Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work

Lemmers, G.P.G.; Lankveld, Wim van; Westert, Gert P; Wees, Philip J. van der; Staal, J. Bart

doi:10.1007/s00586-019-05918-1

Cited by 67 publications

(51 citation statements)

References 71 publications

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“…Choosing Wisely, an initiative established by the American Board of Internal Medicine to avoid unnecessary medical interventions, recommends that spinal imaging should be avoided in patients with no clear indicators of serious pathology and a duration of less than 6 weeks [4]. In addition to the economic cost, inappropriate imaging may lead to patients ascribing their pain to incidental imaging findings, increasing the likelihood of seeking unnecessary interventions [5,6]. Failing to image when indicated may delay timely management of an underlying serious condition.…”

Section: Introductionmentioning

confidence: 99%

Defining and measuring imaging appropriateness in low back pain studies: a scoping review

et al. 2020

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Purpose Patients with low back pain (LBP) rarely have serious underlying pathology but frequently undergo inappropriate imaging. A range of guidelines and red flag features are utilised to characterise appropriate imaging. This scoping review explores how LBP imaging appropriateness is determined and calculated in studies of primary care practice. Methods This scoping review builds upon a previous meta-analysis, incorporating articles identified that were published since 2014, with an updated search to capture articles published since the original search. Electronic databases were searched, and citation lists of included papers were reviewed. Inclusion criteria were studies assessing adult LBP imaging appropriateness in a primary care setting. Twenty-three eligible studies were identified. Results A range of red flag features were utilised to determine imaging appropriateness. Most studies considered appropriateness in a binary manner, by the presence of any red flag feature. Ten guidelines were referenced, with 7/23 (30%) included studies amending or not referencing any guideline. The method for calculating the proportion of inappropriate imaging varied. Ten per cent of the studies used the total number of patients presenting with LBP as the denominator, suggesting most studies overestimated the rate of inappropriate imaging, and did not capture where imaging is not performed for clinically suspicious LBP. Conclusion Greater clarity is needed on how we define and measure imaging appropriateness for LBP, which also accounts for the problem of failing to image when indicated. An internationally agreed methodology for imaging appropriateness studies would ultimately lead to an improvement in the care delivered to patients. Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.Key points 1. Inappropriate imaging for low back pain (LBP) is common, and there are a range of guidelines available for determining imaging appropriateness.2. This study reviews the appropriateness criteria used in primary care studies, identifying broad variation in the criteria used.3. It identifies that many studies include red flags with poor predictive values for serious causes of LBP, and also highlights that studies using varying methods for calculating the proportion of inappropriate imaging.Yates M, Oliveira CB, Galloway JB, Maher CG (2019) Defining and measuring imaging appropriateness in low back pain studies: A scoping review. Eur Spine J; 0 5 10 15 20 Neurological impairment Urinary retenƟon or inconƟnence Fever Loss of anal sphincter tone/faecal inconƟnence Motor deficits Spinal malformaƟons Non mechanical pain Night pain Anaemia Sexual dysfuncƟon Response to NSAIDs Radiculopathy N Bar chart displaying relative frequencies of clinical features used as red flags for LBP imaging. Yates M, Oliveira CB, Galloway JB, Maher CG (2019) Defining and measuring imaging appropriateness in low back pain studies: A scoping review. Eur Spine J;Take Home Messages 1. There is much variation in red flags and method...

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Section: Introductionmentioning

confidence: 99%

Defining and measuring imaging appropriateness in low back pain studies: a scoping review

et al. 2020

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“…Research indicates that diagnostic imaging for LBP is associated with higher medical costs, increased healthcare utilization and more absence from work [49]. This tendency may partly be explained by the lack of knowledge about the normal age-related imaging findings of the spine.…”

Section: Implicationmentioning

confidence: 99%

An exploratory study of different definitions and thresholds for lumbar disc degeneration assessed by MRI and their associations with low back pain using data from a cohort study of a general population

Dragsbæk

Kjær

Hancock

et al. 2020

BMC Musculoskelet Disord

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Background: Lumbar disc degeneration seen on magnetic resonance imaging (MRI) is defined as loss of signal intensity and/or disc height, alone or in combination with other MRI findings. The MRI findings and thresholds used to define disc degeneration vary in the literature, and their associations with low back pain (LBP) remain uncertain. Objective: To explore how various thresholds of lumbar disc degeneration alter the association between disc degeneration and self-reported LBP. Methods: An exploratory, cross-sectional cohort study of a general population. Participants in the cohort 'Backs-on-Funen' had MRI scans and completed questionnaires about LBP at ages 41, 45 and 49 years. The MRI variables, signal intensity (Grades 0-3) and disc height (Grades 0-3), were dichotomised at different thresholds. Logistic regression analyses were used to determine associations. Arbitrarily, a difference in odds ratio (OR) of > 0.5 between thresholds was considered clinically relevant. Receiver Operating Characteristic curves were used to investigate differences between diagnostic values at each threshold. Results: At age 41, the difference in ORs between signal loss and LBP exceeded 0.5 between the thresholds of ≥2 (OR = 2.02) and = 3 (OR = 2.57). Difference in area under the curves (AUC) was statistically significant (p = 0.02). At ages 45 and 49, the difference in ORs exceeded 0.5 between the thresholds of ≥2 and = 3, but the differences between AUC were not statistically significant. At age 41, the difference in ORs between disc height loss and LBP at the thresholds of ≥1 (OR = 1.44) and ≥ 2 (OR = 2.53) exceeded 0.5. Differences in AUC were statistically significant (p = 0.004). At age 49, differences in ORs exceeded 0.5 (OR = 2.49 at the ≥1 threshold, 1.84 at ≥2 and 0.89 at =3). Differences between AUC were not statistically significant.

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“…It also imposes dollar charges to the patients. However, it can lower the days of suffering from undiagnosed disease (e.g., infections of spine or bone tumor) during the period of treatment [11,12]. In terms of pharmacologic therapies, the use of acetaminophen or nonsteroidal anti-inflammatory drugs, in conjunction with self-care are suggested.…”

Section: Introductionmentioning

confidence: 99%

Treatment of Patients with Low Back Pain: A Comparison of Physical Therapy and Chiropractic Manipulation

Khodakarami

2020

Healthcare

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Low back pain (LBP) is a pandemic and costly musculoskeletal condition in the United States (U.S.). Patients with LBP may endure surgery, injections, and expensive visits to emergency departments. Some suggest that using physical therapy (PT) or chiropractic in the earlier stage of LBP reduces the utilization of expensive health services and lowers the treatment costs. Given that there are costs and benefits with each of these treatments, the remaining question is in a short period of time which of these treatments is optimal. The purpose of this study was to investigate the cost-effectiveness of chiropractic versus PT in the U.S. A decision tree analytic model was used for estimating the economic outcomes. The findings showed that the total average cost in the chiropractic group was $48.56 lower than the PT group. The findings also showed that the daily adjusted life years (DALY) in the chiropractic group was 0.0043 higher than the PT group. Chiropractic care was shown to be a cost-effective alternative compared with PT for adults with at least three weeks of LBP over six months.

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Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work

Cited by 67 publications

References 71 publications

Defining and measuring imaging appropriateness in low back pain studies: a scoping review

Defining and measuring imaging appropriateness in low back pain studies: a scoping review

An exploratory study of different definitions and thresholds for lumbar disc degeneration assessed by MRI and their associations with low back pain using data from a cohort study of a general population

Treatment of Patients with Low Back Pain: A Comparison of Physical Therapy and Chiropractic Manipulation

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