ACP Issues Guidelines for Diagnostic Imaging for Low Back Pain

From Medscape Medical News

Laurie Barclay, MD

January 31, 2011 — Routine imaging for low back pain with radiography or advanced imaging methods, such as computed tomography (CT) scanning or magnetic resonance imaging (MRI), does not improve patient health, according to recommendations issued by the Clinical Guidelines Committee of the American College of Physicians (ACP) regarding high-value healthcare for diagnostic imaging for low back pain.
Imaging scan of lower back

The new guidelines, which are first in a series to help physicians and patients identify misused medical treatments and to practice high-value healthcare, are published in the February 1 issue of Annals of Internal Medicine. The recommendations target internists, family physicians, and other clinicians treating adults with low back pain.

"Low back pain is one of the most common reasons for a patient to see a physician and many patients with low back pain receive routine imaging that is not beneficial and may even be harmful," said second author Amir Qaseem, MD, PhD, MHA, director of clinical policy for ACP, in a news release. "Unnecessary imaging can lead to a series of unnecessary additional tests, interventions, follow ups, and referrals that do not improve patient outcomes."

The new recommendations are based on a systematic review and meta-analysis conducted for the diagnosis and treatment of low back pain joint clinical practice guideline from ACP and the American Pain Society. Available imaging modalities for the low back include radiography, CT, and MRI.

Specific recommendations include the following:

* Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic impairments or signs or symptoms indicating a serious or specific underlying condition, or if they are candidates for invasive interventions. Routine imaging is not associated with clinically meaningful benefits in other patients and can lead to harms.
* Immediate imaging is recommended for patients with acute low back pain who have major risk factors for cancer, risk factors for spinal infection, risk factors for or signs of the cauda equina syndrome, or severe or progressive neurologic deficits.
* Imaging after a trial of treatment is recommended for patients who have minor risk factors for cancer, risk factors for inflammatory back disease, risk factors for vertebral compression fracture, signs or symptoms of radiculopathy, or risk factors for or symptoms of symptomatic spinal stenosis.
* Decisions for subsequent imaging should be guided by development of new symptoms or changes in current symptoms, with repeated imaging recommended only in patients with new or changed low back symptoms.
* Efforts to reduce routine imaging will be most effective if these efforts consider clinician behaviors, patient expectations, and financial incentives.
* Patient education is needed to inform patients of current and effective standards of care and to educate them regarding the benefits and potential harms of diagnostic imaging.

Evidence that expanding imaging to patients without indications for advanced or repeated imaging does not improve outcomes includes randomized trials of routine imaging vs usual care without routine imaging in patients without indications for diagnostic imaging. Findings from these trials suggested no clinically meaningful benefits from expanded imaging on outcomes regarding pain, function, quality of life, or mental health. In addition, there is a weak correlation between most imaging findings and symptoms, acute low back pain has a favorable prognosis with or without imaging, the prevalence of serious or specific underlying conditions is low, and the impact of imaging on treatment decisions is unclear.

Potential harms of unnecessary imaging include the radiation exposure involved in lumbar radiography and CT; hypersensitivity reactions and contrast nephropathy for use of iodinated contrast with CT; and the possibility that subsequent unnecessary, invasive, and expensive procedures could be performed. In addition, knowledge of clinically irrelevant imaging findings might hinder recovery by causing patients to worry more, focus excessively on minor back symptoms, or avoid exercise or other recommended activities for fear of causing more structural damage.

Talking Points Advised

To overcome barriers to evidence-based practice regarding use of imaging for low back pain, the ACP recommends using talking points based on evidence-based guidelines to facilitate patient education. Evidence-based online or print education material to supplement face-to-face education may help overcome time constraints. Clinicians who are uncertain about the need for imaging can be reassured once they recognize the low likelihood of serious conditions in the absence of clinical risk factors and review the evidence showing no benefit associated with routine imaging. The ACP also recommends that clinician incentives be based on providing appropriate care, in addition to patient satisfaction.

"Addressing inefficiencies in diagnostic testing could minimize potential harms to patients and have a large effect on use of resources by reducing both direct and downstream costs," the guidelines authors write. "In this area, more testing does not equate to better care. Implementing a selective approach to low back imaging, as suggested by the ...ACP and American Pain Society guideline on low back pain, would provide better care to patients, improve outcomes, and reduce costs."

Financial support for the development of this guideline came exclusively from the ACP operating budget. Some of the guidelines authors have disclosed various financial relationships with Wellpoint, Palladian Health, Consumers Union, Blue Cross Blue Shield Association, American Pain Society, ACP, and Anthem/Wellpoint. Disclosures can also be viewed at the Annals of Internal Medicine Web site .

Ann Intern Med. 2011;154:181-189. Full text