Low back pain: influence of early MR imaging or CT on treatment and outcome--multicenter randomized trial

MRI order appropriateness for chronic neck pain: Comparison of ordering practices and treatment outcomes for primary care physicians and specialists

Chronic neck pain is a common reason for doctor visits in the United States. This diagnosis can be evaluated through patient history, physical examination, and judicious use of radiographs. However, possible inappropriate magnetic resonance imaging (MRI) ordering persists. We hypothesized that no difference in ordering practices, ordering appropriateness, and subsequent intervention would be appreciated regarding physician specialty, location, patient characteristics, and history and physical exam findings. A multisite retrospective review of cervical spine MRI between 2014 and 2018 was performed. A total of 332 patients were included. Statistical analysis was used to assess MRI order appropriateness, detail of history and physical exam findings, and intervention decision-making among different specialties. If significant differences were found, multiple linear regression was performed to evaluate the association of MRI order appropriateness regarding physician specialty, location, patient characteristics and history, and physical exam findings. The significance level for all tests was set at <0.05 Orthopedic surgeons ordered MRIs most appropriately with an average American College of Radiology (ACR) score of 8.4 (p < 0.005). Orthopedic surgeons had more comprehensive physical exams as compared to the remaining specialties. The decision for intervention did not vary by physician specialty or ACR score, except for patients of pain medicine physicians who received pain management (p = 0.000). Orthopedic surgeons utilize MRI most appropriately and have more comprehensive physical exams. These findings suggest a need for increased physician education on what indicates an appropriate MRI order to improve the use of resources and further protect patient risk-benefit profiles. Further research elucidating factors to minimize negative findings in "appropriate" MRIs is indicated. Clinical significance: More detailed physical exams may lead to more appropriately ordered MRIs, subsequently resulting in surgery or procedures being performed when appropriately indicated. This suggests the need for increased physician education on when MRI ordering is appropriate for chronic neck pain to improve the use of resources and further protect patient risk-benefit profiles.

Emergency department use by people with back pain: An investigation

Background

Demand on emergency departments (EDs) is rising, at least in part due to patients with conditions suitable for management in primary care. Pain experienced in the back region is a common reason for patients to seek help and much of the established literature on back pain suggests serious pathologies are rare and the majority of patients can be safely treated in primary care. Emerging international data suggests that patients who present to ED complaining of back pain do not reflect those in primary care, with a higher rate of serious pathologies and non-spinal causes. This exploratory study seeks to quantify the prevalence of people attending ED with back pain, to describe their characteristics and the characteristics of their attendance.

Methods

This observational study is a retrospective analysis of patients attending EDs within an NHS Trust in the North East of England presenting with back pain from 1/10/2017 to 30/09/2018.

Results

Of 212,020 attendances, 3872 (2%) patients presented complaining of back pain on arrival. 36% of patients had no official diagnosis recorded, 5% were categorised as having a potentially serious spinal pathology, 22% had a non-spinal pathology diagnosis and 23% were categorised as simple backache. The majority (56%) had no recorded investigations, 19% received plain radiography, 5% received either CT/MRI, 18% had blood investigations and 17% had cardiac monitoring or electrocardiogram. Most individuals self-presented. NHS 111, primary care and community care referrals accounted for 24% of attendances.

Conclusion

Back pain was a relatively common ED attendance and represented a variety of conditions including non-spinal causes. This suggests that the population of patients with back pain attending ED are a different subgroup to those presenting to primary care. Care should be taken applying primary care guidance to this group and there may be a need for emergency care specific back pain guidelines.

Binary classification of non-specific low back pain condition based on the combination of B-mode ultrasound and shear wave elastography at multiple sites

Introduction: Low back pain (LBP) is a prevalent and complex condition that poses significant medical, social, and economic burdens worldwide. The accurate and timely assessment and diagnosis of LBP, particularly non-specific LBP (NSLBP), are crucial to developing effective interventions and treatments for LBP patients. In this study, we aimed to investigate the potential of combining B-mode ultrasound image features with shear wave elastography (SWE) features to improve the classification of NSLBP patients. Methods: We recruited 52 subjects with NSLBP from the University of Hong Kong-Shenzhen Hospital and collected B-mode ultrasound images and SWE data from multiple sites. The Visual Analogue Scale (VAS) was used as the ground truth to classify NSLBP patients. We extracted and selected features from the data and employed a support vector machine (SVM) model to classify NSLBP patients. The performance of the SVM model was evaluated using five-fold cross-validation and the accuracy, precision, and sensitivity were calculated. Results: We obtained an optimal feature set of 48 features, among which the SWE elasticity feature had the most significant contribution to the classification task. The SVM model achieved an accuracy, precision, and sensitivity of 0.85, 0.89, and 0.86, respectively, which were higher than the previously reported values of MRI. Discussion: In this study, we aimed to investigate the potential of combining B-mode ultrasound image features with shear wave elastography (SWE) features to improve the classification of non-specific low back pain (NSLBP) patients. Our results showed that combining B-mode ultrasound image features with SWE features and employing an SVM model can improve the automatic classification of NSLBP patients. Our findings also suggest that the SWE elasticity feature is a crucial factor in classifying NSLBP patients, and the proposed method can identify the important site and position of the muscle in the NSLBP classification task.

The Benefit of Epidural Transforaminal Injection of Ozone in Comparison With Transforaminal Steroids Injection in the Management of Chronic Low Back Pain in Lebanese Population: One-Year Retrospective Study

Background Chronic low back pain (CLBP) is one of the most common complaints affecting the population worldwide including in Lebanon. Until 15 years ago, surgery was the treatment of choice. However, conservative measures are now preferred because of the large number of post-surgical complications, in addition to the many conditions where surgery cannot be performed. Objective The aim of our study is to determine the effectiveness of transformational epidural injection of ozone (TFEOI) in the management of CLBP among the Lebanese population in the Nabatieh area in comparison with patients who received transformational epidural steroid injection (TFESI). Methods A one-year (2016-2017) retrospective study where 100 patients with CLBP were selected from two hospitals (Alnajdah, and Ragheb Harb hospitals) and divided into two groups. Fifty patients were treated with Ozone injections while the other 50 were treated with steroid injections. For each patient, we recorded the type of pain, irradiation, paresthesia, and the type of injection given (steroid or Ozone). We used the patients' files and contacted them via phone calls. The results of this study were reached based on Vas Score and Mac Nab criteria which are subjective questionnaires. Results The study showed that the TFESI was effective for a short duration (86% of results were excellent and good after one month of injection, but they decreased to 16% after six months). On the other hand, TFEOI was effective over both short and long duration (82% excellent and good after one month, 64% excellent and good after six months). Conclusion Results from this study provide that ozone injection has high benefits in the management of CLBP in the Lebanese population.

A Dysfunctional Descending Pain Modulation System in Chronic Nonspecific Low Back Pain: A Systematic Review and ALE Meta-Analysis

Pain, a physiological protective mechanism, turns into a complex dynamic neural response when it becomes chronic. The role of neuroplastic brain changes is more evident than the peripheral factors in the maintenance, modulation and amplification of chronic low back pain (cLBP). In this background, we summarise the brain changes in cLBP in a coordinate-based activation likelihood estimation (ALE) meta-analysis of previous functional magnetic resonance imaging (fMRI) studies. Databases ('PubMed', 'Scopus' and 'Sleuth') were searched till May 2022 and the activity pattern was noted under the 'without stimulation' and 'with stimulation' groups. A total of 312 studies were selected after removing duplicates. Seventeen (553 cLBP patients, 192 activation foci) studies were fulfilled the eligibility criteria and included in the 'without stimulation' group. Twelve statistically significant clusters are localized in the prefrontal cortex, primary somatosensory cortex, primary motor cortex, parietal cortex, anterior cingulate cortex, caudate, putamen, globus pallidus amygdala, occipital lobe, temporal lobe and associated white matter in this group. Ten studies (353 cLBP patients, 125 activation foci) were selected in the' with stimulation' groups. In this group, seven statistically significant clusters were found in the frontal cortex, orbitofrontal cortex, premotor cortex, parietal cortex, claustrum and insula. These statistically significant clusters indicate a probable imbalance in GABAergic modulation of brain circuits and dysfunction in the descending pain modulation system. This disparity in the pain neuro-matrix is the source of spontaneous and persisting pain in cLBP.

Physical Examination Is Predictive of Cauda Equina Syndrome: MRI to Rule Out Diagnosis Is Unnecessary

STUDY DESIGN

Cross-sectional cohort study.

OBJECTIVES

Cauda equina syndrome (CES) is a neurologic emergency, and delay in diagnosis can result in irreversible impairment. Our purpose was to determine the value of physical examination in diagnosis of CES in patients complaining of bladder and/or bowel complications in the emergency department.

METHODS

Adult patients at one tertiary academic medical center that endorsed bowel/bladder dysfunction, underwent a lumbar magnetic resonance imaging (MRI), and received an orthopedic spine surgery consultation from 2008 to 2017 were included. Patients consulted for trauma or tumor were excluded. A chart and imaging review was performed to collect demographic, physical examination, and treatment data. Sensitivity, specificity, and negative and positive predictive values were calculated, and fast-and-frugal decision trees (FFTs) were generated using R.

RESULTS

Of 142 eligible patients, 10 were diagnosed with CES. The sensitivity and specificity of the exam findings were highest for bulbocavernosus reflex (BCR) (100% and 100%), followed by rectal tone (80% and 86%), postvoid residual bladder (80% and 59%), and perianal sensation (60% and 68%). The positive predictive value was high for BCR (100%), but low for other findings (13% to 31%). However, negative predictive values were consistently high for all examinations (96% to 100%). Two FFTs utilizing combinations of voluntary rectal tone, perianal sensation, and BCR resulted in no false negatives.

CONCLUSIONS

A combination of physical examination findings of lower sacral function is an effective means of ruling out CES and, with further study, may eliminate the need for MRI in many patients reporting back pain and bowel or bladder dysfunction.

Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition

BACKGROUND

The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine.

METHODS

The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members.

RESULTS

Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature.

CONCLUSIONS

The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.

Low back pain: Influence of early MR imaging or CT on treatment and outcome - a randomized controlled study protocol

OBJECTIVE

To establish whether early use of magnetic resonance imaging (MRI) or computed tomography (CT) influences treatment and outcome of patients with low back pain.

METHODS

This study will be implemented from March 2021 to March 2022 at Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University. The experiment was granted through the Research Ethics Committee of Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University (R609320987). Patients who have symptomatic lumbar spine disorders at presentation are eligible for the trial if there is clinical uncertainty about the need for imaging (MRI or CT). Patients are excluded who required immediate referral for imaging (those who had signs suggestive of serious abnormalities or disease or who required surgical intervention), who have undergone MR imaging or CT of the spine within 1 year, who do not need imaging, and who have pain of a nonspinal origin. The primary outcome measure is the Aberdeen Low Back Pain (ALBP) score. Other principal outcome measure is the Short Form 36.

RESULTS

Table 1 will show the quality of life outcome measures between groups.

CONCLUSION

This study may guide the policy makers to develop an evidence-based protocol to assess the effect of early use of MRI or CT in the treatment of patients with low back pain.

The Outcome of Epidural Injections in Lumbar Radiculopathy Is Not Dependent on the Presence of Disc Herniation on Magnetic Resonance Imaging: Assessment of Short-Term and Long-Term Efficacy

OBJECTIVE

Lumbar radiculopathy is a condition with major physical, social, and economic consequences. Despite its favorable prognosis, the burden can be significant. In this study, we aimed to determine the value of magnetic resonance imaging (MRI) and the efficacy of transforaminal epidural injections (TEIs) in patients with lumbar radiculopathy secondary to lumbar disc herniation (LDH) and other causes (non-LDH).

METHODS

Patients with lumbar radiculopathy were reviewed for radiologic diagnosis based on MRI. For patients receiving TEI therapy, response after 6-8 weeks (short-term) and 16 weeks (long-term), number of injections, subsequent surgery, and patient outcome were evaluated. Treatment response was assessed by patient-reported symptom relief and numeric rating scale pain scores.

RESULTS

Overall, 66% of MRI examinations showed a clinically relevant LDH. A total of 486 of 1824 patients received TEI, of whom one third did not show LDH. Of patients, 70% reported a short-term effect with significant pain reduction and 44% reported a long-term effect. No significant differences were observed between the LDH and non-LDH groups. Of patients, 59% required multiple injections and reported similar efficacy compared with patients treated with a single injection.

CONCLUSIONS

A considerable part of MRI examinations in patients with lumbar radiculopathy do not show a clinically relevant LDH. Regardless of the radiologic diagnosis, most patients treated with TEI benefit in both the short-term and the long-term after a single-injection or multiple-injection regime. Subsequent injections are advisable if the effect from the first injection is unsatisfactory or wears off. MRI examination before TEI therapy may be redundant, which allows for expedition of this treatment.

Observational Study of the Downstream Consequences of Inappropriate MRI of the Lumbar Spine

BACKGROUND

Contrary to guidelines, magnetic resonance imaging (MRI) is often ordered in the first 6 weeks of new episodes of uncomplicated non-specific low back pain.

OBJECTIVE

To determine the downstream consequences of early imaging.

DESIGN

Retrospective matched cohort study using data from electronic health records of primary care clinics of the U.S. Department of Veterans Affairs.

PARTICIPANTS

Patients seeking primary care for non-specific low back pain without a red flag condition or an encounter for low back pain in the prior 6 months (N = 405,965).

EXPOSURE

MRI of the lumbar spine within 6 weeks of the initial primary care visit.

MAIN MEASURES

Covariates included patient demographics, health history in the prior year, and baseline pain. Outcomes were lumbar surgery, prescription opioid use, acute health care costs, and last pain score recorded within 1 year of the index visit.

KEY RESULTS

Early MRI was associated with more back surgery (1.48% vs. 0.12% in episodes without early MRI), greater use of prescription opioids (35.1% vs. 28.6%), a higher final pain score (3.99 vs. 3.87), and greater acute care costs ($8082 vs. $5560), p < 0.001 for all comparisons.

LIMITATIONS

Reliance on data gathered in normal clinical care and the potential for residual confounding despite the use of coarsened exact matching weights to adjust for baseline differences.

CONCLUSIONS

The association between early imaging and increased utilization was apparent even in a setting largely unaffected by incentives of fee-for-service care. Reduced imaging cost is only part of the motivation to improve adherence with guidelines for the use of MRI. Early scans are associated with excess surgery, higher costs for other care, and worse outcomes, including potential harms from prescription opioids.

Neurosurgical Evaluation for Patients with Chronic Lower Back Pain

PURPOSE OF REVIEW

Chronic low back pain (CLBP) is a major cause of disability in the USA, and it affects approximately 1 in 4 Americans. CLBP patients are commonly referred to or seek out neurosurgical evaluations and opinions for treatment and management.

RECENT FINDINGS

Literature shows that only a minority of patients with CLBP may benefit from a surgical procedure. These patients that present to clinic often have been ailing for a considerable amount of time and are eager for effective treatment to alleviate pain. However, determining if a patient with CLBP is a surgical candidate is predicated upon having no success of pain relief with non-operative management. Patients with CLBP require thorough and adequate imaging, clinical exam, and diagnostic evaluation. When adequate non-operative management was provided, and proven fruitless, the patient may be considered an operative candidate. In this manuscript, a framework is presented for workup and evaluation of patients with CLBP.

Role of Ultrasound in Low Back Pain: A Review

Low back pain is one of most common musculoskeletal disorders around the world. One major problem clinicians face is the lack of objective assessment modalities. Computed tomography and magnetic resonance imaging are commonly utilized but are unable to clearly distinguish patients with low back pain from healthy patients with respect to abnormalities. The reason may be the anisotropic nature of muscles, which is altered in function, and the scans provide only structural assessment. In view of this, ultrasound may be helpful in understanding the disease as it is performed in real-time and comprises different modes that measure thickness, blood flow and stiffness. By the use of ultrasound, patients with low back pain have been found to differ from healthy patients with respect to the thickness and stiffness of the transversus abdominis, thoracolumbar fascia and multifidus. The study results are currently still not conclusive, and further study is necessary to validate. Future work should focus on quantitative assessment of these tissues to provide textural, structural, hemodynamic and mechanical studies of low back pain. This review highlights the current understanding of how medical ultrasound has been used for diagnosis and study of low back pain and discusses potential new applications.

[Nonspecific low back pain and chronification]

Low back pain is the leading cause of incapacitation and medical rehabilitation. The purpose of this German National Health Care Guideline "Nonspecific low back pain" is to optimize the care of patients with low back pain. This guideline was drawn up by 29 professional societies and organizations. In the case of nonspecific low back pain, a detailed medical history and physical examination should be carried out first, but no further diagnostics unless there are indications of the so-called "red flags". For symptomatic treatment, medicine should be given in low doses, and physical activity should be in the foreground. A physician should act as a point of contact throughout the course of the disease, and the patient must be continuously educated and motivated to have a healthy lifestyle, including regular physical activity.

Lumbosacral Spinal Imaging for Patients Presenting to the Emergency Department With Nontraumatic Low Back Pain

BACKGROUND

Choosing Wisely Canada (CWC) guidelines recommend that in the absence of clinical indicators suggestive of serious underlying pathology, physicians should not order radiological imaging for patients presenting with nonspecific low back pain (LBP).

OBJECTIVE

Our aim was to determine how many patients presenting to the emergency department (ED) with nontraumatic LBP had spinal imaging before and after the release of the CWC guideline.

METHODS

We conducted a retrospective medical record review for patients aged 18-70 years presenting to an academic tertiary care ED with nontraumatic LBP from April 1, 2014 to March 31, 2015 (pre-guideline) and April 1, 2017 to March 31, 2018 (post-guideline).

RESULTS

One-thousand and sixty (545 pre-guideline, 515 post-guideline) patients were included. Pre-guideline, 45 patients (8.3%) had spinal imaging compared to 39 (7.6%) post-guideline (Δ 0.7%; 95% confidence interval [CI] -2.6% to 4.0%). Of the 84 patients (7.9%) who had spinal imaging, 4 (8.9%) had pathologic findings pre-guideline compared to 11 patients (28.2%) post-guideline (Δ 19.3%; 95% CI 2.7% to 35.8%).

CONCLUSIONS

CWC guidelines did not appear to alter the rate of imaging for patients presenting to the ED with nontraumatic LBP. Future clinical recommendations should consider active knowledge dissemination and education strategies to help facilitate guideline adoption.

VA/DoD Clinical Practice Guideline: Diagnosis and Treatment of Low Back Pain

DESCRIPTION

In September 2017, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved the joint Clinical Practice Guideline (CPG) for Diagnosis and Management of Low Back Pain. This CPG was intended to provide healthcare providers a framework by which to evaluate, treat, and manage patients with low back pain (LBP).

METHODS

The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through September 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. A patient focus group was also convened to ensure patient values and perspectives were considered when formulating preferences and shared decision making in the guideline.

RECOMMENDATIONS

The VA/DOD LBP CPG provides evidence-based recommendations for the diagnostic approach, education and self-care, non-pharmacologic and non-invasive therapy, pharmacologic therapy, dietary supplements, non-surgical invasive therapy, and team approach to treatment of low back pain.

The utility of magnetic resonance imaging results in physician decision-making before initial lumbar spinal injection

BACKGROUND CONTEXT

The need for advanced imaging before spinal intervention is an area of ongoing debate. Many studies have demonstrated the accuracy of magnetic resonance imaging (MRI) results in evaluating structural pathology in the lumbar spine, but few have addressed how frequently MRI findings change clinical management. A randomized controlled trial showed that viewing MRI results did not impact outcomes in patients with radiculopathy undergoing epidural steroid injection (ESI). The results suggested ESIs that correlated with both imaging and clinical findings experienced slightly more benefit than the blinded cohort, although statistically insignificantly.

PURPOSE

Three related studies were conducted to (1) increase understanding of the opinions of interventional spine physicians regarding the utility of viewing imaging before injection and (2) evaluate the impact of viewing MRI results on injection planning (retrospective and prospective analyses).

STUDY DESIGN

Survey, prospective, and retrospective analysis.

PATIENT SAMPLE

Patients presenting to a university-based spine center for initial evaluation of back or leg pain who were candidates for spinal intervention.

OUTCOME MEASURES

Self-reported measures from a clinical practice questionnaire distributed to interventional spine physicians to determine rates and rationale for utilization of MRI before spine injection, physiologic measures including MRI results, functional measures including physician decision-making regarding type and location of injection performed.

METHODS

This study was funded by the University of Colorado Health and Welfare Trust. A survey was sent to interventional spine physicians to assess their utilization of MRI results before spine procedures. A retrospective analysis of patients who were candidates for ESI was conducted to evaluate how initial injection plan compared with the postviewing of MRI results on injection performed. In a prospective analysis, injection plans pre- and post-MRI were compared among patients presenting for initial evaluation of low back or leg pain.

RESULTS

Survey responses showed that specialists order MRI studies to correlate with physical exam (91%) and to detect the presence of synovial cysts (68%), whereas tumor/infection (93%) was most likely to cause a change in their approach. In the retrospective review, the physician's planned approach before viewing the MRI was concordant with the actual procedure 49% of the time. A different type of procedure was performed in 15% of planned injections. In such cases, the initial treatment plan was altered (ie, same procedure at a different or additional level or side) in 35% of planned injections. In the prospective data collection, 43% of injections were different from the initial physician decision. The most common reasons for altering the injection was different level affected (36%), facet pathology (22%), and different nerve root affected (16%).

CONCLUSIONS

In clinical practice, MRI before injection frequently changes management decisions in the planning and delivery of lumbar spine injections.

Analyzing inappropriate magnetic resonance imaging (MRI) prescriptions and resulting economic burden on patients suffering from back pain

INTRODUCTION

Back pain is a common global disorder and magnetic resonance imaging (MRI) is one method of assessing its cause. The lack of official and general clinical guidelines is the cause of inadequate supervision of lumbar MRI prescriptions. The goal of this research was to analyze inappropriate lumbar MRI prescriptions and the resulting economic burden on individuals.

METHOD

This is a descriptive-analytical study carried out on a sample of 614 patients who visited four hospitals in Tehran. The appropriateness or inappropriateness of the MRI prescriptions was determined using clinical guidelines and a questionnaire based on previous studies. The economic burden created by inappropriate prescriptions for MRIs was determined after calculating the total direct and indirect costs.

FINDINGS

The total MRI prescription cost paid by the study sample was $26 071, and the cost of inappropriate prescriptions was $10 310. The MRI prescription rate had a significant relationship with gender, age, education, employment, primary insurance type, and supplemental health insurance.

CONCLUSION

The research findings revealed relatively high rates of inappropriate MRI prescriptions in the private and public sectors. Hence, policymakers should design, create, and develop clinical guidelines and enforce the policies and rules to decrease inappropriate MRI prescriptions.

Utility of repeat magnetic resonance imaging in surgical patients with lumbar stenosis without disc herniation

BACKGROUND CONTEXT

Routine use of magnetic resonance imaging (MRI) as a diagnostic tool in lumbar stenosis is becoming more prevalent due to the aging population. Currently, there is no clinical guideline to clarify the utility of repeat MRI in patients with lumbar stenosis, without instability, neurological deficits, or disc herniation.

PURPOSE

To evaluate the utility of routine use of MRI as a diagnostic tool in lumbar stenosis, and to help formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis.

STUDY DESIGN/SETTING

Retrospective radiographic analysis.

PATIENT SAMPLE

Retrospective chart review was performed to review patients with lumbar stenosis, who underwent lumbar decompression without fusion from 2011 to 2015 at a single institution.

OUTCOME MEASURES

Previously established stenosis grading systems were used to measure and compare the initial and the subsequent repeat lumbar MRIs performed preoperatively. If patients were found to have a moderate or severe grade change, and if the surgical plan was altered due to such exacerbated radiographic findings, then their grade changes were considered clinically meaningful.

METHODS

We identified patients with lumbar stenosis without radiographic instability or neurological deficits, who had at least two preoperative lumbar MRIs performed and underwent decompressive surgeries. At each pathologic disc level, the absolute value of the change in grade for central and lateral recess stenosis, right foraminal stenosis, and left foraminal stenosis from the first preoperative MRI to the repeated MRI was calculated. These changed data were then used to calculate the mean and median changes in each of the three types of stenosis for each pathologic disc level. Identical calculations were carried out for the subsample of patients who only underwent discectomy or had a discectomy included as part of their surgery.

RESULTS

Among the 103 patients who met the inclusion criteria, 37 of those patients had more than one level surgically addressed, and a total of 161 lumbar levels were reviewed. Among the subset of patients that had any grade change, the majority of the grades only had a mild change of 1 (36 out of 42 patients, 85.7%, 95% confidence interval [CI]: 73.1%-94.1%); there was a moderate grade change of 2 in two patients (4.8%, CI: 0.8%-14.0%), and a severe change of 3 in one patient (2.4%, CI: 0.2%-10.1%). There were three patients with decreased grade change (7.1%, CI: 1.8%-17.5%). All clinically meaningful grade changes were from the subset of patients who had only discectomy or discectomy as part of the procedure. Lastly, both patients that had a clinically meaningful grade change had their MRIs performed at an interval of greater than 360 days.

CONCLUSIONS

The radiographic evaluation of the utility of routinely repeated MRIs in lumbar stenosis without instability, neurological deficits, or disc herniations demonstrated that there were no significant changes found in the repeated MRI in the preoperative setting, especially if the MRIs were performed less than one year apart. The results of this present study can help to standardize the diagnostic evaluation of lumbar stenosis and to formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis patients.

Effectiveness of lumbar orthoses in low back pain: Review of the literature and our results

Back pain and diseases of the spine are today a health disorder of outstanding epidemiological, medical, and health economic importance. The cost of care for patients with lumbosciatic complaints are steadily increasing. Accordingly, the guidelines and treatments are constantly renewed. One concept is the orthotic care. In the following we want to give an overview of the literature and the effectiveness of lumbar orthoses in low back pain supplemented by our own data. A prospective randomized study with 230 patients, divided into three groups, each with two subgroups. Three Orthoses by the TIGGES-Zours GmbH were prescribed; a demountable two-step lumbar orthosis, three-step bridging orthosis and a four-step flexion orthosis modular system. Each were compared to the nonmodular equivalent. All six groups showed improvement in pain intensity and functional capacity at 6 and 12 weeks. The modular groups were found to have improvement in the frequency of use. The subjective effectiveness and sensitivity for the modular and non-modular groups was assessed as being good. In the literature, there are no clear guidelines for an orthotic supply. The studies do not seem to be meaningful and universal due to the difficult ascertainability of pain. There is a need for further research here. Nevertheless, the authors of this review are of the opinion that the implementation of trunk orthoses is void of side effects and beneficial to patients. The modular systems seem to have an advantage as well as higher patient satisfaction.

Temporal trends in use of tests in UK primary care, 2000-15: retrospective analysis of 250 million tests

OBJECTIVES

To assess the temporal change in test use in UK primary care and to identify tests with the greatest increase in use.

DESIGN

Retrospective cohort study.

SETTING

UK primary care.

PARTICIPANTS

All patients registered to UK General Practices in the Clinical Practice Research Datalink, 2000/1 to 2015/16.

MAIN OUTCOME MEASURES

Temporal trends in test use, and crude and age and sex standardised rates of total test use and of 44 specific tests.

RESULTS

262 974 099 tests were analysed over 71 436 331 person years. Age and sex adjusted use increased by 8.5% annually (95% confidence interval 7.6% to 9.4%); from 14 869 tests per 10 000 person years in 2000/1 to 49 267 in 2015/16, a 3.3-fold increase. Patients in 2015/16 had on average five tests per year, compared with 1.5 in 2000/1. Test use also increased statistically significantly across all age groups, in both sexes, across all test types (laboratory, imaging, and miscellaneous), and 40 of the 44 tests that were studied specifically.

CONCLUSION

Total test use has increased markedly over time, in both sexes, and across all age groups, test types (laboratory, imaging, and miscellaneous) and for 40 of 44 tests specifically studied. Of the patients who underwent at least one test annually, the proportion who had more than one test increased significantly over time.

Prevalence and Correlates of Low Pain Interference Among Patients With High Pain Intensity Who Are Prescribed Long-Term Opioid Therapy

The pain experience may vary greatly among individuals reporting equally high levels of pain. We sought to examine the demographic and clinical characteristics associated with pain interference in patients with high pain intensity. Among patients with chronic musculoskeletal pain who were prescribed long-term opioid therapy and who were recruited from 2 health care systems, we identified a subset who reported high pain intensity (n = 189). All individuals completed self-report assessments of clinical and demographic factors. Analyses examined characteristics associated with pain interference. Within this group of patients with high reported pain intensity, 16.4% (n = 31) had low pain interference, 39.2% (n = 74) had moderate pain interference, and 44.4% (n = 84) had high pain interference. In bivariate analyses, patients with lower pain interference had fewer symptoms of depression and anxiety, less pain catastrophizing, a better quality of life, and greater self-efficacy for managing pain. In multivariate analyses, variables most strongly associated with low pain interference, relative to high interference, were depression severity (odds ratio 0.90; 95% confidence interval 0.82-0.99) and pain self-efficacy (odds ratio 1.07; 95% confidence interval 1.02-1.12). Study results suggest that chronic pain treatments that address symptoms of depression and enhance pain self-efficacy may be prioritized, particularly among patients who are prescribed long-term opioid therapy.

PERSPECTIVE

This article describes the prevalence and correlates of pain interference categories (low, medium, and high) among patients with high pain intensity who are prescribed long-term opioid therapy. Findings reveal that 16.4% of participants with high pain intensity had low impairment. Multivariate analyses indicate that variables significantly associated with low pain interference were lower depression scores and greater pain self-efficacy.

Non-Specific Low Back Pain

BACKGROUND

For many years, low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. The goal of the German Disease Management Guideline (NDMG) on nonspecific low back pain is to improve the treatment of patients with this condition.

METHODS

The current update of the NDMG on non-specific low back pain is based on articles retrieved by a systematic search of the literature for systematic reviews. Its recommendations for diagnosis and treatment were developed by a collaborative effort of 29 scientific medical societies and organizations and approved in a formal consensus process.

RESULTS

If the history and physical examination do not arouse any suspicion of a dangerous underlying cause, no further diagnostic evaluation is indicated for the time being. Passive, reactive measures should be taken only in combination with activating measures, or not at all. When drugs are used for symptomatic treatment, patients should be treated with the most suitable drug in the lowest possible dose and for as short a time as possible.

CONCLUSION

A physician should be in charge of the overall care process. The patient should be kept well informed over the entire course of his or her illness and should be encouraged to adopt a healthful lifestyle, including regular physical exercise.

Treatment for chronic low back pain: the focus should change to multimodal management that reflects the underlying pain mechanisms

Chronic low back pain: Chronic pain is the most common cause for people to utilize healthcare resources and has a considerable impact upon patients' lives. The most prevalent chronic pain condition is chronic low back pain (CLBP). CLBP may be nociceptive or neuropathic, or may incorporate both components. The presence of a neuropathic component is associated with more intense pain of longer duration, and a higher prevalence of co-morbidities. However, many physicians' knowledge of chronic pain mechanisms is currently limited and there are no universally accepted treatment guidelines, so the condition is not particularly well managed.

DIAGNOSIS

Diagnosis should begin with a focused medical history and physical examination, to exclude serious spinal pathology that may require evaluation by an appropriate specialist. Most patients have non-specific CLBP, which cannot be attributed to a particular cause. It is important to try and establish whether a neuropathic component is present, by combining the findings of physical and neurological examinations with the patient's history. This may prove difficult, however, even when using screening instruments. Multimodal management: The multifactorial nature of CLBP indicates that the most logical treatment approach is multimodal: i.e. integrated multidisciplinary therapy with co-ordinated somatic and psychotherapeutic elements. As both nociceptive and neuropathic components may be present, combining analgesic agents with different mechanisms of action is a rational treatment modality. Individually tailored combination therapy can improve analgesia whilst reducing the doses of constituent agents, thereby lessening the incidence of side effects.

CONCLUSIONS

This paper outlines the development of CLBP and the underlying mechanisms involved, as well as providing information on diagnosis and the use of a wide range of pharmaceutical agents in managing the condition (including NSAIDs, COX-2 inhibitors, tricyclic antidepressants, opioids and anticonvulsants), supplemented by appropriate non-pharmacological measures such as exercise programs, manual therapies, behavioral therapies, interventional pain management and traction. Surgery may be appropriate in carefully selected patients.

Back Pain in Children- How Sinister?

Incidence of back pain among children and adolescents is gradually increasing. Children undergo extensive diagnostic workup that ultimately results in a nonconfirmative diagnosis. A good history and clinical examination can, to a large extent help differentiate non-specific from organic causes of backache. Diagnostic workup may be initiated if symptoms are severe and/or persistant. The authors review some of the common causes of back pain in pediatric population, clinical presentations, and the relevant investigations along with their management.

The Impact of Socioeconomic Status on the Utilization of Spinal Imaging

BACKGROUND

Few studies have examined the general correlation between socioeconomic status and imaging. This study is the first to analyze this relationship in the spine patient population.

OBJECTIVE

To assess the effect of socioeconomic status on the frequency with which imaging studies of the lumbar spine are ordered and completed.

METHODS

Patients that were diagnosed with lumbar radiculopathy and/or myelopathy and had at least 1 subsequent lumbar magnetic resonance imaging (MRI), computed tomography (CT), or X-ray ordered were retrospectively identified. Demographic information and the number of ordered and completed imaging studies were among the data collected. Patient insurance status and income level (estimated based on zip code) served as representations of socioeconomic status.

RESULTS

A total of 24,105 patients met the inclusion criteria for this study. Regression analyses demonstrated that uninsured patients were significantly less likely to have an MRI, CT, or X-ray study ordered (P < .001 for all modalities) and completed (P < .001 for MRI and X-ray, P = .03 for CT). Patients with lower income had higher rates of MRI, CT, and X-ray (P < .001 for all) imaging ordered but were less likely to have an ordered X-ray be completed (P = .009). There was no significant difference in the completion rate of ordered MRIs or CTs.

CONCLUSION

Disparities in image utilization based on socioeconomic characteristics such as insurance status and income level highlight a critical gap in access to health care. Physicians should work to mitigate the influence of such factors when deciding whether to order imaging studies, especially in light of the ongoing shift in health policy in the United States.

Generic Preference-based Measures for Low Back Pain: Which of Them Should Be Used?

STUDY DESIGN

Systematic review.

OBJECTIVE

This systematic review examines validity and responsiveness of three generic preference-based measures in patients with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

LBP is a very common incapacitating disease with a significant impact on health-related quality of life (HRQoL). Health state utility values can be derived from various preference-based HRQoL instruments, and among them the most widely ones are EuroQol 5 dimensions (EQ-5D), Short Form 6 Dimensions (SF-6D), and Health Utilities Index 3 (HUI III). The ability of these instruments to reflect HRQoL has been tested in various contexts, but never for LBP populations.

METHODS

A systematic search on electronic literature databases was undertaken to identify studies of patients with LBP where health state utility values were reported. Records were screened using a set of predefined eligibility criteria. Data on validity (correlations and known group methods) and responsiveness (effect sizes, standardized response means, tests of statistical significance) of instruments were extracted using a customized extraction template, and assessed using predefined criteria.

RESULTS

There were substantial variations in the 37 included papers identified in relation to study design and outcome measures used. EQ-5D demonstrated good convergent validity, as it was able to distinguish between known groups. EQ-5D was also able to capture changes of health states as results of different interventions. Evidence for SF-6D and HUI III was limited to allow an appropriate evaluation.

CONCLUSION

EQ-5D performs well in LBP population and its scores seem to be suitable for economic evaluation of LBP interventions. However, the paucity of information on the other instruments makes it impossible to determine its relative validity and responsiveness compared with them.

Low-back pain at the emergency department: still not being managed?

Background

Low-back pain (LBP) affects about 40% of people at some point in their lives. In the presence of “red flags”, further tests must be done to rule out underlying problems; however, biomedical imaging is currently overused. LBP involves large in-hospital and out-of-hospital economic costs, and it is also the most common musculoskeletal disorder seen in emergency departments (EDs).

Patients and methods

This retrospective observational study enrolled 1,298 patients admitted to the ED, including all International Classification of Diseases 10 diagnosis codes for sciatica, lumbosciatica, and lumbago. We collected patients’ demographic data, medical history, lab workup and imaging performed at the ED, drugs administered at the ED, ED length of stay (LOS), numeric rating scale pain score, admission to ward, and ward LOS data. Thereafter, we performed a cost analysis.

Results

Mean numeric rating scale scores were higher than 7/10. Home medication consisted of no drug consumption in up to 90% of patients. Oxycodone–naloxone was the strong opioid most frequently prescribed for the home. Once at the ED, nonsteroidal anti-inflammatory drugs and opiates were administered to up to 72% and 42% of patients, respectively. Imaging was performed in up to 56% of patients. Mean ED LOS was 4 hours, 14 minutes. A total of 43 patients were admitted to a ward. The expense for each non-ward-admitted patient was approximately €200 in the ED, while the mean expense for ward-admitted patients was €9,500, with a mean LOS of 15 days.

Conclusion

There is not yet a defined therapeutic care process for the patient with LBP with clear criteria for an ED visit. It is to this end that we need a clinical pathway for the prehospital management of LBP syndrome and consequently for an in-hospital time-saving therapeutic approach to the patient.

Variation among Primary Care Physicians in the Use of Imaging for Older Patients with Acute Low Back Pain

BACKGROUND

Diagnostic imaging is not recommended in the evaluation and management of non-specific acute low back pain.

OBJECTIVE

To estimate the variation among primary care providers (PCPs) in the use of diagnostic imaging for older patients with non-specific acute low back pain.

DESIGN AND PARTICIPANTS

Retrospective cohort study using 100 % Texas Medicare claims data. We identified 145,320 patients aged 66 years and older with non-specific acute low back pain during the period January 1, 2007, through November 30, 2011, cared for by 3297 PCPs.

MAIN MEASURES

We tracked whether each patient received lumbar imaging (radiography, computed tomography [CT], or magnetic resonance imaging [MRI]) within 4 weeks of the initial visit. Multilevel logistic regression models were used to estimate physician-level variation in imaging use.

KEY RESULTS

Among patients, 27.2 % received radiography and 11.1 % received CT or MRI within 4 weeks of the initial visit for low back pain. PCPs varied substantially in the use of imaging. The average rate of radiography within 4 weeks was 53.9 % for PCPs in the highest decile, compared to 6.1 % for PCPs in the lowest decile. The average rates of CT/MRI within 4 weeks were 18.5 % vs. 3.2 % for PCPs in the highest and lowest deciles, respectively. The specific physician seen by a patient accounted for 25 % of the variability in whether imaging was performed, while only 0.44 % of the variance was due to measured patient characteristics and 1.4 % to known physician characteristics. Use of imaging by individual physicians was stable over time.

CONCLUSIONS

PCPs vary substantially in the use of imaging for non-specific acute low back pain. Provider-level measures can be employed to provide feedback to physicians in an effort to modify imaging use.

Measuring Health Utilities in Children and Adolescents: A Systematic Review of the Literature

Background

The objective of this review was to evaluate the use of all direct and indirect methods used to estimate health utilities in both children and adolescents. Utilities measured pre- and post-intervention are combined with the time over which health states are experienced to calculate quality-adjusted life years (QALYs). Cost-utility analyses (CUAs) estimate the cost-effectiveness of health technologies based on their costs and benefits using QALYs as a measure of benefit. The accurate measurement of QALYs is dependent on using appropriate methods to elicit health utilities.

Objective

We sought studies that measured health utilities directly from patients or their proxies. We did not exclude those studies that also included adults in the analysis, but excluded those studies focused only on adults.

Methods and Findings

We evaluated 90 studies from a total of 1,780 selected from the databases. 47 (52%) studies were CUAs incorporated into randomised clinical trials; 23 (26%) were health-state utility assessments; 8 (9%) validated methods and 12 (13%) compared existing or new methods. 22 unique direct or indirect calculation methods were used a total of 137 times. Direct calculation through standard gamble, time trade-off and visual analogue scale was used 32 times. The EuroQol EQ-5D was the most frequently-used single method, selected for 41 studies. 15 of the methods used were generic methods and the remaining 7 were disease-specific. 48 of the 90 studies (53%) used some form of proxy, with 26 (29%) using proxies exclusively to estimate health utilities.

Conclusions

Several child- and adolescent-specific methods are still being developed and validated, leaving many studies using methods that have not been designed or validated for use in children or adolescents. Several studies failed to justify using proxy respondents rather than administering the methods directly to the patients. Only two studies examined missing responses to the methods administered with respect to the patients’ ages.

Prevention of occupational Back Pain

This paper reviews scientific research on occupational back pain and focuses on prevention of this problem. It discusses some of the challenges of translating the evidence of this multi-factorial condition into policy. Medical science is currently unable to clearly distinguish between back pain caused by work and that possibly due to other causes but which affects the individual's capacity to work. Back pain affects the vast majority of people at some point in their lives and is very costly to both the health care system and the industry. Evidence suggests that heavy lifting, driving, and vibration of the whole body are linked to occupational back pain. Once the risk factors for occupational back pain are identified, an otherwise chronic and disabling condition can be prevented in the majority of patients. As explained in this article, three levels of prevention for occupational back pain have been reported as effective. Failure to implement preventive measures may lead to a high incidence of occupational back pain.

Should routine MRI of the lumbar spine be required prior to lumbar epidural steroid injection for sciatica pain?

Background:

We describe three patients who received lumbar epidural steroid injections (LESI) for lumbosacral radicular pain that resulted in worsening of their symptoms. The procedures were performed following a review of remote diagnostic imaging studies. These cases demonstrate the lack of consensus in pain management domains for how to approach the workup and treatment of persistent/chronic low back pain, with a noted fragmentation in pain management strategies and applied therapies.

Case Description:

We present three patients; two female patients (37 and 38 years old) undergoing LESI for remotely diagnosed disc herniations, and one 61-year-old male receiving an LESI for a presumed, unverified lumbar intervertebral disc disorder. Following a worsening of symptoms after LESI, neurosurgical consultations ultimately determined the presence of, respectively, an epidural hematoma, a neurilemoma, and a lung cancer metastasis to the sacrum as the source of symptoms, instead of being due to the intervertebral disc pathology.

Conclusions:

We would like to emphasize several principles in the diagnosis and use of imaging of the lumbosacral region prior to undertaking invasive neuraxial procedures.

Impact of IT-enabled intervention on MRI use for back pain

BACKGROUND

The purpose of this study was to examine the impact of a multifaceted, clinical decision support (CDS)-enabled intervention on magnetic resonance imaging (MRI) use in adult primary care patients with low back pain.

METHODS

After a baseline observation period, we implemented a CDS targeting lumbar-spine MRI use in primary care patients with low back pain through our computerized physician order entry, as well as 2 accountability tools: mandatory peer-to-peer consultation when test utility was uncertain and quarterly practice pattern variation reports to providers. Our primary outcome measure was rate of lumbar-spine MRI use. Secondary measures included utilization of MRI of any body part, comparing it with that of a concurrent national comparison, as well as proportion of lumbar-spine MRI performed in the study cohort that was adherent to evidence-based guideline. Chi-squared, t-tests, and logistic regression were used to assess pre- and postintervention differences.

RESULTS

In the study cohort preintervention, 5.3% of low back pain-related primary care visits resulted in lumbar-spine MRI, compared with 3.7% of visits postintervention (P <.0001, adjusted odds ratio 0.68). There was a 30.8% relative decrease (6.5% vs 4.5%, P <.0001, adjusted odds ratio 0.67) in the use of MRI of any body part by the primary care providers in the study cohort. This difference was not detected in the control cohort (5.6% vs 5.3%, P = .712). In the study cohort, adherence to evidence-based guideline in the use of lumbar-spine MRI increased from 78% to 96% (P = .0002).

CONCLUSIONS

CDS and associated accountability tools may reduce potentially inappropriate imaging in patients with low back pain.

Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain

OBJECTIVE

To estimate health care utilization and costs associated with adherence to clinical practice guidelines for the use of early magnetic resonance imaging (MRI; within the first 6 weeks of injury) for acute occupational low back pain (LBP).

DATA SOURCES

Washington State Disability Risk Identification Study Cohort (D-RISC), consisting of administrative claims and patient interview data from workers' compensation claimants (2002-2004).

STUDY DESIGN

In this prospective, population-based cohort study, we compared health care utilization and costs among workers whose imaging was adherent to guidelines (no early MRI) to workers whose imaging was not adherent to guidelines (early MRI in the absence of red flags).

DATA COLLECTION/EXTRACTION METHODS

We identified workers (age>18) with work-related LBP using administrative claims. We obtained demographic, injury, health, and employment information through telephone interviews to adjust for baseline differences between groups. We ascertained health care utilization and costs from administrative claims for 1 year following injury.

PRINCIPAL FINDINGS

Of 1,770 workers, 336 (19.0 percent) were classified as nonadherent to guidelines. Outpatient and physical/occupational therapy utilization was 52-54 percent higher for workers whose imaging was not adherent to guidelines compared to workers with guideline-adherent imaging; utilization of chiropractic care was significantly lower (18 percent).

CONCLUSIONS

Nonadherence to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for out-patient, inpatient, and nonmedical services, and disability compensation.

The reliability of red flags in spinal cord compression

Background:

Acute low back pain is a common cause for presentation to the emergency department (ED). Since benign etiologies account for 95% of cases, red flags are used to identify sinister causes that require prompt management.

Objectives:

We assessed the effectiveness of red flag signs used in the ED to identify spinal cord and cauda equine compression.

Patients and Methods:

It was a retrospective cohort study of 206 patients with acute back pain admitted from the ED. The presence or absence of the red flag symptoms was assessed against evidence of spinal cord or cauda equina compression on magnetic resonance imaging (MRI).

Results:

Overall, 32 (15.5%) patients had compression on MRI. Profound lower limb neurologic examination did not demonstrate a statistically significant association with this finding. The likelihood ratio (LR) for bowel and bladder dysfunction (sensitivity of 0.65 and specificity of 0.73) was 2.45. Saddle sensory disturbance (sensitivity of 0.27 and specificity of 0.87) had a LR of 2.11. When both symptoms were taken together (sensitivity of 0.27 and specificity of 0.92), they gave a LR of 3.46.

Conclusions:

The predictive value of the two statistically significant red flags only marginally raises the clinical suspicion of spinal cord or cauda equina compression. Effective risk stratification of patients presenting to the ED with acute back pain is crucial; however, this study did not support the use of these red flags in their current form.

[Indications for magnetic resonance imaging for low back pain in adults]

INTRODUCTION

Low back pain is a common disorder that generates many medical consultations. Magnetic Resonance Imaging (MRI) is commonly used in the clinical management of some of these patients. However, the cost of inappropriate MRI use is high, so there is a need to develop guidelines to help physicians make correct decisions and optimize available resources.

OBJECTIVE

To determine the main clinical indications for MRI scanning in adults with low back pain.

MATERIAL AND METHODS

The RAND/UCLA appropriateness method was used: After a systematic review (May 2012), a list of the clinical indications for MRI scanning in patients with low back pain was prepared. A multidisciplinary expert panel scored each indication from 1, «totally inappropriate» to 9, «totally appropriate». A first on-line round, an in-person panel meeting, where results of the first round were discussed, and a final second on-line round were arranged. A clinical indication was considered appropriate if the median score was 6.5 or higher, and there was agreement between experts (IPRAS index was used).

RESULTS

An MRI test is considered appropriate if cancer, spinal infection or a fracture, even with a negative X-ray test is suspected.; if there is inflammatory back pain; severe/progressive neurological deficit; severe and progressive low back pain; subacute or chronic low back pain with radicular involvement unresponsive to conservative therapy.

CONCLUSIONS

Clinical indications for a MRI scanning are based on the suspicion of a secondary serious pathology. This methodology helps to set clinical indications for MRI, and may be of great value for both clinicians and health managers.

Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the effect of early (receipt ≤30 d postonset) magnetic resonance imaging (MRI) on disability and medical cost outcomes in patients with acute, disabling, work-related low back pain (LBP) with and without radiculopathy.

SUMMARY OF BACKGROUND DATA

Evidence-based guidelines suggest that, except for "red flags," MRI is indicated to evaluate patients with persistent radicular pain, after 1 month of conservative management, who are candidates for surgery or epidural steroid injections. Prior research has suggested an independent iatrogenic effect of nonindicated early MRI, but it had limited clinical information and/or patient populations.

METHODS

A nationally representative sample of workers with acute, disabling, occupational LBP was randomly selected, oversampling those with radiculopathy diagnoses (N = 1000). Clinical information from medical reports was used to exclude cases for which early MRI might have been indicated, or MRI occurred more than 30 days postonset (final cohort = 555). Clinical information was also used to categorize cases into "nonspecific LBP" and "radiculopathy" groups and further divided into "early-MRI" and "no-MRI" subgroups. The Cox proportional hazards model examined the association of early MRI with duration of the first episode of disability. Multivariate linear regression models examined the association with medical costs. All models adjusted for demographic and medical severity measures.

RESULTS

In our sample, 37% of the nonspecific LBP and 79.9% of the radiculopathy cases received early MRI. The early-MRI groups had similar outcomes regardless of radiculopathy status: much lower rates of going off disability and, on average, $12,948 to $13,816 higher medical costs than the no-MRI groups. Even in a subgroup with relatively minimal disability impact (≤30 d of total lost time post-MRI), medical costs were, on average, $7643 to $8584 higher in the early-MRI groups.

CONCLUSION

Early MRI without indication has a strong iatrogenic effect in acute LBP, regardless of radiculopathy status. Providers and patients should be made aware that when early MRI is not indicated, it provides no benefits, and worse outcomes are likely.

LEVEL OF EVIDENCE

3.

Low back pain and associated imaging findings among HIV-infected patients referred to an HIV/palliative care clinic

BACKGROUND

Low back pain is a common cause of chronic pain in human immunodeficiency virus (HIV)-infected patients. The American College of Physicians and American Pain Society guidelines for diagnostic imaging in low back pain are difficult to apply to patients with chronic illnesses like HIV who may have risk factors for cancer or compression fractures, but whether imaging all such patients for low back pain improves outcomes is unknown.

OBJECTIVE

Our objective was to describe patients referred to a chronic pain-focused HIV/palliative care clinic (HPCC) with back pain and their associated lumbar spine imaging findings.

METHODS

We conducted a retrospective chart review of patients at a palliative care clinic that sees patients with HIV, most of whom have chronic pain. Charts with a diagnosis of low back pain were cross-referenced with an imaging database and any magnetic resonance imaging (MRI) of the lumbar spine with or without contrast were identified.

RESULTS

Seventy-six of 137 patients referred to the HPCC were found to have back pain. These patients were mainly young (median age 45, interquartile range 40-51) with well-controlled HIV. Twenty-two (29%) of these patients had an MRI of the lumbar spine, and 11 (50%) of these warranted follow-up, most of whom had degenerative disc disease, including four with findings concerning for malignancy.

DISCUSSION

This is the first study to explore the role of spinal imaging in HIV-infected patients. In our study, four patients had findings concerning for malignancy. These findings suggest that spinal imaging should be considered in the work up of HIV-infected patients with moderate to severe back pain.

Evidence for Policy Making: Clinical Appropriateness Study of Lumbar Spine MRI Prescriptions Using RAND Appropriateness Method

BACKGROUND

MRI is a new and expensive diagnostic technology, which has been used increasingly all over the world. Low back pain is a worldwide prevalent disorder and MRI technique is one of the several ways to diagnose it. This paper aims to identify the appropriateness of lumbar spine MRI prescriptions in Shiraz teaching hospitals using standardized RAND Appropriateness Method (RAM) criteria in 2012.

METHODS

This study consisted of two phases. The first phase involved a qualitative enquiry and the second phase had a quantitative cross-sectional nature. In the first phase RAM was used for developing lumbar spine MRI indications and scenarios. In the second phase, the finalized scenarios were compared with the history and physical examination of 300 patients with low back pain. The rate of appropriateness of lumbar spine MRI prescription was then calculated.

RESULTS

Of 300 cases of lumbar spine MRI prescriptions, approximately 167 (56%) were considered inappropriate, 72 (24%) were uncertain, and 61 (20%) were deemed to be appropriate. The economic burden of inappropriate prescriptions was calculated at 88,009,000 Rials. In addition, the types of expertise and physical examination were considered as related factors to appropriateness of prescriptions.

CONCLUSION

In conclusion, a large proportion of lumbar spine MRI prescriptions, which result in financial burden on the insurance companies and the patients alike is unnecessary. This study suggests that policy makers consider this evidence while decision-making. Our findings highlight the imperative role of Health Technology Assessment (HTA) and Clinical Practice Guidelines (CPGs). As a result, developing local clinical guidelines may create the commitment needed in physicians in prescribing appropriate prescriptions within the health sector. The study further recommends that appropriate scenarios should be considered as a criterion for payment and reimbursement.

Evidence-based imaging and effective utilization: lessons in neuroradiology

Expensive advanced imaging, such as magnetic resonance (MR) imaging, contributes to the unsustainable growth of health care costs in the United States. Evidence-based imaging decreases costs and improves outcomes by guiding appropriate utilization of imaging. Low back pain is an important case illustration. Despite strong evidence that early advanced imaging with MR imaging for uncomplicated low back pain leads to increased costs without significant clinical benefit, MR imaging utilization for acute low back pain has increased. Barriers to evidence-based imaging can be traced to patient- and physician-related factors. Radiologists have a critical role in addressing some of these barriers.

Evolução psicossomática e clínica de pacientes com estenose do canal lombar operados com sistema interespinhoso

OBJETIVO: Procuramos avaliar a eficácia terapêutica de estabilizadores interespinosos na doença degenerativa lombar, e a evolução do índice de depressão e somatização de sintomas preexistentes nesses pacientes. MÉTODOS: Estudamos 20 pacientes com estenose de canal lombar. Considerados diversos critérios de inclusão, os pacientes concordaram em participar do estudo assinando o consentimento livre e esclarecido. Na avaliação clínica e psicossomática utilizamos: Escore Euroqol (EQ-5D); escala visual analógica (EVA) lombar e dos membros inferiores; Oswestry Disability Index versão 2.0 e Modified Somatic Perception Questionnaire (MSPQ) e Zung Self-Rating Depression Scale (ZDS). A análise estatística foi realizada com os testes de Friedman e Wilcoxon, sendo o nível de significância 0,05. RESULTADOS: Existiu uma melhoria em EQ-5D (p<0,001), EVA lombar e dos membros inferiores (p<0,001), ODI (p<0,001), sem alterações significativas no MSPQ (p=0,197). CONCLUSÃO: Em pacientes com doença degenerativa lombar (grau 2 e 3 de Benzel e 3 e 4 de Pfirmann), estáveis em termos psicossomáticos, o uso de estabilizadores interespinosos revelou-se eficaz considerando a evolução clínica e o índice de depressão preexistente relacionado com a patologia diagnosticada.

Factors associated with early magnetic resonance imaging utilization for acute occupational low back pain: a population-based study from Washington State workers' compensation

STUDY DESIGN

A population-based, prospective cohort study.

OBJECTIVE

To identify demographic, job-related, psychosocial, and clinical factors associated with the use of magnetic resonance imaging (MRI) within 6 weeks from injury (early MRI) among workers' compensation claimants with acute occupational low back pain (LBP).

SUMMARY OF BACKGROUND DATA

Early MRI may be associated with increased use of services for treatment and costs. To understand utilization and most appropriately apply guidelines, it is important to identify factors associated with early imaging use for occupational LBP.

METHODS

Workers (N = 1830) were interviewed 3 weeks (median) after submitting a workers' compensation claim for a back injury. Demographic, work, health, clinical, and injury characteristics were ascertained from interviews, medical records, and administrative data. Modified Poisson regression analyses identified factors associated with early MRI use.

RESULTS

Among respondents, 362 (19.8%) received an early MRI. Multivariable regression showed that male workers were 43% more likely to receive an early MRI than female workers (incident rate ratio [IRR]: 1.43, 95% confidence interval [CI]: 1.12-1.82). Initial visit type with a surgeon was associated with 78% greater likelihood of receiving an early MRI than that with a primary care physician (IRR: 1.78, 95% CI: 1.08-2.92). Having a chiropractor as the initial provider was associated with a reduced likelihood of early MRI (IRR: 0.53, 95% CI: 0.42-0.66). Workers with elevated work fear-avoidance, higher Roland scores, or increased injury severity were more likely to receive early MRI than counterparts with lower levels or scores.

CONCLUSION

Nearly 20% of the injured workers with LBP receive early MRI, a rate similar to that reported elsewhere. Early MRI may lead to greater subsequent interventions, potentially poorer outcomes, and increased health care expenditures. On the basis of the characteristics of patients with uncomplicated occupational LBP, providers may be able to provide tailored care, and providers and policy makers may better understand the utilization of imaging and adherence to clinical guidelines.

Early imaging for acute low back pain: one-year health and disability outcomes among Washington State workers

STUDY DESIGN

A population-based, prospective cohort study.

OBJECTIVE

To evaluate the association of early imaging and health and disability status 1 year following acute low back injury, among a population-based sample of Washington State workers' compensation claimants.

SUMMARY OF BACKGROUND DATA

Use of early diagnostic magnetic resonance imaging (MRI) for low back pain (LBP) contributes to increasing health care costs but may not lead to better outcomes than delayed imaging. In the worker's compensation system, LBP is common and costly. This research examines the association between early MRI among workers with LBP and health outcomes (pain intensity, Roland disability score, and 36-Item Short Form Health Survey scores) and disability status 1 year after injury.

METHODS

This nonrandomized prospective cohort study of Washington State workers' compensation claimants with nonspecific LBP used administrative claims and interview data. Multivariable regression methods were used to estimate change in health outcome scores, the relative risk of disability at 1 year, and the rate of recovery 1 year after injury.

RESULTS

Of 1226 participants, 18.6% received early MRI. Most (77.9%) had mild/major sprains and 22.1% had radiculopathy. Participants with early MRI differed significantly at baseline in pain, function, and psychosocial variables. After adjusting for covariates, early imaging was not associated with substantial differences in 1-year health outcomes for sprains or radiculopathy. For workers with mild/major sprain, early imaging was associated with a 2-fold increase in the likelihood of work disability benefits at 1 year (adjusted relative risk: 2.03, 95% confidence interval: 1.33-3.11). Early imaging was not associated with an increased risk of long-term disability for workers with radiculopathy (adjusted relative risk: 1.31, 95% confidence interval: 0.84-2.05). For both groups, early MRI was associated with longer disability duration (P < 0.001).

CONCLUSION

Among workers with LBP, early MRI is not associated with better health outcomes and is associated with increased likelihood of disability and its duration. These associations warrant further testing in a randomized controlled trial. Our findings suggest that adherence to evidence-based guidelines is an important factor in ensuring that workers receive the highest quality care for occupational injuries.