February 10, 2009 - The routine use of radiography, MRI or CT scans in patients with low-back pain but no indication of a serious underlying condition does not improve clinical outcomes, and doctors should refrain from immediate scanning unless they observe features of a serious underlying condition, according to conclusions from an article in this week’s edition of The Lancet.
In the study, written by a team led by Roger Chou, M.D., Oregon Health and Science University, Portland, OR, the researchers did a meta-analysis of randomized controlled trials that compared immediate back imaging - using one of the three scanning types above - with usual clinical care that does not involve immediate imaging. Six trials covering more than 1800 patients were included, reporting a range of outcomes including pain and function, quality of life, mental health, overall patient-reported improvement, and patient satisfaction. The analysis found no significant differences between immediate imaging and usual clinical care. The authors say that the results are most applicable to acute or sub-acute low-back pain of the type assessed in primary-care setting, ie, at the patient's family doctor.
The authors said: "Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition."
They added: "Rates of utilization of lumbar MRI are increasing, and implementation of diagnostic-imaging guidelines for low-back pain remains a challenge. However, clinicians are more likely to adhere to guideline recommendations about lumbar imaging now that these are supported by consistent evidence from higher-quality randomized controlled trials. Patient expectations and preferences about imaging should also be addressed, because 80 percent of patients with low-back pain in one trial would undergo radiography if given the choice, despite no benefits with routine imaging. Educational interventions could be effective for reducing the proportion of patients with low-back pain who believe that routine imaging should be done. We need to identify back-pain assessment and educational strategies that meet patient expectations and increase satisfaction, while avoiding unnecessary imaging."
In an accompanying comment, Professor Michael M. Kochen, department of general practice, University of Göttingen, Germany, and colleagues discuss how certain factors could hamper doctors changing practice to avoid immediate imaging, "such as patients' expectations about diagnostic testing, reimbursement structures providing financial incentives, or the fear of missing relevant pathology." They conclude: "Meanwhile a promising approach seems to be the way of educating patients in and outside general practitioners surgeries."
Source: The Lancet (The Lancet, Volume 373, Issue 9662, Pages 463 - 472, 7 February 2009)
For more information: http://www.thelancet.com
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