Overuse and Underuse of Imaging Common in Low Back Pain Management

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Imaging appropriateness was determined on the basis of established clinical guidelines.
Imaging appropriateness was determined on the basis of established clinical guidelines.

Imaging for low back pain may commonly be overused, but also underused, according to a study published in the Spine Journal.

Inappropriate imaging decisions have been found to lead to misdiagnosis, insufficient care, and unnecessary radiation exposure. Although imaging rates for low back pain are often considered high, it is still unclear how actual rates compare with clinical practice guidelines.

To estimate the frequency of inappropriate imaging decisions, researchers conducted a systematic review and meta-analysis of studies examining diagnostic imaging in patients presenting to primary care providers with low back pain. Imaging appropriateness was determined on the basis of established clinical guidelines.

Among the 33 studies selected for the review, 31.6% and 34.8% of patients referred for lumbar imaging were considered inappropriate, because of an absence of clinical suspicion of a serious pathology, and a lack of red flags indicative of a serious pathology, respectively.

Imaging was performed inappropriately in 27.7% of patients presenting for care, based on pain duration; in 9.0%, based on absence of red flags; and on 7.0%, based on absence of clinical suspicion of pathology. Imaging was not performed in patients presenting for care, contrary to the guidelines in 65.6% of patients with red flags and in 60.8% of patients with clinical suspicion of pathology.

Review limitations include low-quality ratings for some of the studies.

"This review highlights that both overuse and underuse of imaging are common in the management of [low back pain]," concluded the review authors. "[S]trategies to improve proportions of appropriate imaging decisions, rather than reduction of imaging rates alone, should be developed and implemented."

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Reference

Jenkins H, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis [published online January 5, 2018]. Spine Journal. doi: 10.1016/j.spinee.2018.05.004

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