Appropriate Use of Lumbar Imaging for Evaluation of Low Back Pain

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Direct Costs

Direct costs of imaging include costs of equipment and facilities, radiologic department staff, professional fees for interpreting the test, and other overhead. Because direct costs are often difficult to measure, reimbursement rates or charges are often used as surrogate measures. Although estimates vary substantially depending on geographic location, insurance status, and other factors, reimbursement rates and charges for lumbar spine CT generally run 5 to 10 times higher than lumbosacral

Practice Variations

Clinicians vary substantially in how frequently they obtain low back pain imaging. One study found that Medicare beneficiaries living in high-use geographic areas in the United States were more than five times more likely to undergo lumbar spine MRI and CT than if they lived in low-use areas.11 In addition, wide variations in diagnostic testing rates have been observed between, and within, medical specialties.29, 30, 31, 32 One survey found internists almost evenly divided regarding whether

Effectiveness

The ultimate goal of any diagnostic test is to improve clinical outcomes. Most studies of diagnostic tests estimate how accurately they can identify a disease or condition, or how well the test provides prognostic information. However, even accurate tests do not necessarily result in improved patient outcomes. The ultimate effects of diagnostic testing depend on how clinicians and patients use the test results, the effectiveness of subsequent treatments, and harms related to the diagnostic test

Cost-effectiveness

A prerequisite to evaluating the cost-effectiveness of a clinical service is to understand its clinical effectiveness.13 In this case, for patients with no red flags, routine imaging is no more effective than usual care without routine imaging. Performing imaging is also more expensive. Services that are more costly than the alternative, yet offer no clear clinical advantages (or do more harm than good), cannot be cost-effective, because they will always be associated with higher (or negative)

Favorable Natural History

In most patients with acute back pain, with or without radiculopathy, substantial improvement in pain and function occurs in the first 4 weeks, regardless of whether and how patients are treated.49, 50 Routine imaging is unlikely to improve on this already favorable prognosis. Thus, the natural history of low back pain helps explain why routine imaging does not result in better clinical outcomes.

Low Prevalence of Serious Underlying Conditions

Another reason routine imaging is not beneficial is that the frequency of conditions that require

Radiation exposure

Lumbar plain radiography and CT contributes to an individual’s cumulative low-level radiation exposure, which could promote carcinogenesis (Table 3). Lumbar spine CT is associated with an average effective radiation dose of 6 millisieverts (mSv).70 Based on the 2.2 million lumbar CT scans performed in the United States in 2007, one study projected 1200 additional future cancers.71 Another study estimated that cancer would be expected to occur as a result of radiation exposure in approximately 1

Patient Expectations

One reason that current practice is not consistent with the evidence is patient expectations.79 Patients want a specific diagnosis to explain their symptoms. In addition, patients may equate a decision to not obtain imaging or provide a precise diagnosis with low-quality or suboptimal care, or interpret the decision to not perform imaging as implying that their pain is not legitimate or important.78 In patients with chronic back pain, the desire for diagnostic tests is a frequent reason for

When to Image

Routine imaging in low-risk patients does not improve patient outcomes but increases costs and exposes patient to harms, including unnecessary radiation exposure and invasive treatments, and the deleterious effect of likely labeling that person as a patient with a degenerative spinal disorder. Several professional societies have issued practice guidelines and standards to help address overuse of low back imaging. In 2007, the American College of Physicians (ACP) and the American Pain Society

Summary

Strong evidence shows that routine back imaging does not improve patient outcomes, exposes patients to unnecessary harms, and increases costs. However, imaging practices remain inconsistent with evidence-based guidelines and use continues to rise. Diagnostic imaging studies should only be performed in selected higher-risk patients who have severe or progressive neurologic deficits or are suspected of having a serious or specific underlying condition, and advanced imaging with MRI or CT should

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      Citation Excerpt :

      Imaging might also be indicated when a reasonable trial of care has failed to produce results. In the absence of red flags, however, imaging likely offers no benefit and may have a negative impact on outcomes that would amount to substandard care.25,26,30,31,34-40 For patients presenting with nonspecific low back pain and no red flags, early imaging does not improve outcomes compared with proceeding with conservative treatment without imaging, and not imaging patients with acute low back pain will thus reduce harms and costs without affecting clinical outcomes.25,40

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    Funding statement: No funding was received for this manuscript.

    Disclosures: Roger Chou was the lead author on guidelines developed by the American Pain Society and American College of Physicians on diagnosis and management of low back pain, including recommendations on imaging, and has consulted with Wellpoint Inc, Blue Cross Blue Shield Association, and Palladian Health on implementing low back pain guidelines.

    Jeffrey G. Jarvik is a consultant to General Electric Healthcare serving on their Comparative Effectiveness Advisory Board. He also consults with HealthHelp, a radiology benefits management company. He is a cofounder of PhysioSonics, a company that uses high-intensity focused ultrasound for diagnostic purposes, is a stockholder, and receives royalties for intellectual property.

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