بسم الله الرحمن الرحیم

1. بسم الله الرحمن الرحیم دکتر شریفی 5/10/91

2. Case scenario: 30 year old woman with a history of sever back pain reported that she has had this pain for seven days .she stated that the pain is lower lumbar and not radiation to her legs and gets better at rest and gets worse with activity .she has no morning stiffness and peripheral joint pain. Her medical history is not notable for any drugs. Physical examination: L5 level paravertebral tenderness is positive The SLR test was negative bilaterally her lower extremity Strength has normal There are no sensory loss in either the upper or lower extremities. Bilaterally her refluxes were normal and symmetric in upper and extremities. Past medical history: No trauma and no cancer Dose This Patient Need Imaging?

3. PICO P:30 year old woman with acute low back pain I:Imaging (radiography ,MRI ,CT Scan) C:No imaging O:Pain ,Function ,Quality of life ,mental health

4. Imaging strategies for low-back pain: systematic review and meta-analysis Lancet 2009

5. ALBP is defined as pain of <3 months' duration. Full recovery can be expected in 85% of adults with ALBP without leg pain. Most have purely "mechanical" symptoms (i.e., pain that is aggravated by motion and relieved by rest). The initial assessment excludes serious causes of spine pathology that require urgent intervention, including infection, cancer, or trauma. Risk factors for a serious cause of ALBP are shown in Table 15-1. Laboratory and imaging studies are unnecessary if risk factors are absent. CT or plain spine films are rarely indicated in the first month of symptoms unless a spine fracture is suspected. HARRISON 2012

6. Table 15-1 Acute Low Back Pain: Risk Factors for an Important Structural Cause History Pain worse at rest or at night Prior history of cancer History of chronic infection (esp. lung, urinary tract, skin) History of trauma Incontinence Age >70 years Intravenous drug use Glucocorticoid use History of a rapidly progressive neurologic deficit Examination Unexplained fever Unexplained weight loss Percussion tenderness over the spine Abdominal, rectal, or pelvic mass Patrick's sign or heel percussion sign Straight leg or reverse straight leg–raising signs Progressive focal neurologic deficit

7. Introduction Studies have consistently shown that clinicians vary widely in how frequently they obtain imaging tests for assessment of low-back pain. In the absence of historical or clinical features (so-called red flags), suggestive of a serious underlying condition (such as cancer, infection, or caudaequinasyndrome), the 1994 Agency for Healthcare Policy and Research (AHCPR) guideline made recommendations against lumbar imaging in the first month of acute low-back pain.

8. 1-a low frequency of serious conditions in patients without red flags 2- weak correlation between findings on lumbar imaging studies and clinical symptoms 3-high likelihood for acute low-back pain to Improve 4-lack of evidence that imaging is helpful for guiding treatment decisions These recommendations were based on observational studies that indicated Some guidelines have also advised against lumbar imaging for chronic low-back pain without red flags.

9. Some clinicians still do lumbar-spine imaging routinely or without a clear indication 1- reassure their patients and themselves, to meet patient expectations about diagnostic tests 2- identify a specific anatomical diagnosis for LBP Imaging can be harmful because of 1-radiation exposure (radiography and CT) 2- risks of labelling of patients with anatomic diagnosis that might not be the actual cause of symptoms. 3-Furthermore, imaging studies have high direct and indirect costs. 4-Increased frequency of lumbar MRI is associated with higher rates of spine surgery, without clear differences in patient outcomes.

10. Since the publication of the AHCPR guidelines, several randomised trials of immediate, routine lumbar imaging versus usual clinical care without immediate imaging have been published. purpose of this systematic review and meta-analysis was to see whether immediate, routine lumbar-spine imaging is more effective than usual clinical care without immediate lumbar imaging in patients with low-back pain and no features suggesting a serious underlying condition.

11. Methods: We searched Medline (from 1966 to first week of August, 2008) and the Cochrane Central Register of controlled trials(third quarter of 2008)

12. Step 1 479 titles and abstracts identified through searches Step 2 466 citations excluded not randomised trial or imaging strategies for LBP Step 3 13 full-text articles retrieved for more detailed evaluation Step 5 Six trials included • Four trials of immediate plain lumbar radiography vs usual care without immediate imaging • One trial of immediate lumbar MRI or CT vs usual care without immediate imaging • One trial of immediate MRI in all patients, with randomisation to immediate provision of results vs provision of results only if clinically necessary Step 4 Three articles excluded • One was not a randomisedtrial • Two compared two imaging modalities, not immediate imaging vs no imaging

13. Results

15. Primary outcomes were improvement in pain or function. Secondary outcomes were improvement in mental health, quality of life, patient satisfaction, and overall improvement. Other than overall improvement,which was assessed as a dichotomous variable with various scales, all other outcomes were assessed as continuous variables. We categorised outcomes as short term (≤3 months), long term (>6 months to ≤1 year),or extended (>1 year).

16. Figure 2: Improvement in pain (A) and function (B) for immediate lumbar imaging versus usual clinical care without immediate imaging RDQ=Ronald disability questionnaire. VAS=visual analogue scale. The arrow indicates that the upper limit of the confidence interval extends beyond a standardised mean difference of 0・8.

17. Figure 2: Improvement in pain (A) and function (B) for immediate lumbar imaging versus usual clinical care without immediate imaging RDQ=Ronald disability questionnaire. VAS=visual analogue scale. The arrow indicates that the upper limit of the confidence interval extends beyond a standardised mean difference of 0・8.

18. Improvement in quality of life (A) and mental health (B) for immediate lumbar imaging versus usual clinical care without immediate imaging

19. Improvement in quality of life (A) and mental health (B) for immediate lumbar imaging versus usual clinical care without immediate imaging

20. Overall improvement for immediate lumbar imaging versus usual clinical care without immediate imaging

21. Discussion Our meta-analysis of randomised controlled trials showed that immediate, routine lumbar-spine imaging in patients with low-back pain and no features suggesting serious underlying conditions did not improve clinical outcomes compared with usual clinical care without immediate imaging. Results were limited by small numbers of trials for some analyses, but seemed consistent for the primary outcomes of pain and function, and for quality of life ,mental health, and overall improvement. Data for patient satisfaction could not be pooled, but showed no clear difference.

22. Our study has several limitations First, the trials included are clinically diverse, and varied in the type of imaging modality or strategy assessed, the duration of low-back pain in enrollees, and trial quality . However , other trials have shown no difference between immediate lumbar MRI and radiography Second, we pooled trials that assessed different pain or function measures, which could introduce heterogeneity. However, conclusions were similar when we analysed trials that reported the same outcome measure Finally, we were unable to assess effects of baseline patient characteristicson estimates because we did not have access to individual patient data.

23. We identified several factors related to the management and reporting of randomised trials of lumbar imaging that could be improved.. First, all trials had methodological shortcomings. Future trials should describe randomisation methods in more detail, use blinded outcome assessors, and report intention-to-treat analyses. Second, assessment and reporting of outcomes was not well standardised

24. Our study confirmed that clinicians should refrain from routine, immediate lumbar imaging in patients with low-back pain and without features suggesting a serious underlying condition.

25. Conclusions mainly apply to patients with acute or sub acute,non-specificlow-back pain assessed in primary-care settings. Results from one trial suggested that MRI or CT might also not be routinely indicated for chronic low-back pain because of unclear or small benefits.

26. Patient expectations and preferences about imaging should also be addressed, because 80% of patients with low-back pain in one trial would undergo radiography if given the choice, despite no benefits with routine imaging. Educational interventions could be effective for reducing the proportion of patients with low-back pain who believe that routine imaging should be done.We need to identify back-pain assessment and educational strategies that meet patient expectations and increase satisfaction, while avoiding unnecessary imaging.

27. Diagnosis of Low Back Pain: A Joint Clinical PracticeGuideline from the American College of Physicians and the AmericanPain Society Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).