Lower back pain? You may not need that CT

In Looking for Dr. Little I posted on a study that showed physicians tend not to prescribe exercise for lower back pain, even though it’s one of the things that works.

One of the things that doesn’t help –but is sometimes down anyway— is diagnostic imaging. From MedPage Today (Routine Lumbar Imaging No Help for Low Back Pain)

PORTLAND, Ore., Feb. 5 — Routine imaging to assess acute or subacute low back pain holds no clinically relevant benefits for patient outcomes, researchers here affirmed.

Patients with low back pain who had radiography, MRI, or CT scans done without a clear indication had no significant improvement in pain or function in the short or long term through 12 months compared with patients who did not have imaging done, Roger Chou, M.D., of the Oregon Health and Science University here, and colleagues reported in the Feb. 7 issue of The Lancet.

Based on their meta-analysis findings, clinicians should refrain from routine, immediate lumbar imaging for patients with acute or subacute low back pain unless they present with “red-flag” features suggestive of a serious underlying condition, such as cancer, infection, or cauda equina syndrome, the researchers said.

These results are consistent with existing evidence based guidelines, but those guidelines are often ignored. Why?

Factors such as “patients’ expectations about diagnostic testing, reimbursement structures that provide financial incentives for imaging, or the fear of missing relevant pathology are likely to hamper clinicians from changing practice,” they wrote.

Education of patients about the limited value of imaging may be a promising approach, Dr. Kochen’s group said.

The researchers noted that imaging can be harmful because of radiation exposure with radiography and CT, risk of labeling of patients with an anatomic diagnosis that might not be the actual cause of symptoms, and high indirect costs, such as higher rates of spinal surgery without a clear outcome benefit.

So if you’re a patient, don’t insist on a scan when you go in with lower back pain. (For that matter, don’t insist on a prescription either.)

They key to solving the health care cost crisis is reduced utilization. Reducing unneeded and potentially harmful diagnostic imaging seems like a reasonable first step.

February 6, 2009

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