Saturday, February 7, 2009

Need x-rays (or CT or MRI)?

Many healthcare providers operate under the aphorism "to see is to know" and order spinal x-rays or MRI immediately upon seeing a patient with low back pain. This week the venerable British medical journal The Lancet published a systematic review and meta-analysis concerning imaging and low back pain.
Systematic Reviews and Meta-analyses
A systematic review is a type of paper wherein the authors search the biomedical literature (research) for every paper on a topic. They use a plan that details how they will search and what factors about a study should cause it to be used or not used in their review. Then they use a detailed method to determine the quality of the study. Not all research is done equally well so the studies must be critically appraised, tossing out those studies that have fatal flaws in their design. This is a systematic review. The remaining studies are then subjected to a meta-analysis. A meta-analysis is done by collecting data from the remaining high quality studies and essentially pooling them statistically into a single larger more robust study. As poker has a hierarchy of more important hands (e.g. 3 of a kind beating a pair) with scientific research there is a hierarchy and systematic review and meta-analysis are the research equivalent of a royal flush in poker.
From the study's abstract:
Interpretation Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.
By lumbar imaging the authors of this study mean x-ray, CT & MRI. Does not improve clinical outcomes means that getting the imaging studies does not help the patient get any better. Thus, they found from the research that has been published is that patients with acute or subacute low back pain who did not have indications of serious underlying condition there was no difference in the way the patient's felt whether they had imaging or not. Simple thought, if doing the imaging study, which takes both time and money and if radiographs or CTs exposes one to radiation, but does not result in a benefit why do them?

What are the "indications of serious underlying conditions"?
  • History of cancer
  • Rapidly progressive or severe neurologic deficits - loss of muscle strength, fecal incontinence, and bladder dysfunction (incontinence or retention)
  • Potential infection - fever, intravenous drug use, or recent infection
  • Vertebral compression fracture - older age, history of osteoporosis, and steroid use
  • Ankylosing spondylitis - younger age, morning stiffness, improvement with exercise, alternating buttock pain, and awakening due to back pain during the second part of the night only
  • Some organic diseases - pancreatitis, nephrolithiasis, aortic aneurysm, endocarditis or viral syndromes,
There are those who might say that these guidelines do not apply to chiropractors because we look for other important things on radiographs. Well about a year ago a group of chiropractic radiologists came up with essentially the same spinal diagnostic imaging guidelines. Why did the chiropractic researcher find the same thing as medical researchers? Because modern chiropractors and modern medical doctors use imaging for the exact same purpose - to ensure that the patient does not have a serious underlying disorder which isn't likely to respond to non-surgical management. For the vast majority of people with acute/subacute low back pain non-surgical management is best, imaging doesn't improve the patient's outcome (one doesn't get better faster or improve more) and doctors of chiropractic are the non-surgical spinal specialist. See the latest evidence on low back pain spinal manipulation from the World Health Organization's task force for the Bone and Joint Decade.
So if your doctor (MD or DC) is rushing to do diagnostic imaging when you have acute low back pain. Maybe, just maybe you need to find a doctor who is practicing with 21st century knowledge. How to find such a doctor? One source is the NCQA Back Pain Recognition Program. One might also look at the member ship of The West Hartford Group, Inc


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