Imaging in Low Back Pain: Is X-ray or Rapid MRI Better?
Abstract & Commentary
Source: Jarvik JG, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: A randomized controlled trial. JAMA 2003;289:2810-2818.
This randomized, controlled trial compared rapid magnetic resonance imaging (MRI) with plain radiographs as the initial diagnostic imaging test in patients with low back pain. Patients 18 years and older were recruited from four different imaging centers where the patient’s physician had ordered radiographs to evaluate their low back pain. The primary outcome measure was the modified Roland back pain disability scale, done 12 months after randomization, with higher scores signifying worse function. Secondary outcome measures included back pain scores; the Medical Outcomes Study 36-Item Short Form Health Survey; days of reduced or lost work; patient satisfaction with care; reassurance and preference scores; and costs.
At 12 months, primary outcomes of functional disability were obtained from 89% of the 380 patients enrolled. The baseline characteristics of the radiograph and rapid MRI groups were similar. The 12-month modified Roland score in the radiograph group was 8.75 vs. 9.34 in rapid MRI group (mean difference, -0.59; 95% CI -1.69 to 0.87). The mean differences in the secondary outcomes were not statistically significant. Ten patients in the rapid MRI group vs. four in the radiograph group had lumbar spine operations (risk difference, 0.34; 95% CI, -0.06 to 0.73). The rapid MRI strategy had a mean cost of $2,380 vs. $2,059 for the radiograph strategy (mean difference, $321; 95% CI, -1100 to 458).
Commentary by Stephanie Abbuhl, MD
This well-done study showed that substituting lumbar spine radiographs with a rapid MRI scan in an outpatient population resulted in no long-term difference in disability, pain, or general health status. On the other hand, it does not appear that rapid MRI causes harm or greatly increases costs, and it provides more reassuring information for both patients and physicians (but does not increase overall satisfaction). Not surprising, there was a trend toward more lumbar spine operations in the rapid MRI group and these patients did not have improved outcome scores when compared to those who did not have surgery.
From the ED vantage point, one obvious question is whether the same results would be found in our patients. Interestingly, the patients were referred not only from primary care physicians, but half were referred from rheumatologists, physical medicine specialists, and other provider types. While there is limited clinical information about the patients in this study, the results appear to lend more evidence for our practice of avoiding time-consuming and expensive imaging for low back pain when there are no "red flags" on either history or physical exam. We already knew that plain radiographs are infrequently necessary for non-trauma related back pain, and now we know that more is probably not better.
Dr. Abbuhl, Medical Director, Department of Emergency Medicine, The Hospital of the University of Pennsylvania; Associate Professor of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, is on the Editorial Board of Emergency Medicine Alert.
This randomized, controlled trial compared rapid magnetic resonance imaging with plain radiographs as the initial diagnostic imaging test in patients with low back pain.
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