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.