Early Imaging Unhelpful in Older Adults With New Back Pain

Megan Brooks

March 20, 2015

Older adults with new-onset back pain should not undergo diagnostic imaging immediately because it's costly and won't improve outcomes, a new study shows.

"We hope that groups responsible for clinical guidelines will incorporate this new information into revised recommendations," Jeffrey G. Jarvik, MD, MPH, from the University of Washington, Seattle, told Medscape Medical News.

When to image older adults with back pain remains "controversial," he and his colleagues note in an article published March 17 in JAMA.

In contrast to recommendations for younger adults, many guidelines allow for older adults with new back pain to undergo imaging without waiting 4 to 6 weeks because of a higher prevalence of serious underlying conditions in this age group, they point out.

Dr Jeffrey G. Jarvik

However, given the equally high prevalence of incidental findings in older adults, imaging soon after initial presentation may lead to a "cascade of subsequent interventions that increase costs without benefits," they note.

Controversial Topic

Dr Jarvik and colleagues studied 5239 patients aged 65 years or older with a new primary care visit for back pain who did not have radiculopathy; within 6 weeks of the index visit, 1174 had plain radiography taken and 349 underwent MRI or computed tomography (CT).

At 12 months, neither the early radiography group nor the early MRI/CT group differed significantly from controls on measures of back or leg pain–related disability, based on the modified Roland-Morris Disability Questionnaire, the investigators report.

The mean score for patients who underwent early radiography was 8.54 vs 8.74 among controls (difference, –0.10 [95% confidence interval (CI), –0.71 to 0.50]; mixed model P = .36). The mean score for the early MRI/CT group was 9.81 vs 10.50 for controls (difference, –0.51 [95% CI, –1.62 to 0.60]; mixed model P = .18).

"The clinical implications," Dr Jarvik said, "are that older adults with new episodes of low back pain should not be treated differently than younger adults with respect to imaging recommendations. In the absence of 'red flags' (eg, a history of cancer, being immunocompromised, signs and symptoms of cauda equina syndrome, et cetera) older adults should not undergo routine early lumbar spine imaging."

Not surprisingly, there were marked differences in 1-year resource use and costs. The researchers estimate that 1-year total payments (payer and patient contributions) were $1380 higher for patients who underwent early radiography and $1430 higher for those who had MRI/CT imaging, relative to controls.

Red Flags

Roger Chou, MD, is professor in the Departments of Medicine and Medical Informatics & Clinical Epidemiology at Oregon Health & Science University, Portland, and director of the American Pain Society Clinical Practice Guidelines Development Program.

Reached for comment, he told Medscape Medical News that this study "looks consistent with what we've found before in analyzing the [randomized controlled trials] of routine imaging vs usual care with no imaging in showing no beneficial effects of early imaging."

"What makes this study different," he said, "is that it focused on older patients. In the past being older has been considered a 'red flag' and an indication for imaging because it is associated with increased risk for cancer and other things like vertebral compression fractures."

However, Dr Chou added, "it is a relatively weak risk factor for cancer (changing the likelihood from just under 1% to just over 1%) and it is probably reasonable to treat these patients without early imaging if there are not progressive neurological deficits or other worrisome clinical features," such as a history of cancer, fevers or urinary retention.

The study was supported by the Agency for Healthcare Research and Quality and the National Institutes of Health Intramural Research Program. Dr Jarvik has served on the Comparative Effectiveness Advisory Board for GE Healthcare; is a cofounder and stockholder of PhysioSonics, a high-intensity focused ultrasound company; receives royalties for intellectual property; and is a consultant for HealthHelp, a radiology benefits management company. A complete list of author disclosures appears with the original article.

JAMA. 2015;313:1143-1153. Abstract

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