Elsevier

The Spine Journal

Volume 18, Issue 12, December 2018, Pages 2266-2277
The Spine Journal

Clinical Study
Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis

https://doi.org/10.1016/j.spinee.2018.05.004Get rights and content

Abstract

Background Context

The problem of imaging patients with low back pain (LBP) when it is not indicated is well recognized. The converse is also possible, although rarely considered. The extent of these two problems is presently unclear.

Purpose

This study aimed to estimate how commonly overuse, and also underuse, of imaging occurs in the management of LBP, and how appropriate use of imaging is assessed.

Design

This is a systematic review and meta-analysis.

Patient Sample

The sample comprised patients with LBP presenting to primary care.

Outcome Measures

Proportions of inappropriate referral, and inappropriate non-referral, for diagnostic imaging for LBP were the outcome measures.

Methods

MEDLINE, EMBASE, and CINAHL were searched from January 1, 1995 to December 17, 2017. Two authors independently assessed study quality and extracted data. Meta-analyses were performed where appropriate, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation system.

Results

Thirty-three studies were included. In patients referred for lumbar imaging, 34.8% (95% confidence interval [CI]: 27.1, 43.3) were judged inappropriate by the absence of red flags for serious pathology and 31.6% (95% CI: 28.3, 35.1) were judged inappropriate by the criteria of no clinical suspicion of pathology. In patients presenting for care, imaging was inappropriately performed in 27.7% of cases (95% CI: 21.3, 35.1) when judged by duration of episode, 9.0% of cases (95% CI: 7.4, 11.0) when judged by absence of red flags, and 7.0% (95% CI: 1.8, 23.3) when judged by no clinical suspicion of pathology. In patients presenting for care, imaging was not performed where appropriately indicated in 65.6% (95% CI: 51.8, 77.2) of patients who presented with red flags, and 60.8% (95% CI: 42.0, 76.8) with clinical suspicion of serious pathology.

Conclusions

Inappropriate imaging is common in LBP management, including both overuse in those where imaging is not indicated and underuse of imaging when it is indicated. Appreciating that both underuse and overuse can occur is fundamental to efforts to improve imaging practice to align with current guidelines and best evidence.

Introduction

Evidence & Methods

Studies evaluating use of imaging most often focus on inappropriate over-use.

In this systematic review, the authors reviewed studies to determine rates for both over-use and under-use of radiographs in low back pain based upon available guidelines. They found that both over-use and under-use were frequent.

The paper is one of a few to note that too often patients who need films (earlier diagnosis, earlier appropriate treatment) often don't get them when indicated. Re-education of primary care physicians may be helpful; a focus on “less is more” to decrease costs may occasionally be harmful.

Imaging for acute low back pain (LBP) is considered appropriate when there is clinical suspicion of serious pathology or surgery is being considered to address a specific pathology [1]. Imaging may also be used in the diagnosis of chronic LBP; however, specific indicators for appropriate imaging use are less well defined, with pain lasting longer than 6 weeks being an indicator for imaging in some guidelines but not in others [2].

Serious pathology (eg, infection or tumor) or specific pathology (eg, spinal canal stenosis) are estimated to be the cause of LBP in less than 1% and 10% of presentations, respectively [1], [3], [4], [5]. Therefore, commonly reported imaging rates for acute LBP of about 35% [6], [7] are considered too high, resulting in increased health-care costs, increased radiation exposure, and potentially inappropriate treatment [8], [9]. As such, much focus has been on reducing rates of imaging; however, there has been limited success [10].

Although imaging rates are considered high, it is currently uncertain what proportion of imaging decisions are appropriate when compared with clinical practice guidelines. It is likely that overuse of imaging is occurring, but it is uncertain as to the extent. It is also possible that patients for whom imaging is indicated miss out on imaging, potentially leading to misdiagnosis and inappropriate or insufficient care. Determining the extent of imaging overuse and underuse is important for informing remedial action in this area.

The aim of this systematic review was to estimate how common inappropriate imaging decisions for LBP are, including both inappropriate referral (overuse) and inappropriate non-referral (underuse). We also investigated the criteria used to judge imaging appropriateness.

Section snippets

Methods

The protocol was determined in advance and conducted in accordance with the PRISMA and MOOSE statements [11], [12]. The review protocol was registered with PROSPERO (http://www.crd.york.ac.uk/PROSPERO); registration number: CRD42016049731. Study selection, data extraction, and risk of bias (ROB) assessment were conducted independently by two reviewers, with disagreements resolved by discussion or arbitration of a third reviewer.

Study characteristics

Database searches identified 6,501 records with an additional 19 records identified from other sources. Inclusion criteria were met by 36 studies (Fig. 1). Of these, three studies were excluded [17], [18], [19] as they reported on the same sample as other included studies [20], [21], [22] with less informative data. There was substantial initial agreement in the study selection between the two authors (kappa=0.68). The majority of the discrepancies were resolved by discussion between the two

Main findings

This review found low to moderate quality evidence that both inappropriate overuse and underuse of imaging occur in the management of LBP. Between 31.6% (95% CI: 28.3, 35.1) and 34.8% (95% CI: 27.1, 43.3) of referred imaging is considered inappropriate. Of LBP patients presenting for care who were inappropriate for imaging, between 7.0% (95% CI: 1.8, 23.3) and 27.7% (95% CI: 21.3, 35.1) were subsequently referred for imaging depending on how appropriateness was judged in the studies. The

Conclusion

This review highlights that both overuse and underuse of imaging are common in the management of LBP. This finding is important as to date, attention has almost exclusively focused on overuse of imaging. To improve the use of imaging in the clinical management of LBP, strategies to improve proportions of appropriate imaging decisions, rather than reduction of imaging rates alone, should be developed and implemented.

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    FDA device/drug status: Not applicable.

    Author disclosures: HJJ: Nothing to disclose. ASD: Nothing to disclose. CGM: Nothing to disclose. NAM: Nothing to disclose. JSM: Nothing to disclose. MJH: Nothing to disclose.

    Registration: The review protocol was registered with PROSPERO (http://www.crd.york.ac.uk/PROSPERO); registration number: CRD42016049731.

    This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

    All authors declare no support from any organization for the submitted work and no competing interests or other relationships or activities that could appear to have influenced the submitted work.

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