Use of lumbar spine films. Statistical evaluation at a university teaching hospital. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Radiography for back pain presenting to accident and emergency departments. Evidence against the use of lumbar spine radiography for low back pain. Lumbar spine x-rays: a multihospital study. Lumbar spine films in primary care: current use and effects of selective ordering criteria.
Use of lumbar spine films was evaluated in a retrospective review of 1,095 lumbar radiological examinations in 871 patients. Patients' histories and physical examination findings were correlated with four groups of radiological findings: (1) radiologically normal, (2) incidental findings unrelated to patients' complaints, (3) diagnostic films compatible with symptoms, and (4) radiological findings of questionable clinical significance. The high percentage of nondiagnostic and questionable results suggests overuse of lumbar spine films. Forty-six percent of all studies in this investigation were normal or had incidental findings, and an additional 31.8% had radiological findings of questionable clinical significance. Three hundred seventy-five follow-up examinations (64.2%) demonstrated no radiological interval changes. Radiation exposure and medical cost of noncontributory studies may be substantially reduced by judicious consideration of the potential diagnostic yield of the examination and by careful selection of repeated or follow-up studies. To determine the prevalence of serious pathology in patients presenting to primary care settings with acute low back pain, and to evaluate the diagnostic accuracy of recommended "red flag" screening questions.
                An inception cohort of 1,172 consecutive patients receiving primary care for acute low back pain was recruited from primary care clinics in Sydney, Australia. At the initial consultation, clinicians recorded responses to 25 red flag questions and then provided an initial diagnosis. The reference standard was a 12-month followup supplemented with a specialist review of a random subsample of participants.
                There were 11 cases (0.9%) of serious pathology, including 8 cases of fracture. Despite the low prevalence of serious pathology, most patients (80.4%) had at least 1 red flag (median 2, interquartile range 1-3). Only 3 of the red flags for fracture recommended for use in clinical guidelines were informative: prolonged use of corticosteroids, age >70 years, and significant trauma. Clinicians identified 5 of the 11 cases of serious pathology at the initial consultation and made 6 false-positive diagnoses. The status of a diagnostic prediction rule containing 4 features (female sex, age >70 years, significant trauma, and prolonged use of corticosteroids) was moderately associated with the presence of fracture (the area under the curve for the rule score was 0.834 [95% confidence interval 0.654-1.014]; P = 0.001).
                In patients presenting to a primary care provider with back pain, previously undiagnosed serious pathology is rare. The most common serious pathology observed was vertebral fracture. Approximately half of the cases of serious pathology were identified at the initial consultation. Some red flags have very high false-positive rates, indicating that, when used in isolation, they have little diagnostic value in the primary care setting. In order to determine the relevance of radiographs of the lumbar spine in an A&E department 225 consecutive patients presenting in a 6-month period with acute back pain were studied. An analysis of the number of radiographs performed and their association with particular factors in the history and examination of the patient was performed. A total of 108 patients had radiographs (48%), with a total of seven fractures (6% of radiographs). All the patients with fractures had a history of direct trauma. Radiographs had no bearing on the decision to admit the patient. The indications for radiography of the lumbar spine in the A&E department are discussed. To review abnormalities reported on plain radiographic examination of the lumbar spine in patients referred with low back pain by general practitioners. Additionally, we evaluated and stratified the prevalence of these abnormalities by age. Finally, the diagnostic impact of lumbar spine radiography for the diagnosis of degenerative change, fracture, infection and possible tumour, was modelled.
                A retrospective review of 2007 radiographic reports of patients referred with low back pain for lumbar spine radiography to a large radiology department was performed. The reports were classified into different diagnostic groups and subsequently stratified according to age. The potential diagnostic impact of lumbar spine radiography was modelled by using the prevalence of conditions studied as pre-test probabilities of disease.
                The prevalence of reported lumbar spine degeneration increased with age to 71% in patients aged 65-74 years. The overall prevalence of fracture, possible infection, possible tumour was low in our study population: 4, 0.8 and 0.7%, respectively. Fracture and possible infection showed no association with age. Possible tumour was only reported in patients older than 55 years of age.
                Although the prevalence of degenerative changes was high in older patients, the therapeutic consequences of diagnosing this abnormality are minor. The prevalence of possible serious conditions was very low in all age categories, which implies radiation exposure in many patients with no significant lesions. To define the usefulness of the lumbar spine x-ray series in the emergency department and to generate clinical criteria for optimizing its application, we retrospectively studied 552 consecutive emergency department patients for whom lumbar spine x-rays were ordered. Patients were divided into traumatic (47.6%) and nontraumatic (52.4%) groups. Three subgroups were created based on radiological findings: 1) "negative" (55.8%), 2) "possibly significant" (37%), and 3) "positive" (7.2%). The "positive" subgroup was compared with the other two subgroups in an attempt to define physical markers that correlated with positive radiological findings. Four clinical findings were present in significantly different frequencies between the positive group and others: an abnormal physical examination (90% vs 61.5%, respectively) (P less than .0001), tenderness (72.5% vs 41.2%) (P less than .0005), multiple positive findings (42.5% vs 20.7%) (P less than .005), and contusion or abrasion (15% vs 2.7%) (P less than .0005). Low back pain (LBP) often prompts radiography, although the diagnostic yield of lumbar spine films is low, and many radiographic abnormalities are unrelated to symptoms. Criteria have been proposed for selective x-ray use, but their value and safety are uncertain. To evaluate these criteria, the authors prospectively studied 621 walk-in patients with LBP. The yield of explanatory x-ray findings was over three times greater among patients with indications for radiography than among those without. Furthermore, an indication for x-rays existed for all patients found to have a malignancy, and for 13 of 14 patients with an identified fracture. Actual physician ordering, however, did not correspond well with the recommended indications. Application of selective criteria appears safe and may improve the yield of useful findings. It may not, however, reduce x-ray utilization from current levels without further refinement in the criteria.