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Resources back smart imaging for low back pain: imaging is indicated only if spinal causes other than radiculopathy or stenosis are suspected.

NEW ORLEANS--Physicians who'd like to opt out of the rampant over-or-dering of imaging studies for patients with acute low back pain will find a solid ally in the joint American College of Physicians/American Pain Society guideline on low back pain.

The essential message of the guideline is that imaging studies are appropriate right away only in the small fraction of patients who present with low back pain having a suspected specific spinal cause other than radiculopathy or spinal stenosis, Dr. Leanne M. Yanni noted at the annual meeting.

This small group of patients with low back pain for whom prompt imaging is "absolutely indicated" is comprised of those with suspected vertebral infection, cauda equina syndrome, cancer, severe progressive neurologic deficits, or vertebral compression fracture. That's 5% or less of all patients with acute low back pain, she said.

"In almost all of these cases, the patient will present with signs and symptoms that will enable you to identify one of these conditions," added Dr. Yanni, medical director of palliative medicine at the Bon Secours Richmond (Va.) Health System.

Studies demonstrate that when patients present with acute low back pain, based solely on that complaint, 22 out of 100 physicians will order a lumbar x-ray at an estimated direct cost of $18,950. If the patients also report having sciatica, 62 of 100 physicians would order an imaging study. Yet those imaging studies will make no difference in terms of pain, function, quality of life, or overall patient-rated improvement, in large part because most patients with low back pain will have a spontaneous recovery, according to one analysis (Ann. Intern. Med. 2011;154:181-9).

It's worth bearing in mind that there are harms associated with this unnecessary imaging, Dr. Yanni continued. In addition to the enormous financial cost, there is the significant radiation exposure, the fact that further tests and procedures may follow in the event of inconclusive imaging findings, the increased likelihood that patients will label themselves as impaired or disabled, and the distinct possibility that imaging will lead to unnecessary surgery.

Low back pain is the fifth most common reason for physician visits in the United States. The estimated direct health care costs related to low back pain are in excess of $30 billion annually.

The joint American College of Physicians/American Pain Society guideline on low back pain recommends that physicians use their clinical expertise to triage patients presenting with acute low back pain into three broad categories (Ann. Intern. Med. 2007;147:478-91).

By far the largest group--accounting for 87% of the total--is composed of patients with nonspecific or uncomplicated low back pain. Because they have a high likelihood of spontaneous recovery, no imaging is indicated and reevaluation at 4-6 weeks is appropriate.

The second group is made up of patients with symptoms suggesting radiculopathy or spinal stenosis. Again, no imaging is indicated right away, and reevaluation at 4-6 weeks is appropriate. Imaging is warranted for patients in this group only if intervention--surgery or an injection--is under consideration.

A focused history and physical examination will identify the small percentage of patients who fit into "another specific spinal cause" category warranting imaging. Vertebral infection, for example, is suggested by fever, recent infection, or intravenous drug abuse. Back pain accompanied by urinary retention and/or fecal incontinence suggests cauda equina. And a history of osteoporosis or systemic corticosteroid use increases the likelihood of vertebral compression fracture, she continued.

Dr. Yanni said that she turns to appropriate-use guidelines from the American College of Radiology to select the most cost-effective imaging modality in patients with acute low back pain who fall into the "another specific spinal cause" category Am. Coll. Radiol. 2009;6:401-7).

For patients with cauda equina syndrome, the ACR report recommends MRI without contrast, with an estimated cost of $1,642 based on data from a large nonprofit health care system. For patients suspected of having cancer or vertebral infection, MRI with and without contrast is recommended as the most appropriate study, at a cost of $2,052. And for patients with a suspected osteoporotic vertebral compression fracture, the ACR appropriateness criteria give the nod to MRI without contrast. Dr. Yanni noted that this recommendation is at odds with the ACP/American Pain Society guideline, which recommends a lumbar spine x-ray as the imaging method of choice in suspected vertebral compression fractures.

EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE AMERICAN COLLEGE OF PHYSICIANS

She reported having no conflicts.
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Title Annotation:RHEUMATOLOGY
Author:Jancin, Bruce
Publication:Internal Medicine News
Date:Jun 15, 2012
Words:742
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