the internal database of the City of Health and Science of Turin, one of the largest hospitals in Italy and one of the most involved center in treating COVID-19 patients, painting an interesting scenario: In the 3 wk after the lockdown that took place in Italy (March 8th-29th, 2020), the total number of patients getting access to the EDs for back pain or sciatica was significantly lower than that of the previous 3 wk from February 15th to March 7th, 2020 (182 vs 32, P < .001). Among patients with a diagnosis of back pain, in the postlockdown group, a significantly higher percentage of traumatic history (21.8% vs 4.9%, P < .001) as well as more cases requiring instrumental tests (28.1% vs 3.8%, P < .0001) was reported, thus suggesting a higher amount of accesses that really required urgent care during the epidemic emergency.

Several considerations must be made to globally explain these results. Is the reduction of improper nonurgent accesses for back pain the only reason of this relevant difference between the 2 groups? The argument that the fear of infection inhibits patients from accessing the ED is obvious and needs to be taken into account. Nevertheless, pain is well-known to be one of the worst-tolerated symptoms for patients and often becomes the cause of conflict with healthcare professionals, for requests for both immediate instrumental diagnostic tests and resolutive therapy.¹ Changes in daily routine after the lockdown, with less physical performance demands, could be an additional element to justify these results. That said, reduced mobility is also a predisposing cause for the onset of back pain in patients with degenerative spine disease.² Hence, a reliable interpretation of these data suggests that probably most of the patients improperly access EDs for back pain under normal circumstances, and could reasonably be managed in an outpatient setting.

In conclusion, it would be desirable for the Italian healthcare system to carefully reconsider, after this pandemic, the real opportunity to allow free-of-charge emergency treatments for degenerative pain syndromes like those involving the spine.³

Disclosures

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.