Rapid Communication
Austin J Radiol. 2021; 8(12): 1173.
Appropriate Use of Lumbar Spine X-Ray for Low Back Pain-An Investigation of Limited Clinical Value
Saadawy A*
Department of Radiology, West Suffolk Hospital, Addenbrookes Hospitals, UK
*Corresponding author: Ahmed Saadawy, Department of Radiology, West Suffolk Hospital, Addenbrookes Hospitals, UK
Received: October 22, 2021; Accepted: November 17, 2021; Published: November 24, 2021
Introduction
NICE has been advising for years against routine imaging for low back pain, unless the result is likely to change patient management. The recent GIRFT report further highlighted this as an area of concern and that we should be reducing ’low value imaging’.
In 2017-18, >400,000 lumbar X-rays were undertaken across England. Just over half of these from GP referrals.
Back pain is usually the result of conditions that cannot be diagnosed on XR (osteoporotic collapse an exception). MRI if physiotherapy did not help.
Referrals for lumbar spine x-ray from non-specialists are currently rejected in the absence of red flag symptoms and referral to physiotherapy is recommended.
Why Not Just Start With an XR?
431060 - 68 y/o Female
The delay between XR and appropriate investigation: (21st May – 13 July 2021)
XR:
• Good alignment of thoracic and lumbar spine. No fracture.
• Some degenerative changes but no evidence of aggressive disease.
MRI:
• Tumour replacement of the body of L1, T12 with canal narrowing.
• Another MRI done 7 days later showed progression compared to initial MRI.
M05 Acute Back Pain (≤6 Weeks) with Potentially Serious Features
Neurological (cauda equina syndrome)
• Sphincter and gait disturbance (Table 1-3)
• Saddle anaesthesia
• Severe or progressive motor loss
• Widespread neurological deficit
Other features include
• Previous malignancy
• Immunosuppression
• Steroid use
• Fever
Aim, Objectives & Standards
Aim
To assess the number of x-rays performed inappropriately for low back pain in the absence of red flag symptoms.
Standards
Lumbar spine X-rays performed from GP referral for back pain without red flag symptoms or concern for Fracture (Target = 0%)
Methodology
• Data collected via CRIS search with the help of Amanda Yeldham.
• Lumbar spine x-rays performed via a GP referral.
• January to June 2021 timescale.
• Referral forms evaluated for information present assessing for any red flag symptoms or other acceptable reasons for performing x-ray.
• Data collected into an excel sheet to allow further analysis.
NICE-Red Flags
Spinal fracture
Red flags include:
• Sudden onset of severe central spinal pain which is relieved by lying down.
• A history of major trauma (such as a road traffic collision or fall from a height),
• minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids.
• Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra)may be present.
• there may be point tenderness over a vertebral body.
Cancer
Red flags include:
• The person being 50 years of age or more.
• Gradual onset of symptoms.
• Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain.
• Localised spinal tenderness.
• No symptomatic improvement after four to six weeks of conservative low back pain therapy.
• Unexplained weight loss.
• Past history of cancer-breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine.
Results
See Figure 1.
Limitations
Data collection
The reliance on a request that does not fulfil the criteria can be misleading when the patient has an underlying pathology that is not mentioned, however, would have been an indication for XR.
Data analysis
Implementing the red flags when reading requests can sometimes be difficult when the clinical information is vague/the referrer is a poor communicator.
Action Required, Learning and Improvement
• Radiologists to support radiographers in rejecting referrals for lumbar spine x-rays and directing patients to appropriate pathways. Reminder to radiographers of red flag symptoms/signs.
• Review and amend departmental justification procedures, policies, rules and standards for lumbar radiography.
• Amending the referral form for GPs to be more readable and to contain easier to implement guidance and awareness of red flags.
• Re-audit aiming for 100% compliance with standards.
Acknowledgements
Project lead: Dr Elliott Rees, for his continuous support and encouragement in this project and others.