Appropriate Use of Lumbar Imaging for Evaluation of Low Back Pain
Section snippets
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
References (113)
- et al.
Imaging strategies for low-back pain: systematic review and meta-analysis
Lancet
(2009) - et al.
A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned
Spine J
(2011) - et al.
Real-world practice patterns, health-care utilization, and costs in patients with low back pain: the long road to guideline-concordant care
Spine J
(2011) - et al.
Are first-time episodes of serious LBP associated with new MRI findings?
Spine J
(2006) - et al.
The power of the visible: the meaning of diagnostic tests in chronic back pain
Soc Sci Med
(1999) - et al.
ACR appropriateness criteria on low back pain
J Am Coll Radiol
(2009) - et al.
Back pain prevalence and visit rates
Spine
(2006) - et al.
Physician office visits for low back pain: Frequency, clinical evaluation, and treatment patterns from a U.S. national survey
Spine
(1995) - et al.
Diagnosis and treatment of low back pain
BMJ
(2006) - et al.
Estimates and patterns of direct health care expenditures among individuals with back pain in the United States
Spine
(2004)
Expenditures and health status among adults with back and neck problems
JAMA
Lost productive time and cost due to common pain conditions in the US workforce
JAMA
Epidemiology of low back pain
Neurosurg Clin N Am
Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society
Ann Intern Med
Rapidity and modality of imaging for acute low back pain in elderly patients
Arch Intern Med
Rates of advanced spinal imaging and spine surgery
Spine
Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes
J Occup Environ Med
High-value, cost conscious care: concepts for clinicians to evaluate benefits, harms, and costs of medical interventions
Ann Intern Med
Overutilization of radiological examinations
Radiology
Overtreating chronic back pain: time to back off?
J Am Board Fam Med
Nationwide surveys of chest, abdomen, lumbosacral spine radiography, and upper gastrointestinal fluoroscopy: a summary of findings
Health Phys
Cascade effects of medical technology
Annu Rev Public Health
Prevalence, complications, and hospital charges associated with use of bone-morphogenetic proteins in spinal fusion procedures
JAMA
The impact of diagnostic testing on therapeutic interventions
JAMA
Increases in lumbosacral injections in the Medicare population
Spine
An international comparison of back surgery rates
Spine
Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration
Spine
Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial
BMJ
2001 Volvo award winner in clinical studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group
Spine
Surgery for degenerative lumbar spondylosis: updated Cochrane review
Spine
Lumbar fusion outcomes in Washington state workers' compensation
Spine
The rising prevalence of chronic low back pain
Arch Intern Med
Patterns of ordering diagnostic tests for patients with acute low back pain. The North Carolina Back Pain Project
Ann Intern Med
Physician variation in diagnostic testing for low back pain. Who you see is what you get
Arthritis Rheum
A survey of primary care physician practice patterns and adherence to acute low back problem guidelines
Arch Fam Med
Survey of acute low back pain management by specialty group and practice experience
J Occup Environ Med
Variation in the delivery of health care: the stakes are high
Ann Intern Med
Slowing the growth of health care costs—lessons from regional variation
N Engl J Med
The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care
Ann Intern Med
Low back pain and best practice care. A survey of general practice physicians
Arch Intern Med
Brief report: physicians' initial management of acute low back pain versus evidence-based guidelines
J Gen Intern Med
Rising use of diagnostic medical imaging in a large integrated health system
Health Aff
A long way to go. Practice patterns and evidence in chronic low back pain care
Spine
Low back pain in older adults? are we utilizing healthcare resources wisely?
Pain Med
Diagnostic testing and treatment of low back pain in United States emergency departments
Spine
The efficacy of diagnostic imaging
Med Decis Making
A framework for clinical evaluation of diagnostic technologies
Can Med Assoc J
The architecture of diagnostic research
BMJ
Implementation barriers for general practice guidelines on low back pain
Spine
Cited by (0)
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.