DOI: 10.1097/01.NT.0000396257.69347.a6
,
Issn Print: 1533-7006
Publication Date: 2011/03/17
Facebook
Twitter
LinkedIn
Email
 |
Checking for direct PDF access through Ovid | |
Excerpt
“Unless it is serious and unrelenting and the physician suspects a progressive neurological deficit or the patient has a history of cancer, the rule should be ‘wait,'” said Roger Chou, MD, a member of the Clinical Guidelines Committee for the American College of Physicians, which released a clinical guideline in the Feb. 1 Archives of Internal Medicine.
Dr. Chou, associate professor of medicine and scientific director of the Oregon Health & Science University Evidence-based Practice Center, and his colleagues reviewed a meta-analysis of six randomized studies, comprising a total of 1,804 patients with unexplained low back pain. They found no difference between routine lumbar imaging and usual care without imaging. The groups reported the same levels of pain, quality of life and overall improvement (as rated by the patients).
Most problems do not even show up on a CT, lumbar radiography or MRI, and routine imaging does not seem to improve clinical outcomes, Dr. Chou said. “What's more, findings identified on the scan could have nothing to do with their pain and these patients can be referred for surgery.”
The total health costs for low back and neck pain increased 65 percent from $4,795 in 1997 to $6,096 in 2005, according to a 2008 paper in The Journal of the American Medical Association. Much of this cost, Dr. Chou said, is due to imaging and the prescriptions that follow from the readout.
Studies also suggest that many people have abnormalities on lumbar scans “but that does not mean that they are associated with their low back pain,” said Dr. Chou.
In one cross-sectional study, 36 percent of people over the age of 60 had evidence of a herniated disk diagnosed on a lumbar scan; 21 percent had spinal stenosis, and 90 percent had a degenerated or bulging disc. And none of them had symptoms.
“It is important to understand that the presence of imaging abnormalities need not mean that the abnormalities are responsible for symptoms,” the committee wrote.
Most patients with acute back pain get better within four weeks, Dr. Chou said. “Acute low back pain has a favorable natural history. The expected yield of routine imaging is low,” the committee said.
A review of 68,000 lumbar radiographs prescribed for patients between the ages 20 and 50, for example, identified a clinically unsuspected finding in one of every 2,500 patients.
Furthermore, the studies suggested that it rarely affects the treatment choices and could add to the anxiety levels of patients told that they have evidence of an abnormal scan.
These patients tend to report “more pain and worse overall health status than those who did not have a radiograph,” said Dr. Chou.
The working group was also concerned about the studies that found increased rates for spinal surgery on the heels of imaging. In a randomized clinical trial, people with low back pain who had a rapid MRI were sent into surgery twice as often as patients who had radiography. Another study found that patients who had an MRI within the first month of their complaints of low back pain had an eight-fold increase in surgery compared to those who had no imaging.
The group created a list of recommendations that includes holding off on imaging. If the low back pain remains severe after three months then imaging might be advised.
