The effect of restricting the indications for lumbosacral spine radiography in patients with acute back symptoms

Abstract

A prospective study was performed to evaluate the effect of using a special requisition form on the utilization of lumbosacral spine radiography for patients presenting in the emergency room with acute lower back complaints. Over a 1-year period, emergency room house officers were encouraged to complete a special form that listed only three acceptable indications for lumbosacral spine radiographs: history of trauma, evidence of focal neurologic abnormality, and "other." Neurologic abnormalities included hypesthesia, hyperesthesia or anesthesia of lumbar or sacral dermatomes, weakness or hyporeflexia of the lower extremities, and bladder or bowel incontinence. If the indication "other" was chosen, radiographs were done only if the form contained both a one- to two-sentence history and the signed approval of a supervising attending physician. The number and results of lumbosacral spine examinations were compared with those from the previous year, which served as a control. In the control year 1443 examinations were performed, and in the experimental year only 759 were done (a decrease of 47%). The percentage of patients with vertebral fractures increased from 5.1% to 5.8% in the experimental year if only the detection of new fractures was considered positive, and from 9.1% to 13.4% if the detection of fractures of all ages was regarded as significant. The use of the special requisition form appears to be a simple and effective means of reducing unnecessary lumbosacral radiography in the emergency room setting.

Effectiveness of interventions designed to reduce the use of imaging for low-back pain: a systematic review

“…The studies comprised 5 cluster RCTs 7,18-21 and 2 interrupted time series studies. 17,24 One trial was performed in a hospital setting 24 with the remainder in primary care. The interventions investigated in the studies were divided into 4 categories: clinical decision support and targeted reminders, 7,24 audit and feedback, 7,20,21 practitioner education 18,19 and postal guideline dissemination.…”

“…Two other studies 7,18 enrolled primary care clinics into the study and reported imaging expressed as rates (low-back imaging per 1000 patients seen); in these 2 studies, imaging rates were not confined to patients presenting with low-back pain. Three studies 17,21,24 reported imaging counts that were not confined to patients presenting with low-back pain; the total number of patients presenting for care was not reported.…”

“…19,20 The studies reporting on rates per 1000 patients presenting with any complaint 7,18 were considered to have outcome measures of uncertain reliability. Those reporting counts of imaging 17,21,24 were considered to have unreliable outcome measures.…”

“…7,24 The interrupted time series study by Baker and colleagues 24 for imaging. 24 Although time series regression analysis was not performed in the original study, we were able to conduct it with the data reported.…”

“…These include strategies targeted at the practitioner such as guideline dissemination, [15][16][17] education workshops, 18,19 audit and feedback of imaging use, 7,20,21 ongoing reminders 7 and clinical decision support. [22][23][24] It is unclear which, if any, of these strategies are effective. 25 We conducted a systematic review to investigate the effectiveness of interventions designed to reduce imaging rates for the management of low-back pain.…”