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: 35.29). 07/1997; 277(22):1782-6. DOI: 10.1001/jama.277.22.1782
Source: PubMed


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.
    Full-text · Article · Feb 2008 · Journal of Clinical Epidemiology
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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.
    Full-text · Article · Nov 2006 · Joint, bone, spine: revue du rhumatisme
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    • "Reocurrent and chronic back pain account for 75–85% of all costs associated with lower back pain [8,9]. The cause of low back pain is non-specific in most cases and serious conditions are relatively rare [10,11]. These serious conditions are usually marked by "red flag" factors that include: age of onset <20 and >50 years, recent history of violent trauma, constant progressive non mechanical pain (no relief with bed rest), thoracic pain, past medical condition of malignancy, prolonged use of corticosteroids, drug abuse, immunosuppression, HIV, systemically unwell, unexplained weight loss, widespread neurological symptoms, cauda equina syndrome, structural deformity and fever [12]. "
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    ABSTRACT: To discuss the role of depression in chronic lower back pain and comment on appropriate methods of screening and co-management. The current scientific literature was investigated using the online web databases CINAHL, Medline/PUBMED, Proquest, Meditext and from manual library searches. Databases were searched from 1980 to the present (2005). Articles were searched with the key words "depression" and "low back pain". Over three hundred articles were sourced and articles were then selected on their relevance to the chronic spinal pain states that present to manual therapy practitioners. Pain is a subjective awareness of peripheral nociceptive stimulation, projected from the thalamus to the cerebral cortex with each individual's pain experience being mediated by his or her psychological state. Thus a psychological component will often be associated with any painful experience. A number of studies suggest (among other things) that the incidence of depression predicts chronicity in lower back pain syndromes but that chronic lower back pain does not have the reciprocal action to predict depression. The aetiology of chronic pain is multifactorial. There is sufficient evidence in the literature to demonstrate a requirement to draw treatment options from many sources in order to achieve a favourable pain relief outcome. The treatment should be multimodal, including mental and emotional support, counseling and herbal advice. While a strong correlation between depression and chronic low back pain can be demonstrated, an apparent paucity of literature that specifically addresses the patient response to chiropractic treatment and concurrent psychotherapy identifies the need for prospective studies of this nature to be undertaken. It is likely that multimodal/multidisciplinary treatment approaches should be encouraged to deal with these chronic lower back pain syndromes.
    Full-text · Article · Jul 2005 · Chiropractic & Osteopathy
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