Back Pain - Indications for Imaging

1/13/2003 (Somerset)

Question: when should imaging studies be perfomed on a patient with low back pain?

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<1>

Unique Identifier:12353946

Authors: Jarvik JG. Deyo RA.

Institution: Department of Radiology, University of Washington, Seattle, Washington 98195, USA. jarvikj@u.washington.edu

Title: Diagnostic evaluation of low back pain with emphasis on imaging. [Review] [93 refs]

Source: Annals of Internal Medicine. 137(7):586-97, 2002 Oct 1.

Abstract: PURPOSE: To review evidence on the diagnostic accuracy of clinical information and imaging for patients with low back pain in primary care settings. DATA SOURCE: MEDLINE search (January 1966 to September 2001) for articles and reviews relevant to the accuracy of the clinical and radiographic examination of patients with low back pain. STUDY SELECTION: The authors reviewed abstracts and selected articles for review on the basis of a combined judgment. Data on the clinical examination were based primarily on recent systematic reviews; data on imaging tests were based primarily on original articles. DATA EXTRACTION: Diagnostic results were extracted by one or the other author. Quality of methods was evaluated informally. Major potential biases were identified, but neither quantitative data extraction nor scoring was done. DATA SYNTHESIS: Formal meta-analysis was not used because the diagnostic hardware and software, gold standards, and patient selection methods were heterogeneous and the number of studies was small. Sensitivity for cancer was highest for magnetic resonance imaging (0.83 to 0.93) and radionuclide scanning (0.74 to 0.98); specificity was highest for magnetic resonance imaging (0.9 to 0.97) and radiography (0.95 to 0.99). Magnetic resonance imaging was the most sensitive (0.96) and specific (0.92) test for infection. The sensitivity and specificity of magnetic resonance imaging for herniated discs were slightly higher than those for computed tomography but very similar for the diagnosis of spinal stenosis. CONCLUSIONS: The data suggest a diagnostic strategy similar to the 1994 Agency for Health Care Policy and Research guidelines. For adults younger than 50 years of age with no signs or symptoms of systemic disease, symptomatic therapy without imaging is appropriate. For patients 50 years of age and older or those whose findings suggest systemic disease, plain radiography and simple laboratory tests can almost completely rule out underlying systemic diseases. Advanced imaging should be reserved for patients who are considering surgery or those in whom systemic disease is strongly suspected. [References: 93]

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Unique Identifier:10223094

Authors: Staiger TO. Paauw DS. Deyo RA. Jarvik JG.

Institution: Department of Medicine, University of Washington School of Medicine, Seattle 98195, USA. staiger@u.washington.edu

Title: Imaging studies for acute low back pain. When and when not to order them. [Review] [14 refs]

Source: Postgraduate Medicine. 105(4):161-2, 165-6, 171-2, 1999 Apr.

Abstract: Acute low back pain is generally a self-limited condition, and most patients recover within a few weeks without the need for imaging studies. However, physicians need to be on the lookout for red flags that point to more serious conditions, such as infection or malignancy, which require imaging. In this article, the authors identify these warning signs and discuss the appropriate use of imaging studies for a variety of symptoms and conditions. [References: 14]

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Unique Identifier:8901390

Authors: Materson RS.

Institution: Department of Medical Affairs, National Rehabilitation Hospital, Washington, DC, USA.

Title: The AHCPR practice guidelines for low back pain.

Source: Bulletin on the Rheumatic Diseases. 45(2):6-8, 1996 Apr.

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Unique Identifier:8689413

Authors: Boos N. Lander PH.

Institution: Division of Orthopaedic Surgery, McGill University, Royal Vitoria Hospital, Montreal, Quebec, Canada.

Title: Clinical efficacy of imaging modalities in the diagnosis of low-back pain disorders. [Review] [142 refs]

Source: European Spine Journal. 5(1):2-22, 1996.

Abstract: This review provides methodological background and some guidelines for the evaluation of imaging modalities for the lumbar spine and reviews the current literature on the basis of different levels of efficacy which consider standards beyond technical quality or diagnostic accuracy. From a MEDLINE search, 672 articles (1985-1995) were retrieved which focused on the development or application of imaging modalities for lumbar spinal disorders. The papers were categorized according to different efficacy levels at which the imaging modalities were assessed. This review has demonstrated that the vast majority of reports evaluate imaging studies for the lumbar spine only at the technical efficacy level. A minor proportion of the articles focus on the evaluation at the level of diagnostic accuracy. Articles which assess imaging studies on a higher level of efficacy (e.g., diagnostic and therapeutic impact, patient outcome and cost-benefit analysis) are sparse. This review has outlined frequent methodological flaws in patient selection and design of imaging studies for the lumbar spine. The spine specialist should therefore become very critical in the interpretation of those studies and pay attention to patient selection and spectrum, choice of the reference standard, sample size, various forms of biases, and the reasoning behind clinical recommendations in order to improve his patient care. [References: 142]

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Unique Identifier:7877388

Authors: Wipf JE. Deyo RA.

Institution: Department of Medicine, University of Washington, Seattle.

Title: Low back pain. [Review] [64 refs]

Source: Medical Clinics of North America. 79(2):231-46, 1995 Mar.

Abstract: Low back pain is a common reason for physician visits and is associated with enormous costs to health care and industry. Radiographic abnormalities of the lumbar spine, including disk protrusion, are common in asymptomatic subjects and only loosely associated with symptoms and neurologic examination. Therefore, highly selective evaluation is required to avoid subjecting patients with back pain to unnecessary tests and surgical procedures. Reassurance about the favorable prognosis of low back pain is an important component of therapy. Most patients with simple back pain recover with symptomatic treatment. Plain radiographs are indicated for evaluation of patients with radiculopathy and those with risk factors for underlying medical conditions. The majority of patients with back pain, even those with radiculopathy, improve with conservative management and surgery is unnecessary. Surgical consultation and CT or MR imaging scans are indicated for patients with persistent or progressive neurologic deficits or persistent sciatica with nerve root tension signs. Acute radiculopathy with bilateral neurologic deficits, saddle anesthesia, or urinary symptoms is suggestive of cord compression or cauda equina syndrome and requires urgent surgical referral. [References: 64]