Radiographs as Good as MRI for Most Patients With Low Back Pain

Laurie Barclay, MD

June 03, 2003

June 3, 2003 — Plain radiographs are as good as magnetic resonance imaging (MRI) for most patients with low back pain, according to the results of a randomized controlled trial published in the June 4 issue of The Journal of the American Medical Association. Although MRI increased the cost by increasing the number of spine operations, the outcomes were the same. The editorialist suggests that people with low back pain may be better off coping on their own rather than choosing to become patients.

"A major impetus for this work was the concern that substituting radiographs with rapid MRI scans would result in worse patient outcomes because incidental abnormalities would foster increased interventions and unnecessary morbidity," write Jeffrey G. Jarvik, MD, MPH, from the University of Washington in Seattle, and colleagues. "Our study suggests that substituting rapid MRI scan for radiographs is likely safe but may in fact result in more specialist consultations and operations. Despite the higher rate of surgery, average outcomes were not better among those in the rapid MRI group."

Between November 1998 and June 2000, the authors recruited 380 patients aged 18 years or older whose primary physicians had ordered x-rays for evaluation of their low back pain. Study sites included a university-based teaching program, a nonuniversity-based teaching program, and two private clinics. Patients were randomized to receive lumbar spine evaluation by rapid MRI or by radiograph. At 12 months, 337 (89%) of the 380 patients were available for assessment of functional disability with the back-related disability modified Roland score. Mean score was 8.75 in the radiograph evaluation group and 9.34 in the rapid MRI evaluation group (mean difference, -0.59; 95% confidence interval [CI], -1.69 to 0.87). Secondary outcomes of pain bothersomeness, pain frequency, subscales of bodily pain and physical functioning did not differ significantly between groups.

Ten patients in the rapid MRI group and four in the radiograph group had lumbar spine operations. Mean cost per patient was $2,380 for the rapid MRI strategy and $2,059 for the radiograph strategy (mean difference, $321; 95% CI, -1,100 to 458).

"Given the current evidence, it is difficult to make strong recommendations regarding the use of rapid MRI for patients with low back pain," the authors write. "We recommend that rapid MRI not become the first imaging test for primary care patients with back pain until its consequences for surgical rates and costs are better defined."

The Agency for Healthcare Research and Quality and the National Institute for Arthritis and Musculoskeletal and Skin Diseases supported this study through grants.

In an accompanying editorial, Nortin M. Hadler, MD, from the University of North Carolina at Chapel Hill, suggests that based on this study, rapid MRI "joins the ranks of appealing innovations that have proved illusory.... Cost has little to do with cost-effectiveness if imaging is ineffective."

He questions the need to develop a more rapid MRI and the importance of defining lumbosacral spine anatomy in patients with regional back pain. Low specificity limits the diagnostic utility of MRI scans, which cannot be used to predict back pain and which are insensitive to anatomical changes that might correlate with new symptoms, he writes.

"Today, individuals with regional back pain might fare less poorly by managing as best they can on their own, perhaps with some lay advice, than if they choose to be primary care patients," he writes. "Imaging only serves to bolster the notion that back pain is nothing more than the symptom of an underlying disease. This is a social construct that nurtures an enormous treating enterprise far more than it helps the patient."

JAMA. 2003;289:2810-2818, 2863-2864

Reviewed by Gary D. Vogin, MD

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