Imaging Use For Low Back Pain Please turn
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THESIS Diagnostic imaging can be helpful in recognizing various spine related problems, including spinal canal stenosis, trauma, and infection. Various studies suggest that imaging is being overused by physicians for diagnosis of lower back pain (LBP), which can lead to negative effects for the patients, unnecessary surgeries, and wasteful healthcare spending. Back || Next
OBJECTIVE S ➢ Define lower back pain (LBP) and state probable causes ➢ Discuss the role of imaging in diagnosing lumbar pathologies ➢ Identify current protocol for imaging LBP ➢ Explain the harmful effects of excessive imaging for LBP ➢ Discuss wasteful healthcare spending ➢ Review studies stating overuse of imaging by physicians for LBP ➢ Identify potential options to reduce overuse of imaging Back || Next
What is Low Back Pain? ➢ ➢ ➢ The lumbar spine is made of 4 -6 vertebrae that enables our body to bend, twist, and protect the spinal cord. ○ Nerves from the spinal cord attach around the vertebrae. Low back pain is discomfort in the lumbar region of the spine. Symptoms include back pain, leg pain, or a combination of the two. ○ Sharp and shooting; dull and aching; isolated or widespread pain (Khanduja, 2018). Normal L-spine anatomy Normal L-spine X-ray Cross-section of L-spine vertebrae Back || Next https: //www. physio-pedia. com/Lumbar_spinal_stenosis https: //emedicine. medscape. com/article/1263961 -overview
What is Low Back Pain? Continued… Abnormal MRI of the lumbar spine ➢ LBP is the fifth most common complaint to primary physicians in the US (Khanduja, 2018). ➢ Leading cause of disability for individuals under the age of 45 (ACR Appropriateness Criteria, 2015). ➢ Some causes may be traumatic injury, disc herniation, spinal stenosis, and congenital deformities. Herniated Nucleus Pulposus ➢ Nonspecific lumbar disc abnormalities are common in patients even those who are asymptomatic (ACR Appropriateness Criteria, 2015). ➢ The modalities for imaging low back pain include diagnostic x https: //www. orthomanhattan. com/case-studies-new-york-city/lumbar-herniated-disc/ -ray, computed tomography(CT), and magnetic resonance imaging(MRI). Back || Next
Degree of Low Back Level of Pain. Duration of Pain Acute Back Pain Less than 6 weeks Subacute Back Pain 4 -12 weeks Chronic Back Pain 12 weeks or longer (Low Back Pain Fact Sheet, n. d. ) ➢ Patients with new lower back pain should not have imaging done within the first 6 weeks after onset of pain (Imaging for Low Back Pain, 2018). Back || Next
Low Back Pain Imaging Guidelines Uncomplicated; no no red flags Low velocity trauma; osteoporosis Preferred imaging exam imaging No No imaging needed MRIofoflumbarspine X-rays of lumbar spine MRI without with andand without contrast MRIofoflumbarspine MRI without contrast If preferred is not available N/A lumbar spine CTCT ofof lumbar spine without contrast CT of lumbar CT lumbarspinewith or without contrast Criteria N/A Suspicion of cancer, infection, etc. infection, MRIofoflumbarspine MRI without contrast v Patients with ‘red flags’ are recommended for imaging. ○ Prior to surgery (ACR Appropriateness Criteria, 2015) Red flags of LBP include but are not limited to: history of or recent trauma, unexplained weight loss, urinary infection, immunosuppression, h/o of cancer, IV drug use, over the age of 70, pain lasting longer than 6 weeks, loss of anal sphincter tone, fecal incontinence, and weakness of lower limbs (ACR Appropriateness Criteria, 2015). Back || Next
Possible Reasons For Overuse of Imaging For LBP ➢ ➢ ➢ Medical liability fears (Yu, 2016) ○ Doctors may fear malpractice claims if pathologies exist and imaging was not ordered. Meeting patient’s demand (Yu, 2016) ○ Patients might expect imaging done, and if the doctor doesn’t order it they may assume the doctor doesn’t have their best interest in mind. Economic motivation (Yu, 2016) ○ MRIs are expensive, and facilities or staff may increase income for the equipment used. Physicians unaware of low back pain imaging guidelines (Khanduja, 2018) ○ Physicians could be unaware of hospital LBP guidelines for that particular facility and incorrectly order imaging. Lack of complete patient history and physical examinations (Khanduja, 2018) Back || Next ○ Patient history and patient questions should be discussed thoroughly when ordering
Harmful Effects for Patients with LBP Ø Lack of patient knowledge may lead to: Anxiety and stress with additional exams o Unnecessary radiation • The average radiation for a lumbosacral spine x-ray exam is 0. 5 -1. 8 m. Sv [Equal to 24 -90 days of background radiation] (Peck, 2017). o Unnecessary procedures and/or treatment (French, 2019) • Imaging may lead to finding pathologies not contributing to pain. • May result in costly procedures, treatment, medications, and invasive procedures that can lead to unnecessary physical harm or infection (Yu, 2016). Ø MRI can be misleading o Can not differentiate from symptomatic and asymptomatic spine abnormalities (Yu, 2016). Ø Low back MRI coincides more frequently with spine surgery. o Usually with no significant outcome (Khanduja, 2018). o Back || Next
Wasteful Healthcare Spending ➢ The cost of evaluating and treating acute LBP cost billions of dollars annually (Jenkins, 2018). ○ Choosing Wisely Campaign estimates $35. 6 million in waste for back pain imaging from 2007 -2011 (Colla, 2014). ➢ Over $6 billion is spent on direct low back pain treatment each year in Canada (French, 2019). ➢ Most lumbar MRI findings are asymptomatic; therefore, some findings for symptomatic patients may not be causing pain, and intervention could be wasteful (Wnuk, 2018). ○ Mild disc degeneration or bulging is considered normal. ➢ Imaging within 6 weeks from the onset of pain can add to cost and not necessarily improve outcomes (ACR Appropriateness Criteria, 2015). Back || Next
Study #2 Study #1 Low Back Pain Imaging Studies Study #3 Back || Next
• Imaging for Low Back Pain: Is Clinical Use Consistent with Guidelines? (Jenkins, 2018) Reviewed 33 studies for over and underuse of appropriate imaging of the lumbar spine. Ordered [VALUE imaging before ] the 6 week mark Did not consist [VALUE of any red flags ] [VALUE] No clinical suspicion of pathology • • In 5 studies, 9% of patients were referred inappropriately. Conclusion- Suitable imaging decisions, along with strategies other than imaging, should be implemented within the healthcare field in order to reduce unnecessary imaging orders. Back
• 5, 365 lumbar spine MRI exams from January 2007 to December 2008 from specialty clinics, an emergency department, and an outpatient primary care center. Magnetic Resonance Imaging of the Lumbar Spine: Determining Clinical Impact and Potential Harm from Overuse (Wnuk, 2018) 37 Suspecte d cancer cases 6/9 Strongly worded reports Correct diagnosis All weakly worded reports False positives • 93% of lumbar spine MRI exams were considered appropriate; yet only 13% had a detectable impact on patient management. • Conclusion: High rates of false positives may result in potential patient harm and increased economic and psychological costs. Back ○ False positives were five times higher than the rate of new diagnoses.
➢ According to a MRI low back pain study done in China, 41. 3% of 3, 107 patients were diagnosed as “clinically positive” and 58. 3% of those were considered to be “clinically negative”. ○ ○ The Use of Lumbar Spine Magnetic Resonance Imaging in Eastern China: Appropriateness and Related Factors (Yu, 2016) ➢ Clinically positive - diagnoses that may need other clinical involvement. Clinically negative - diagnoses that does not need other clinical involvement. Top three Simplemost leg common chief complaints: pain 11. 8 40 Back and leg pain ➢ 27. 2 Top three most common diagnosis Disc herniation evaluated: 15 32. 7 Disc bulging ➢ ➢ Simple back pain Normal L-spine 26. 2 The study confirmed that having both back and leg pain could be an appropriate use of MRI. Conclusion: Most MRIs of the lumbar spine Back were clinically negative and did not find any
Similaritie s Between Findings of The Studies All 3 studies had imaging data from at least 3, 100 patients. All concluded that there was an unnecessary use of low back pain imaging. Most patients examined, lacked any “red flags” and were examined regardless. All mention the usage of ineffective appropriateness criteria. Each study stated that MRIs on individuals with nonspecific back pain led to unfavorable outcomes for the patients with degeneration or false positive imaging. Back || Next
Discussion Ø Malpractice concerns lead doctors to order more unnecessary imaging. o Proper communication with patients is key (Jenkins, 2018). o Provide empathy, legitimation, and clear recommendations (Imaging for Ø Ø Ø Low Back Pain, 2018). Evaluating and treating LBP cost billions every year (Jenkins, 2018). MRIs may lead to incidental findings, which could potentially lead to unnecessary procedures, treatments, and medicines. 100% weakly worded ordering comment reports were false positives (Wnuk, 2018). o Radiologist’s wording and probability of disease are directly correlated. Overuse of imaging for LBP is an issue that had been recognized internationally (China, Canada). Other treatments for LBP include physical therapy, exercise, yoga (Khanduja, 2018). o Some patients with LBP found relief with these methods and imaging Back || Next
Conclusion ➢ One third of ordered imaging did not have “red flags” and warrant imaging studies for the patients (Jenkins, 2018) ○ Jenkins, et al. found that new strategies in regards to ordering imaging is necessary to lower inappropriate studies Ø LBP imaging is overused and often does more damage than good. ○ ○ “Uncomplicated acute lower back pain doesn’t warrant imaging orders; most individuals with LBP go back to their normal routines within 30 days” (ACR Appropriateness Criteria, 2015). 26. 2% of patients have disc bulging and 15% have disc herniation; both are normal and the healing process may subside pain within 8 weeks (Yu, 2016). Ø Overuse of imaging for diagnosing lower back pain may lead to negative effects for the patients, unnecessary surgeries, and wasteful healthcare spending. Back || Next
QUIZ Read the questions on the following slides and click on the background to see the correct answer. Back || Next
How long should a physician wait before ordering imaging on a patient with complaint of lower back pain without any ‘red flags’? 6 weeks Back || Next
What are three imaging modalities commonly used for diagnosing lower back pain? MRI, CT, and xray/radiographs Back || Next
What are considered ‘red flags’ according to the ACR? Recent trauma, Unexplained weight loss, Unexplained fever, Immunosuppression, Hx of cancer, IV drug use, Over the age of 70, Pain lasting longer than 6 weeks Back || Next
What are the harmful effects of over-imaging for patients with LBP? Anxiety and stress, Unnecessary radiation, Unnecessary medical bills, Surgeries Back || Next
How long does chronic back pain last? 12 weeks or longer Back || Next
What is the preferred method of imaging for lumbar spine with suspicion of cancer or infection? MRI with and without contrast Back || Next
What are some treatments for lower back pain? Physical therapy, yoga, and exercise Back || Next
The End. Thank you! Back || Next
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References ACR. org Home. (n. d. ). Retrieved November 17, 2015 from https: //acsearch. acr. org/docs/69483/Narrative/ Colla, C. H. , Morden, N. E. , Sequist, T. D. , Schpero, W. L. , & Rosenthal, M. B. (2014, November 6). Choosing Wisely: Prevalence and Correlates of Low-Value Health Care Services in the United States. Retrieved November 18, 2019, from https: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 4314495/ French, S. D. , Green, M. E. , Bhatia, R. S. , Peng, Y. , Hayden, J. A. , Hartvigsen, J. , … Norman, K. E. (2019, February 2). Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study - the Back ON study. Retrieved November 13, 2019, from https: //www. ncbi. nlm. nih. gov/pubmed/30711002 Imaging for Low Back Pain. (2018, April 24). Retrieved November 18, 2019, from https: //www. aafp. org/patient-care/clinicalrecommendations/all/cw-back-pain. html Jenkins, H. J. , Downie, A. S. , Maher, C. G. , Moloney, N. A. , Magnussen, J. S. , & Hancock, M. J. (2018, December). Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. Retrieved November 13, 2019, from https: //www. ncbi. nlm. nih. gov/pubmed/29730460 Khanduja, S. , Loomba, V. , Salama-Hannah, J. , Upadhyay, A. , Khanduja, N. , & Chauhan, G. (2018, October). Retrospective Review of Magnetic Resonance Imaging of the Lumbosacral Spine: Are We Overinvestigating? . Retrieved November 13, 2019, from https: //www. ncbi. nlm. nih. gov/pubmed/30531654 Low Back Pain Fact Sheet. (n. d. ). Retrieved November 25, 2019, from https: //www. ninds. nih. gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet Peck, D. , & Samei, E. (2017, March). How to Understand Communicate Radiation Risk. Retrieved November 13, 2019, from https: //www. imagewisely. org/Imaging-Modalities/Computed-Tomography/How-to-Understand-Communicate-Radiation-Risk Wnuk, N. M. , Alkasab, T. K. , & Rosenthal, D. I. (2018, September). Magnetic resonance imaging of the lumbar spine: determining clinical impact and potential harm from overuse. Retrieved November 13, 2019, from https: //www. ncbi. nlm. nih. gov/pubmed/29679728 Yu, L. , Wang, X. , Lin, X. , & Wang, Y. (2016, January). The Use of Lumbar Spine Magnetic Resonance Imaging in Eastern China: Appropriateness and Related Factors. Retrieved November 13, 2019, from https: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 4701169/ Next
Image References Gaballah, S. (n. d. ). Low Back Pain - Introduction. Retrieved December 1, 2019 from https: //www. orthobullets. com/spine/2034/low-back-pain--introduction. Herniated Nucleus Pulposus. (2019, November 9). Retrieved December 1, 2019, from https: //emedicine. medscape. com/article/1263961 -overview. Lumbar Herniated Disc New York City: Spinal Nerve Compression NYC. (n. d. ). Retrieved December 1, 2019, from https: //www. orthomanhattan. com/case-studies-new-york-city/lumbar-herniated-disc/. Lumbar spinal stenosis. (n. d. ). Retrieved December 1, 2019, from https: //www. physiopedia. com/Lumbar_spinal_stenosis BACK || HOME
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