Use of Lumbar Radiographs for the Early Diagnosis of Low Back Pain: Proposed Guidelines Would Increase Utilization

Public Health Sciences Department, Healthcare Quality and Outcomes Research Centre, Edmonton, Alberta, Canada.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 07/1997; 277(22):1782-6. DOI: 10.1001/jama.277.22.1782
Source: PubMed

ABSTRACT The Agency for Health Care Policy and Research (AHCPR) has recently published guidelines for the management of patients with acute low back pain, which include recommendations for the use of lumbar radiographs, based on the identification of "red flags" for fractures, tumors, or infections. The purpose of this study was to evaluate the potential impact of these guidelines in patients with new episodes of low back pain seen in primary care settings.
Retrospective cohort study.
Four family clinics (18 physicians) in Edmonton, Alberta.
The records of all patients seen in 1992 and 1993 with a new episode of low back pain were reviewed: 963 patients had a history of back pain of less than 3 months.
Lumbar radiograph utilization at the initial low back pain visit. Charts were also reviewed to determine subsequent occurrence of spinal tumors, infection, or fractures that could be related to low back pain.
One hundred twenty-seven (13%) of the 963 patients with acute low back pain had lumbar radiographs during their first visit, 68 (54%) with oblique views. If the AHCPR guidelines had been applied to this population, 426 (44%) of the patients would have undergone radiography, increasing current utilization by 238%. Eight of the 963 patients had a diagnosis of fracture or bone tumor during follow-up. The sensitivity of the guidelines to potentially detect these diseases was higher than the physicians' utilization patterns, but their specificity and positive predictive values were low.
The implementation of the AHCPR guidelines for the initial use of radiographs in patients with low back pain may increase utilization and economic costs. A more restricted and cost-efficient set of guidelines should be proposed.

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    • "Vertebral fracture is associated with significant pain and disability [3] and with increased mortality [4]. The prevalence of vertebral fracture in patients presenting to primary care practitioners with acute low back pain has been estimated to be between 0.5% [5] and 4% [6], yet it is estimated that only 30% of vertebral fractures are diagnosed in clinical practice [7] because the presentation is similar to that of nonspecific low back pain [7] [8]. Vertebral fracture not only requires specific appropriate treatment, but is a contraindication to spinal manipulative therapy, a common treatment that is endorsed in clinical practice guidelines for acute nonspecific low back pain [9]. "
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    ABSTRACT: To determine the accuracy of clinical features in diagnosing vertebral fracture in low back pain patients and assess the psychometric properties of the Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews (QUADAS) scale. A diagnostic systematic review was performed on all available records in MEDLINE, CINAHL, and EMBASE. Studies were considered eligible if they investigated clinical features associated with vertebral fracture in a cohort of low back pain patients. All eligible studies were assessed for methodological quality using the QUADAS scale, and two authors extracted true-positive, true-negative, false-positive, and false-negative data for each clinical feature. Twelve studies were identified by the review, investigating 51 clinical features. Five clinical features were useful to raise or lower the probability of vertebral fracture: age>50 years (likelihood ratio [LR]+=2.2, LR-=0.34), female gender (LR+=2.3, LR-=0.67), major trauma (LR+=12.8, LR-=0.37), pain and tenderness (LR+=6.7, LR-=0.44), and a distracting painful injury (LR+=1.7, LR-=0.78). The QUADAS had low internal consistency, and only three items had high inter-rater reliability. There was inadequate reporting of many methodological quality items. Five clinical features were identified that can be used to screen for vertebral fracture. The psychometric properties of the QUADAS scale raise concerns about its use to rate the quality of low back pain diagnosis studies.
    Journal of Clinical Epidemiology 02/2008; 61(2):110-118. DOI:10.1016/j.jclinepi.2007.04.013 · 5.48 Impact Factor
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    • "tion; if the recommendations of the AHCPR guidelines had been applied, 44% of the patients would have been referred for imaging, which would have meant a 238% increase [9]. "
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    ABSTRACT: A review of the recent literature shows that guidelines on the management of low back pain (LBP) have little impact on the use of radiological imagery. Among the factors which might account for the use of radiological examination, a review of the literature points to some that refer to the patient, others to the clinician and still others to the therapeutic interaction. This leads one to question the importance of radiological examination for both the patient and the physician. The matter at stake in this review is the relationship that may exist between this type of examination and the patient's and/or the physician's anxiety. If these aspects are associated or causally related, this relationship can be two-sided and is thus susceptible to affect the patient, the physician, or both. Some possible keys which emphasize the central role of the therapeutic relationship in this predicament are also reviewed.
    Joint, bone, spine: revue du rhumatisme 11/2006; 73(5):508-13. DOI:10.1016/j.jbspin.2006.01.005 · 3.22 Impact Factor
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    ABSTRACT: Background. Low back pain is one of the most frequent reasons for consulting general practitioner. Little is known about etiology and pathogenesis of low back pain. Ge- neral practitioner use different methods for the treatment of patients with low back pain. The choice of kind of therapy is not related with the used diagnostic method. A large variety of therapeutic interventions is available for the treatment of low back pain, but the effectiveness of most of them has not been demonstrated. The treatment of low back pain is mainly con- servative and symptomatic. Conclusions. In the article are reviewed and critically evalu- ated different diagnostic and therapeutic methods used by physicians for the treatment of patients with low back pain. Results of existing studies suggest that applied therapeutic treatments mainly do not base on scientific based results. Ključne besede: prevalenca; absentizem; potek bolezni; dia- gnostika; zdravljenje Izvleček - Izhodišča. Bolečina v križu je eden najpogostejših simptomov, s katerim se vsakodnevno srečuje zdravnik splo- šne medicine. O etiologiji in patogenezi bolečine v križu je malo znanega. Pri obravnavi bolnika z bolečino v križu se uporabljajo številni diagnostični postopki, ki pa večinoma ne vplivajo na vrsto terapije. Pri bolečini v križu obstajajo in se uporabljajo različne vrste terapije. Zdravljenje bolečine v kri- žu je v glavnem konzervativno in simptomatsko. Učinkovitost večine terapevtskih metod pa ostaja nedokazana. Zaključki. V prispevku so opisani in kritično ovrednoteni dia- gnostični in terapevtski postopki, ki jih uporabljajo zdravniki pri obravnavi bolečine v križu. Številne študije kažejo, da upo- rabljeni postopki v glavnem ne temeljijo na znanstveno ute- meljenih ugotovitvah.
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