Consistency between physical medicine and rehabilitation specialists and a radiologist in interpretation of lumbosacral radiographs
To investigate intra- and inter-observer reliability among physical medicine and rehabilitation specialists and a radiologist in interpretation of plain lumbar spine X-ray films in patients with low back pain. Three assessors (A: a resident of PM&R, B: an experienced PM&R specialist, C: an experienced radiologist) read the standard lumbosacral plain radiographs of 79 patients with 2-3 month time interval. Each assessor recorded the presence or absence of abnormalities on the radiograph according to a standardized assessment form. For assessors B and C, all kappa values were > 0.40. Transitional vertebrae abnormalities reached to the highest agreement ratio. The intrarater agreement showed higher kappas than the interrater agreement. The radiologists had the highest intrarater agreement, closely followed by the experienced PM&R specialist. Agreement among three assessors was substantial in sacralisation, lumbarisation and facet joint pathologies. We usually obtained a good intrarater agreement, especially for the experienced PM&R specialist and the radiologist indicating that experience increases diagnostic consistency. Besides the systematic differences in radiographic interpretation between the assessors, institutional specific conditions (esp. patient profile and regularities) may cause the phycians to pay more attention to a specific group of pathologies.
- [Show abstract] [Hide abstract] ABSTRACT: Introduction There are studies showing differences among health professionals regarding the application of imaging techniques for the evaluation of low back pain, showing the existence of a wide clinical variability. These studies have found poor adherence of primary care professionals to the Clinical Practice Guidelines recommendations published for the management of low back pain, in particular with regard to the appropriate use of clinical history, physical examination and lumbar spine x-rays. Proper use of lumbar x-rays in non-specific low back pain, which is essentially a diagnosis based on the exclusion of any underlying pathology, would mean increased safety for patients, by eliminating unnecessary ionizing radiation; shorter waiting lists for diagnostic imaging tests; reduced consumption of staff and patient time and better use of resources. This is why it is necessary to provide healthcare professionals with current, high-quality scientific evidence on the appropriate use of radiography in patients with non-specific low back pain, to promote good clinical practice. Objective Determine criteria for appropriate use of radiography in the diagnosis of low back pain, in order to contribute to a reduction in variability of clinical practice, reduce risks to patient health and make rational use of health resources. Methodology A systematic review of the scientific literature was conducted, comprising a literature search focused on identifying systematic reviews, clinical trials, observational studies, clinical practice guidelines and evaluation reports in a variety of biomedical databases. The search covered publications from 2006 to December 2013, that evaluate the use of radiography as a diagnostic test in adult patients with non-specific low back pain. A secondary review was conducted, on the bibliographies of the identified articles. A critical reading was carried out on the selected items, in order to identify any methodological problems that might affect their validity. Economic analysis: YES NO Experts Opinion: YES NO Results The literature search identified 25 studies with relevant information about the use of x-ray in diagnosing low back pain, of which 14 corresponded to Clinical Practice Guidelines and 11 to Systematic Reviews. Following a fulltext review of the available studies, nine Clinical Practice Guidelines and seven Systematic Reviews were included, on the basis of their high methodological quality. The available evidence indicates that in patients with acute, non-specific low back pain without red flags, lumbar spine x-ray is not justified, due to its limited diagnostic validity. Radiography is indicated when the symptoms are indicative of cancer, ankylosing spondylitis, vertebral fracture or spinal infection. Conclusions Routine imaging studies are not recommended in patients with non-specific low back pain without red flags. Radiography is indicated based on suspicion of serious underlying disease. The main indications for lumbosacral radiography are: suspected vertebral fracture, suspected cancer, suspected ankylosing spondylitis or suspected infection.0Comments 0Citations