الرحیم الرحمن الله بسم

شریفی دکتر5/10/91

Case scenario:

30 year old woman with a history of sever back pain reported that she has had this pain for seven days .she stated that the pain is lower lumbar and not radiation to her legs and gets better at rest and gets worse with activity .she has no morning stiffness and peripheral joint pain.Her medical history is not notable for any drugs.Physical examination:

L5 level paravertebral tenderness is positiveThe SLR test was negative bilaterally her lower extremityStrength has normalThere are no sensory loss in either the upper or lower extremities.Bilaterally her refluxes were normal and symmetric in upper and extremities.Past medical history:No trauma and no cancer

Dose This Patient Need Imaging ?

PICOP:30 year old woman with acute low back pain

I:Imaging (radiography ,MRI ,CT Scan)

C:No imaging

O:Pain ,Function ,Quality of life ,mental health

Imaging strategies for low-back pain: systematic review and meta-analysis

Lancet 2009

ALBP is defined as pain of <3 months' duration. Full recovery can be expected in 85% of adults with ALBP without leg pain. Most have purely "mechanical" symptoms (i.e., pain that is aggravated by motion and relieved by rest).The initial assessment excludes serious causes of spine pathology that require urgent intervention, including infection, cancer, or trauma. Risk factors for a serious cause of ALBP are shown in Table 15-1. Laboratory and imaging studies are unnecessary if risk factors are absent. CT or plain spine films are rarely indicated in the first month of symptoms unless a spine fracture is suspected.

HARRISON 2012

Table 15-1 Acute Low Back Pain: Risk Factors for an Important Structural Cause

HistoryPain worse at rest or at nightPrior history of cancerHistory of chronic infection (esp. lung, urinary tract, skin)History of traumaIncontinenceAge >70 yearsIntravenous drug useGlucocorticoid useHistory of a rapidly progressive neurologic deficitExaminationUnexplained feverUnexplained weight lossPercussion tenderness over the spineAbdominal, rectal, or pelvic massPatrick's sign or heel percussion signStraight leg or reverse straight leg–raising signsProgressive focal neurologic deficit

Introduction

Studies have consistently shown that clinicians vary widely in how frequently they obtain imaging tests for assessment of low-back pain.In the absence of historical or clinical features (so-called red flags), suggestive of a serious underlying condition (such as cancer, infection, or cauda equina syndrome), the 1994 Agency for Healthcare Policy and Research (AHCPR) guideline made recommendations against lumbar imaging in the first month of acute low-back pain.

Some guidelines have also advised against lumbar imaging for chronic low-back pain without red flags.

These recommendations were based on observational studies that indicated

1-a low frequency of serious conditions inpatients without red flags2- weak correlation between findings on lumbar imaging studies and clinical symptoms3-high likelihood for acute low-back pain toImprove4-lack of evidence that imaging is helpful forguiding treatment decisions

Some clinicians still do lumbar-spine imagingroutinely or without a clear indication

1- reassure their patients and themselves, to meet patient expectations about diagnostic tests2- identify a specific anatomical diagnosis for LBP

1-radiation exposure (radiography and CT) 2- risks of labelling of patients with anatomic diagnosis that might not be the actual cause of symptoms.3-Furthermore, imaging studies have high direct and indirect costs.4-Increased frequency of lumbar MRI is associated with higher rates of spine surgery, without clear differences in patient outcomes.

Imaging can be harmful because of

purpose of this systematic review and meta-analysis was tosee whether immediate, routine lumbar-spine imaging ismore effective than usual clinical care without immediatelumbar imaging in patients with low-back pain and nofeatures suggesting a serious underlying condition.

Since the publication of the AHCPR guidelines, severalrandomised trials of immediate, routine lumbar imagingversus usual clinical care without immediate imaging havebeen published.

Methods:We searched Medline (from 1966 to first week of August, 2008) and the Cochrane Central Register of controlled trials(third quarter of 2008)

Step 1479 titles and abstracts identified through searches

Step 2466 citations excludednot randomised trial or imaging strategies for LBP

Step 313 full-text articles retrieved for more detailed evaluation

Step 4Three articles excluded• One was not a randomised trial• Two compared two imaging modalities, not immediate imaging vs no imaging

Step 5Six trials included • Four trials of immediate plainlumbar radiography vs usualcare without immediateimaging• One trial of immediate lumbarMRI or CT vs usual care withoutimmediate imaging• One trial of immediate MRI inall patients, with randomisationto immediate provision ofresults vs provision of resultsonly if clinically necessary

Results

Primary outcomes were improvement in pain or function. Secondary outcomes were improvement in mental health, quality of life, patient satisfaction, and overall improvement. Other than overall improvement,which was assessed as a dichotomous variable with various scales, all other outcomes were assessed as continuous variables.We categorised outcomes as short term (≤3 months), long term (>6 months to ≤1 year),or extended (>1 year).

Figure 2: Improvement in pain (A) and function (B) for immediate lumbar imaging versus usual clinical care without immediate imagingRDQ=Ronald disability questionnaire. VAS=visual analogue scale. The arrow indicates that the upper limit of the confidence interval extends beyond a standardised mean difference of 0・ 8.

Figure 2: Improvement in pain (A) and function (B) for immediate lumbar imaging versus usual clinical care without immediate imagingRDQ=Ronald disability questionnaire. VAS=visual analogue scale. The arrow indicates that the upper limit of the confidence interval extends beyond a standardised mean difference of 0・ 8.

Improvement in quality of life (A) and mental health (B) for immediate lumbar imaging versus usual clinical care without immediate imaging

Improvement in quality of life (A) and mental health (B) for immediate lumbar imaging versus usual clinical care without immediate imaging

Overall improvement for immediate lumbar imaging versus usual clinical care without immediate imaging

Discussion

Our meta-analysis of randomised controlled trials showed that immediate, routine lumbar-spine imaging in patients with low-back pain and no features suggesting serious underlying conditions did not improve clinical outcomes compared with usual clinical care without immediate imaging.Results were limited by small numbers of trials for some analyses, but seemed consistent for the primary outcomes of pain and function, and for quality of life ,mental health, and overall improvement. Data for patient satisfaction could not be pooled, but showed no clear difference.

Our study has several limitationsFirst, the trials included are clinically diverse, and varied in the type of imaging modality or strategy assessed, the duration of low-back pain in enrollees, and trial quality . However , other trials have shown no difference between immediate lumbar MRI and radiographySecond,we pooled trials that assessed different pain or function measures, which could introduce heterogeneity. However, conclusions were similar when we analysed trials that reported the same outcome measureFinally, we were unable to assess effects of baseline patient characteristicson estimates because we did not have access to individual patient data.

We identified several factors related to the management and reporting of randomised trials of lumbar imaging that could be improved..

First, all trials had methodological shortcomings. Future trials should describe randomisation methods in more detail, use blinded outcome assessors, and report intention-to-treat analyses.

Second, assessment and reporting of outcomes was not well standardised

Our study confirmed that clinicians should refrain from routine, immediate lumbar imaging in patients with low-back pain and without features suggesting a serious underlying condition.

Conclusions mainly apply to patients with acute or sub acute,non-specific low-back pain assessed in primary-care settings. Results from one trial suggested that MRI or CT might also notbe routinely indicated for chronic low-back pain because of unclear or small benefits.

Patient expectations and preferences about imaging should also be addressed, because 80% of patients with low-back pain in one trial would undergo radiography if given the choice, despite no benefits with routine imaging. Educational interventions could be effective for reducing the proportion of patients with low-back pain who believe that routine imaging should be done.We need to identify back-pain assessment and educational strategies that meet patient expectations and increase satisfaction, while avoiding unnecessary imaging.

Recommendation 1: Clinicians should conduct a focused historyand physical examination to help place patients with low back paininto 1 of 3 broad categories: nonspecific low back pain, back painpotentially associated with radiculopathy or spinal stenosis, or backpain potentially associated with another specific spinal cause. Thehistory should include assessment of psychosocial risk factors, whichpredict risk for chronic disabling back pain (strong recommendation,moderate-quality evidence).Recommendation 2: Clinicians should not routinely obtain imagingor other diagnostic tests in patients with nonspecific low back pain(strong recommendation, moderate-quality evidence).Recommendation 3: Clinicians should perform diagnostic imagingand testing for patients with low back pain when severe or progressiveneurologic deficits are present or when serious underlyingconditions are suspected on the basis of history and physical examination(strong recommendation, moderate-quality evidence).Recommendation 4: Clinicians should evaluate patients with persistentlow back pain and signs or symptoms of radiculopathy orspinal stenosis with magnetic resonance imaging (preferred) orcomputed tomography only if they are potential candidates forsurgery or epidural steroid injection (for suspected radiculopathy)(strong recommendation, moderate-quality evidence).

Diagnosis of Low Back Pain: A Joint Clinical PracticeGuideline from the American College of Physicians and the American

Pain Society