Megan Brooks
Medscape
Gerry Gajadharsingh writes:
I remember when I qualified 28 years ago, a GP having a go at me for manipulating a 50 year old male patient with simple recent onset mechanical low back pain, because I had not x-rayed his back first.
He did not seem to accept that a good history and clinical examination, with the absence of radicular (nerve root) pain or red flags was a reasonable approach and that in the majority of cases imaging was usually unhelpful.
Then about 15 years ago the RCGP issued guidelines to GP suggesting that for simple mechanical back pain, imaging often did not help with treatment or management for patients with recent onset back pain. So this idea is not new but, because this research focuses on older adult,s it is helpful to both clinicians and patients wondering if imaging will be helpful. As always diagnostic testing needs to be based on a clear rationale and when used appropriately can be immensely helpful in diagnosis, treatment management and prognosis.
Older adults with new-onset back pain should not undergo diagnostic imaging immediately because it’s costly and won’t improve outcomes, a new study shows.
“We hope that groups responsible for clinical guidelines will incorporate this new information into revised recommendations,” Jeffrey G. Jarvik, MD, MPH, from the University of Washington, Seattle, told Medscape Medical News.
When to image older adults with back pain remains “controversial,” he and his colleagues note in an article published on March 17 2015 in JAMA.
In contrast to recommendations for younger adults, many guidelines allow for older adults with new back pain to undergo imaging without waiting 4 to 6 weeks because of a higher prevalence of serious underlying conditions in this age group, they point out.
However, given the equally high prevalence of incidental findings in older adults, imaging soon after initial presentation may lead to a “cascade of subsequent interventions that increase costs without benefits,” they note.
Controversial Topic
Dr Jarvik and colleagues studied 5239 patients aged 65 years or older with a new primary care visit for back pain who did not have radiculopathy; within 6 weeks of the index visit, 1174 had plain radiography taken and 349 underwent MRI or computed tomography (CT).
At 12 months, neither the early radiography group nor the early MRI/CT group differed significantly from controls on measures of back or leg pain–related disability, based on the modified Roland-Morris Disability Questionnaire, the investigators report.
The mean score for patients who underwent early radiography was 8.54 vs 8.74 among controls (difference, –0.10
“The clinical implications,” Dr Jarvik said, “are that older adults with new episodes of low back pain should not be treated differently than younger adults with respect to imaging recommendations. In the absence of ‘red flags’ (eg, a history of cancer, being immunocompromised, signs and symptoms of cauda equina syndrome, et cetera) older adults should not undergo routine early lumbar spine imaging.”
Not surprisingly, there were marked differences in 1-year resource use and costs. The researchers estimate that 1-year total payments (payer and patient contributions) were $1380 higher for patients who underwent early radiography and $1430 higher for those who had MRI/CT imaging, relative to controls.
Red Flags
Roger Chou, MD, is professor in the Departments of Medicine and Medical Informatics & Clinical Epidemiology at Oregon Health & Science University, Portland, and director of the American Pain Society Clinical Practice Guidelines Development Program.
Reached for comment, he told Medscape Medical News that this study “looks consistent with what we’ve found before in analyzing the [randomized controlled trials] of routine imaging vs usual care with no imaging in showing no beneficial effects of early imaging.”
“What makes this study different,” he said, “is that it focused on older patients. In the past being older has been considered a ‘red flag’ and an indication for imaging because it is associated with increased risk for cancer and other things like vertebral compression fractures.”
However, Dr Chou added, “it is a relatively weak risk factor for cancer (changing the likelihood from just under 1% to just over 1%) and it is probably reasonable to treat these patients without early imaging if there are not progressive neurological deficits or other worrisome clinical features,” such as a history of cancer, fevers or urinary retention.
The study was supported by the Agency for Healthcare Research and Quality and the National Institutes of Health Intramural Research Program. Dr Jarvik has served on the Comparative Effectiveness Advisory Board for GE Healthcare; is a cofounder and stockholder of PhysioSonics, a high-intensity focused ultrasound company; receives royalties for intellectual property; and is a consultant for HealthHelp, a radiology benefits management company. A complete list of author disclosures appears with the original article.
JAMA. 2015;313:1143-1153