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Defining and measuring imaging appropriateness in low back pain studies: a scoping review

  • Mark YatesEmail author
  • Crystian B. Oliveira
  • James B. Galloway
  • Chris G. Maher
Open Access
Review Article

Abstract

Purpose

Patients with low back pain (LBP) rarely have serious underlying pathology but frequently undergo inappropriate imaging. A range of guidelines and red flag features are utilised to characterise appropriate imaging. This scoping review explores how LBP imaging appropriateness is determined and calculated in studies of primary care practice.

Methods

This scoping review builds upon a previous meta-analysis, incorporating articles identified that were published since 2014, with an updated search to capture articles published since the original search. Electronic databases were searched, and citation lists of included papers were reviewed. Inclusion criteria were studies assessing adult LBP imaging appropriateness in a primary care setting. Twenty-three eligible studies were identified.

Results

A range of red flag features were utilised to determine imaging appropriateness. Most studies considered appropriateness in a binary manner, by the presence of any red flag feature. Ten guidelines were referenced, with 7/23 (30%) included studies amending or not referencing any guideline. The method for calculating the proportion of inappropriate imaging varied. Ten per cent of the studies used the total number of patients presenting with LBP as the denominator, suggesting most studies overestimated the rate of inappropriate imaging, and did not capture where imaging is not performed for clinically suspicious LBP.

Conclusion

Greater clarity is needed on how we define and measure imaging appropriateness for LBP, which also accounts for the problem of failing to image when indicated. An internationally agreed methodology for imaging appropriateness studies would ultimately lead to an improvement in the care delivered to patients.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

Keywords

Low back pain Imaging appropriateness Red flags Guideline compliance 

Introduction

Low back pain (LBP) is the worldwide leading cause of disability and a common presentation to medical services, with an age-standardised point prevalence of 9.4% [1]. LBP is usually benign and self-limiting, but can be the presenting feature of serious spinal pathology such as malignancy, occurring in 1.4–5% of presentations [2, 3]. Choosing Wisely, an initiative established by the American Board of Internal Medicine to avoid unnecessary medical interventions, recommends that spinal imaging should be avoided in patients with no clear indicators of serious pathology and a duration of less than 6 weeks [4]. In addition to the economic cost, inappropriate imaging may lead to patients ascribing their pain to incidental imaging findings, increasing the likelihood of seeking unnecessary interventions [5, 6]. Failing to image when indicated may delay timely management of an underlying serious condition.

Multiple studies have investigated rates of inappropriate LBP imaging; estimates vary markedly ranging from 3.8 to 88.5% [7]. Appropriateness is often judged by red flags: clinical features thought to raise suspicion of serious pathology. However, the nature and number of red flags vary widely between guidelines [8]. Which red flags to include when assessing LBP imaging appropriateness is important, given the wide variation in their predictive value [9, 10]. In addition, studies vary in how they calculate the numerator and denominator to determine imaging appropriateness. Both these issues likely contribute to uncertainty on how much lumbar imaging is inappropriate.

Here we review the criteria studies use to assess appropriateness of LBP imaging in primary care, assess compliance with clinical guidelines, and how proportions of inappropriate imaging are calculated.

Methods

This scoping review built upon the work of a systematic review and meta-analysis by Jenkins et al. that identified studies assessing appropriateness of imaging for LBP [7]. This review included studies identified by Jenkins et al. published in the last 5 years (since 2014), plus studies from a repeat of the original search to identify subsequently published papers.

MEDLINE, EMBASE, and CINAHL were searched from 1st of January 2018 to 20th of February 2019, using the same search terms as Jenkins et al. [7]. Citation lists of included papers were also reviewed. Inclusion criteria were as follows: studies assessing LBP imaging appropriateness; studies in a primary care setting; and studies of adult patients. The following article types were excluded: case reports; case series; reviews; conference abstracts.

One author performed the initial title and abstract screen, identifying studies appropriate for a full-text review. These were combined with studies identified by Jenkins et al. in the last 5 years to give a complete list of eligible studies. Data extraction was performed by two authors using a data collection proforma. Detail was collected on the clinical setting a study was conducted in, the criteria to assess imaging appropriateness and its consistency with relevant national guidelines, how studies attained the information (i.e. chart review or insurance claims data), and the method by which studies calculated the proportion of appropriate imaging.

Results

The electronic search identified 708 papers. A total of 674 were excluded after title and abstract review, leaving 34 for full manuscript review. A further 27 were excluded after full review. In total, seven studies eligible for inclusion were identified from the electronic search. These were combined with the 15 studies identified from the Jenkins et al. review published since 2014, and one further study identified from citation lists review, to give a total of 23 eligible studies. See Fig. 1 for more detail.
Fig. 1

Flow diagram of included studies

Table 1 describes the included studies, with detail on the criteria used to assess imaging appropriateness, guidelines followed or adapted by the study, and the source from which studies collected data.
Table 1

Included studies with details on indications to image

Citation

Country

Imaging appropriateness criteria

Referenced guideline

Data source

Suman 2018 [11]

Netherlands

Trauma + age > 60, female, low body weight, corticosteroid use, or spinal malformation

Onset > age 50

Continuous pain

Night pain

Malaise

History of malignancy

Unexplained weight loss

Elevated ESR

Onset < age 20 + male sex, iridocyclitis, history of unexplained peripheral arthritis or inflammatory bowel disease, night pain, nocturnal, morning stiffness > 1 h, less pain when moving, positive reaction on NSAIDs, or elevated ESR

Onset < age 20 + palpable misalignment of the spinous processes at the L4–L5 level

Netherlands primary care guideline

Chart review

Blackmore 2018 [12]

USA

Trial of conservative therapy

Lumbar spine surgery in last 90 days

History of malignancy

History of congenital spine or spinal cord malformations

History of inflammatory or autoimmune disorders

History of infectious conditions

History of spinal vascular malformations and/or the cause of occult subarachnoid haemorrhage

History of spinal cord infarction

History of local radiation therapy

Spinal abnormalities associated with scoliosis, syringohydromyelia, postoperative fluid collections and soft tissue changes

Trauma

IV drug abuse

Neurological impairment

HIV

Unspecified immune deficiencies

Intraspinal abscess

OP8 guideline

Insurance claims data

Zafar 2018 [13]

USA

< 4 weeks radicular symptoms + emergent/progressive findings on assessment

< 4 weeks symptoms plus risk factor for serious condition: history of malignancy; fever; IV drug abuse; recent infection; urinary retention; motor deficits at multiple levels; faecal incontinence; saddle anaesthesia; progressive motor weakness

> 4 weeks radicular symptoms

ACP and APS guidelines

Order request review

Colla 2018 [14]

USA

< 6 weeks symptoms + red flag: history of malignancy; history of spinal fracture; suspected spinal fracture; progressive neurological symptoms; infection; osteopenia; osteoporosis; axial spondyloarthritis; suspected malignancy

Choosing Wisely

Insurance claims data

Wang 2018 [15]

USA

< 6 weeks symptoms + red flag: history of malignancy; unexplained weight loss; immunosuppression; urinary infection; IV drug abuse; prolonged corticosteroids; significant trauma; minor fall or heavy lift in osteoporosis or elderly; acute onset urinary retention or overflow incontinence; loss of anal sphincter tone or faecal incontinence; saddle anaesthesia; global or progressive motor weakness of lower limbs;

> 6 weeks symptoms + not improved with conservative therapy

ACR-AC

Chart review

Kullgren 2018 [16]

USA

< 6 weeks symptoms + red flag: history of malignancy; history of spinal fracture; suspected spinal fracture; progressive neurological symptoms; infection; osteopenia; osteoporosis; axial spondyloarthritis; suspected malignancy

Choosing Wisely

Chart review

Isaac 2018 [17]

USA

History of malignancy

Trauma

IV drug abuse

Neurological impairment

Unexplained weight loss

Immunosuppression

Corticosteroid use

Fever

History of urinary infection

History of abdominal aortic aneurysm

History of Low back pain

Intraspinal abscess

Choosing Wisely

Chart review

Rosenthal 2018 [18]

USA

< 6 weeks symptoms + red flag: history of malignancy; history of spinal fracture; suspected spinal fracture; progressive neurological symptoms; infection; osteopenia; osteoporosis; axial spondyloarthritis; suspected malignancy

Choosing Wisely

Insurance claims data

Allen 2014 [19]

USA

> 28 days radicular symptoms

> 84 days symptoms

No

Insurance claims data

Charlesworth 2016 [20]

USA

< 6 weeks symptoms + red flag: history of malignancy; trauma; IV drug abuse; neurological impairment; endocarditis; septicaemia; TB; osteomyelitis; fever; weight loss; malaise; night sweats; anaemia not due to bloods loss; myelopathy; neuritis; or radiculopathy

> 6 weeks persistent symptoms

NICE + Choosing Wisely

Insurance claims data

Gidwani 2016 [21]

USA

History of malignancy (excl primary skin and prostate) in last year

Trauma in last 45 days

IV drug abuse in last year

Neurological impairment in last year

HIV diagnosis in last year

Immunodeficiency diagnosis in last year

Lumbar spine surgery in last 90 days

Spinal abscess in last 30 days

Compression fracture in last 30 days

Osteomyelitis in last year

Chiropractic or physical therapy in last 60 days

NQF CMS measure, amended

Order request and chart review

Graves 2014 [22]

USA

< 6 weeks symptoms + red flag: absent reflexes (knee or ankle); bladder complaints; or neurological abnormalities (including sensory loss or muscle weakness)

American College of Occupational and Environmental Medicine, ACP, APS

Insurance claims data

Hong 2017 [23]

USA

Neurological deficits

Constitutional symptoms

Tuberculosis, current or in last year

Septicaemia

Endocarditis

Osteomyelitis

Trauma

History of malignancy in last year

IV drug abuse in last year

Choosing Wisely

Insurance claims data

Ip 2014 [24]

USA

< 4 weeks radicular symptoms + emergent/progressive findings on assessment

< 4 weeks symptoms + risk factor for serious condition: history of malignancy; fever; IV drug abuse; recent infection; urinary retention; motor deficits at multiple levels; faecal incontinence; saddle anaesthesia; progressive motor weakness)

> 4 weeks radicular symptoms

ACP and APS guidelines

Chart review

Kennedy 2014 [25]

Canada

Trauma

Unexplained weight loss

Osteoporosis

Unexplained fever

Recent infection

Immunosuppression

History of malignancy

Corticosteroid use

History of IV drug abuse

Age > 70 years

Focal neurological deficit with progressive or disabling symptoms

> 6 weeks symptoms

Prior spinal surgery

ACR-AC

Order request review

Kost 2015 [26]

USA

Age < 18 years

Attendance for acute back pain in last 3 months

Pre-existing chronic back pain

Temperature > 38 °C

New-onset bowel or bladder symptoms

Saddle anaesthesia,

History of malignancy

Current IV drug abuse

Unexplained weight loss

Choosing Wisely

Order request and chart review

Lin 2016  [27]

Australia

Suspicion of spinal fracture, tumour, or inflammatory disorder

Pain of non-spinal origin (e.g. visceral referred pain)

ACP

Order request and chart review

Mohammadi 2016 [28]

Iran

Absolute indications:

Chronic back pain

Radicular pain

Sexual dysfunction

Urinary incontinence

Motor disorders in the lower limbs

Relative indications:

Age > 70 years

Spinal trauma

Spinal tenderness

Uveitis

Inflammatory bowel disease

Morning stiffness

Long-term corticosteroids

History of malignancy

Fever

Night pain

Based upon NICE and ACR-AC, then amended by an expert panel

Order request and chart review

Rao 2015  [29]

USA

< 6 weeks symptoms + red flag: history of malignancy; unexplained weight loss; immunosuppression; urinary infection; IV drug abuse; prolonged corticosteroids; significant trauma; minor fall or heavy lift in osteoporosis or the elderly; acute onset urinary retention or overflow incontinence; loss of anal sphincter tone or faecal incontinence; saddle anaesthesia; global or progressive motor weakness of lower limbs

> 6 weeks symptoms + not improved with conservative therapy

ACR-AC

Order request and chart review

Schlemmer 2015 [30]

USA

< 6 weeks symptoms + history in last year of: malignancy; trauma; IV drug abuse; neurological impairment; osteoporosis; compression fracture; ankylosing spondylitis; rheumatoid arthritis, or; low back surgery

> 6 weeks symptoms

ACR-AC + expert opinion

Insurance claims and administrative data

Tahvonen 2016 [31]

Finland

Age < 20 years or > 55 years

Sphincter or gait disturbance

Saddle anaesthesia

Severe or progressive motor loss

Widespread neurological deficit

History of malignancy

Systemically unwell

HIV

Weight loss

IV drug abuse

Corticosteroid use

Spinal structural deformity

Non-mechanical pain

RCR guideline

Order request and chart review

Tan 2016 [32]

USA

< 4 weeks symptoms + history within last year of: trauma; malignancy; IV drug abuse; neurological impairment

ACP and APS guidelines

Insurance claims data

Thackeray 2017 [33]

USA

Possible non-musculoskeletal cause (urinary tract infection, kidney or gallbladder stones)

Possible red flag condition: malignancy; spinal fracture; osteomyelitis; or cauda equina syndrome

No

Insurance claims data + chart review

All eligible studies were reviewed by two authors

ESR erythrocyte sedimentation rate, NSAIDs non-steroidal anti-inflammatory drugs, IV intravenous, HIV human immunodeficiency virus, ACP American College of Physicians, APS American Pain Society, ACR-AC American College of Radiology appropriateness criteria, NICE National Institute for Health and Care Excellence, TB tuberculosis, NQF National Quality Forum, CMS Centers for Medicare & Medicaid Services, RCR Royal College of Radiologists

Fourteen of the 23 (61%) eligible studies considered prolonged symptom duration as an indication for imaging. Two of the nine studies that did not consider symptom duration included a trial of conservative therapy as an indication. Most studies (19/23, 83%) assessed imaging as inappropriate or appropriate in a binary manner, whereas four used a grading system to give an appropriateness score.

A broad range of red flags were utilised and can be stratified into three groups: (1) clinical features (23 in total); (2) suspicion of pathology (5 in total); and (3) past medical history (14 in total). The total number of red flags considered by each study ranged from 1 to 18. The most frequent clinical feature red flag was neurological impairment, present in 16/23 (70%) of studies. Age was used by seven studies but with inconsistent cut-offs. One study stratified red flags by age, with the combination of red flags required for imaging dependent on age (e.g. age over 60 years + history of trauma + female gender, corticosteroid use, or increased thoracic kyphosis). This was also the only study that utilised clusters of red flags, rather than relying on individual features [11]. The number of studies that endorsed each of the clinical feature red flags is detailed in Fig. 2.
Fig. 2

Bar chart displaying relative frequencies of clinical features used as red flags for LBP imaging

Far fewer studies (n = 4) considered clinical suspicion of a serious pathology as a red flag. Past medical history was used widely, but with marked variation. History of malignancy was employed in 19/23 (83%) of studies. Four studies limited to history of malignancy within the last year, with one study also excluding primary skin and prostate cancers. The frequency of clinical suspicion and past medical history red flags are in Table 2.
Table 2

Relative frequencies of suspicion of pathology and past medical history red flags

N = 23

Frequency

a. Suspicion of pathology

 

 Spinal fracture

4

 Malignancy

2

 Infection

1

 Cauda equina syndrome

1

 Non-musculoskeletal cause of pain

1

b. Past medical history

 

 Malignancy

19

 Infection

13

 IV drug abuse

13

 Trauma

12

 Auto-inflammatory condition

8

 Osteoporosis

7

 Immunosuppression

6

 Spinal fracture

6

 HIV

3

 Spinal surgery

4

 Spinal abscess

3

 Previous presentation with LBP

2

 Neurological impairment

1

 Abdominal aortic aneurysm

1

A total of 10 guidelines were referenced, with 16/23 (70%) assessing imaging appropriateness in line with a guideline. Seven studies combined, amended, or did not reference any guideline [19, 20, 21, 22, 28, 30, 33].

The method of calculating the proportion of imaging that was inappropriate varied between studies. The two most common approaches, used in seven studies each, were:
$$\frac{{{\text{Number}}\,{\text{ of}}\,{\text{ inappropriate}}\,{\text{ imaging}}\,{\text{ requests}}\,{\text{ for}}\,{\text{ LBP}}}}{{{\text{Number}}\,{\text{ of}}\,{\text{ LBP }}\,{\text{imaging}}\,{\text{ requests}}}}$$
and
$$\frac{{{\text{Number }}\,{\text{of}}\,{\text{ inappropriate}}\,{\text{ imaging}}\,{\text{ requests }}\,{\text{for}}\,{\text{ LBP}}}}{{{\text{Number }}\,{\text{of}}\,{\text{ LBP }}\,{\text{patients }}\,{\text{not }}\,{\text{requiring}}\,{\text{ imaging}}}}$$

Two studies calculated the proportion of appropriate imaging decisions, allowing an estimation of when imaging had been inappropriately not performed, as well as performed [29, 30]. Four of the studies calculated the proportion of all patients presenting with LBP who had imaging, in order to compare interventions. Two studies calculated the number of inappropriate LBP imaging requests, as a proportion of all patients presenting with LBP, and one assessed the total number of LBP imaging requests without calculating a proportion.

Discussion

This review highlights that widely varying criteria are employed to assess appropriateness of imaging for LBP. Most studies used red flag features to define imaging as appropriate, but the list of red flags varied substantially between studies. A Cochrane review assessed the predictive value of red flag features for spinal malignancy in patients presenting with LBP [34]. Frequently used red flag features such as age, neurological symptoms, and duration of symptoms had high false-positive rates, with only a previous history of malignancy having moderate predictive value. A further study assessed the performance of red flag features in predicting vertebral fracture, malignancy, infection, or cauda equina syndrome. Combinations of red flags performed well in predicting serious pathology; for example, a history of trauma in an individual older than 70 had a positive predictive value of 20.4. Night pain, pain that awakens a patient from sleep, did not predict any serious pathology [9]. Most studies identified in this review included at least one red flag with limited predictive value for serious pathology, and only one study measured against clusters of red flags.

Only a handful of the studies used clinician suspicion of serious pathology, rather than relying on the presence of individual red flag features. This approach requires clinical acumen and discretion but would provide clarity for clinicians.

Guidelines were inconsistently followed in the included studies, with nearly a third combining amending, or not following guidelines, and studies from similar geographical regions opting for different guidelines. While inter-regional variation in guideline choice is to be expected, variation in guideline choice between studies within a country is less expected, as is authors’ decisions to amend, combine, or not use guidelines at all.

This variation in approach renders comparability problematic: it is likely that a clinical case deemed appropriate for imaging in one study may well have been considered inappropriate in another study. It also undermines the substantial effort and resources put into creating guidelines in the first place.

The use of  varying methods to calculate the proportion of inappropriate imaging impacts on comparability. Seven of the studies assessed the proportion of appropriate imaging by dividing the number of inappropriate requests by the total number of imaging requests. This method when used alone is flawed, as it will not capture instances where imaging has been inappropriately not performed and will overestimate the proportion of inappropriate imaging. The following example explains this further:

In a study, 1000 people presented with LBP. A total of 100 underwent LBP imaging, 10 of which were deemed inappropriate.

If the total number of LBP imaging requests is used as the denominator, this would be construed as 10/100 (10%) of patients presenting with LBP having inappropriate imaging.

If the number of patients presenting with LBP is used as the denominator, one can see that the actual proportion of LBP patients undergoing inappropriate imaging was 10/1000 (1%).

This crucial limitation impacts on comparability between studies and prevents the identification of cases where patients with clinically suspicious LBP are not imaged. The two studies that included inappropriate non-imaging reported that nearly two-thirds of patients with clinically suspicious LBP were not imaged when they should have been [29, 30], suggesting this is a poorly recognised issue.

This scoping review identified studies from a broad electronic search of three databases, building upon the work of a previously published systematic review and meta-analysis [7], giving confidence that all eligible studies have been captured. The granularity of information extracted has enabled an in-depth comparison of how appropriateness of imaging for LBP is assessed, the degree to which studies follow clinical guidelines, and how studies calculate the proportion of inappropriate imaging for the first time.

The included studies had varying clarity when describing how appropriateness of imaging was assessed. If a guideline was cited with no further details, the reference was reviewed with appropriateness criteria extracted. As much detail as possible has been included, with review by a second author to reduce the likelihood that any information was omitted.

This review focuses on LBP imaging in primary care. The findings should not be generalised to secondary or specialist services, as it is likely that the practice in these settings will be substantially different, often with a higher index of suspicion of serious pathology, and greater clinical expertise.

Conclusions

Reducing inappropriate lumbar imaging is a very common Choosing Wisely recommendation but if we cannot agree on how to define and measure appropriateness, we do not know how big a problem there is or if progress is being made in solving the problem. Notably, the Choosing Wisely imaging recommendation does not consider the problem of failing to image when it is indicated.

Given its societal and economic impact, efficient assessment and management of LBP is crucial. To this end, care providers are increasingly embedding clinical decision support in online test ordering systems, but until the evidence base is clear as to which features should indicate imaging, their full benefit will not be realised. Further work and collaboration is urgently needed to identify and employ an internationally recognised methodology for defining and measuring imaging appropriateness for LBP.

Notes

Funding

Mark Yates' salary is funded by grants from the British Society for Rheumatology and Versus Arthritis.

Compliance with ethical standards

Conflict of interest

James B. Galloway has received honoraria from Abbvie, Celgene, Janssen, Pfizer, and UCB. Mark Yates has received honoraria from UCB.

Supplementary material

586_2019_6269_MOESM1_ESM.pptx (144 kb)
Supplementary material 1 (PPTX 144 kb)

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Authors and Affiliations

  1. 1.The Centre for Rheumatic Diseases, Weston Education CentreKing’s College LondonLondonUK
  2. 2.Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and HealthThe University of SydneyCamperdownAustralia

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