Regardless of patient age, imaging for nonspecific low back pain associated with increased cost but not with better outcomes

Among older adults who had a new primary care visit for back pain, early imaging was not associated with better 1-year outcomes, a study found.

To compare function and pain at the 12-month follow-up visit among older adults who received early imaging (defined as lumbar spine imaging within 6 weeks of an index visit) and those who did not, researchers conducted a prospective cohort study of 5,239 patients 65 years of age or older with a new (defined as no prior visits for low back pain within the previous 6 months) primary care or urgent visit for low back pain from March 2011 to March 2013 in 3 health care systems. Data came from the Back Pain Outcomes Using Longitudinal Data (BOLD) project.

Researchers matched controls 1:1 using propensity score matching for diagnosis, pain severity, pain duration, and functional status. Diagnostic imaging included plain films, CT, or MRI of the lumbar or thoracic spine within 6 weeks of the index visit. Primary outcomes included back- or leg-pain-related disability measured by the modified Roland-Morris Disability Questionnaire (score range, 0-24; higher scores indicate greater disability) 12 months after enrollment.

Study results were published by the Journal of the American Medical Association on March 17.

Among the patients, 1,174 had early radiographs and 349 had early MRIs/CTs. At 12 months, neither the early radiograph group nor the early MRI/CT group differed significantly from controls on the disability questionnaire. The mean score for patients who underwent early radiography was 8.54 versus 8.74 among the control group (P=0.36). The mean score for the early MRI/CT group was 9.81 versus 10.50 for the control group (P=0.18).

In contrast, there were marked differences in 1-year resource use and costs. Mean total relative value units were about 40% higher (P<0.001) in the early radiograph and 50% higher (P=0.01) in the early MRI/CT group than in the no early imaging or no imaging groups. Overall costs were 27% (P<0.001) higher in the early radiograph group and 30% (P<0.04) higher in the early MRI/CT group. Estimated monetary differences in 1-year total payments (payer and patient contributions) were $1,380 higher (95% CI, $692 to $2,060) for patients with early radiographs and $1,430 higher (95% CI, $36.8 to $2,820) for patients with early MRIs/CTs.

The researchers noted that about 90% of older adults have incidental findings on spine imaging, which can lead to adverse labeling and unneeded interventions. Yet, a systematic review recommended considering plain radiography for patients older than 50 years, the American College of Radiology's guidelines state that early imaging with MRI is appropriate for patients older than 70 years and may be appropriate for patients older than 50 years with osteoporosis, and European guidelines for nonspecific low back pain classify patients older than 55 years in the red-flag category justifying imaging.

“Despite the lack of evidence supporting routine imaging for older adults with back pain, guidelines commonly recommend that older patients with back pain undergo imaging, the authors wrote. “Our study results support an alternative position that regardless of age, early imaging should not be performed routinely.”

ACP guidelines, published in Annals of Internal Medicine in 2011, recommend against routinely obtaining imaging or other diagnostic tests in patients with nonspecific low back pain.