According to international guidelines, radiological examinations of the lumbar spine are of limited value and do not improve clinical outcome unless there are clinical red flags present suggesting serious pathology. Nevertheless, the utilization of lumbar spine imaging remains high.
Purpose
To follow up the effects of active referral guideline implementation and education on the number and appropriateness of lumbar spine radiographs and computed tomography (CT) examinations in young patients and to evaluate whether the appropriate radiographs have more significant findings.
Material and Methods
Referral guidelines for spine examinations and info pocket cards on radiation protection were distributed to referring practitioners. Educational lectures were provided annually. The number of lumbar spine radiographs and CT examinations on patients aged <35 years was analyzed before and three years after the interventions. Appropriateness and findings of 313 radiographs and appropriateness of 117 CT scans of the lumbar spine were assessed.
Results
The number of lumbar spine radiographs and CT scans decreased significantly after the interventions and the level remained unchanged during the follow-up (−33% and −72%, respectively, P < 0.001). Appropriateness improved significantly in radiographs from 2005 to 2009 (65% vs. 85%) and in CT scans already from 2005 to 2007 (23% vs. 63%). Radiographs that were in accordance with the guidelines had more significant findings compared to radiographs that were not; in young adults, this was 56% versus 21% (P < 0.001).
Conclusion
A combination of interventions can achieve a sustained reduction in the number of lumbar spine examinations and improve appropriateness. Inappropriate lumbar spine radiographs do not seem to contain significant findings that would affect patient care.
GBD 2015 DALYs and HALE Collaborators.
Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: A systematic analysis for the global burden of disease study 2015.Lancet2016;
388:1603–1658.
2.
HoyDBainCWilliamsG, et al.
A systematic review of the global prevalence of low back pain.Arthritis Rheum2012;
64:2028–2037.
3.
Calvo-MuñozIGómez-ConesaASánchez-MecaJ.Prevalence of low back pain in children and adolescents: A meta-analysis.BMC Pediatr2013;
13:14.
4.
KoesBWvan TulderMLinCW, et al.
An updated overview of clinical guidelines for the management of non-specific low back pain in primary care.Eur Spine J2010;
19:2075–2094.
van TulderMWAssendelftWJKoesBW, et al.
Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies.Spine (Phila Pa 1976)1997;
22:427–434.
7.
RichardsPJGeorgeJMetelkoM, et al.
Spine computed tomography doses and cancer induction.Spine (Phila Pa 1976)2010;
35:430–433.
8.
Committee to assess health risks from exposure to low levels of ionizing radiation and national research Council. Health risks of exposure to low levels of ionizing radiations: BEIR VII phase 2. Washington (DC): National Academies Press (US), 2006.
9.
MaloneJGuleriaRCravenC, et al.
Justification of diagnostic medical exposures: Some practical issues. Report of an International Atomic Energy Agency consultation.Br J Radiol2012;
85:523–538.
10.
BrennerDJEllistonCDHallEJ, et al.
Estimated risks of radiation-induced fatal cancer from pediatric CT. AJRAm J Roentgenol2001;
176:289–296.
11.
EspelandAAlbrektsenGLarsenJL.Plain radiography of the lumbosacral spine. An audit of referrals from general practitioners.Acta Radiol1999;
40:52–59.
12.
OakeshottPKerrySMWilliamsJE.Randomized controlled trial of the effect of the Royal College of Radiologists’ guidelines on general practitioners' referrals for radiographic examination.Br J Gen Pract1994;
44:197–200.
13.
IsaacsDMMarinacJSunC.Radiograph use in low back pain: A United States emergency department database analysis.J Emerg Med2004;
26:37–45.
14.
BiancoAZuccoRLotitoF, et al.
To what extent do hospitalised patients receive appropriate CT and MRI scans? results of a cross-sectional study in southern Italy.BMJ Open2018;
8:e018125.
15.
BouetteAKaroussou-SchreinerADucou Le PointeH, et al.
National audit on the appropriateness of CT and MRI examinations in Luxembourg.Insights Imaging2019;
10:9.
16.
LehnertBEBreeRL.Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: How critical is the need for improved decision support?J Am Coll Radiol2010;
7:192–197.
GrimshawJMThomasREMacLennanG, et al.
Effectiveness and efficiency of guideline dissemination and implementation strategies.Health Technol Assess2004;
8:72.
19.
Tahvonen P, Oikarinen H, Niinimäki J, et al. Justification and active guideline implementation for spine radiography referrals in primary care. Acta Radiol 2017;58:586–592.
20.
Oikarinen H, Meriläinen S, Pääkkö E, et al. Unjustified CT examinations in young patients. Eur Radiol 2009;19:1161–1165.
21.
Tahvonen P, Oikarinen H, Paakko E, et al. Justification of CT examinations in young adults and children can be improved by education, guideline implementation and increased MRI capacity. Br J Radiol 2013;86:20130337.
22.
Tenkanen-Rautakoski P. Number of radiological examinations in finland in 2005. STUK-B-STO 62. Available at: http://urn.fi/URN:NBN:fi-fe2014120249208 (2006, accessed 22 June 2019).
23.
Tenkanen-Rautakoski P. Number of radiological examinations in finland in 2008. STUK-B 121. Available at: http://urn.fi/URN:NBN:fi-fe2014120249589 (2010, accessed 22 June 2019).
24.
Influence of Royal College of Radiologists’ guidelines on referral from general practice.
Royal College of Radiologists working party.BMJ1993;
306:110–111.
25.
KerrySOakeshottPDundasD, et al.
Influence of postal distribution of the Royal College of Radiologists’ guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: A randomized controlled trial.Fam Pract2000;
17:46–52.
26.
de vos MeiringPWellsIP.The effect of radiology guidelines for general practitioners Plymouth.Clin Radiol1990;
42:327–329.
27.
GlavesJ.The use of radiological guidelines to achieve a sustained reduction in the number of radiographic examinations of the cervical spine, lumbar spine and knees performed for GPs.Clin Radiol2005;
60:914–920.
28.
BakerSRRabinALantosG, et al.
The effect of restricting the indications for lumbosacral spine radiography in patients with acute back symptoms. AJR Am J Roentgenol1987;
149:535–538.
29.
EcclesMSteenNGrimshawJ, et al.
Effect of audit and feedback, and reminder messages on primary-care radiology referrals: A randomised trial.Lancet2001;
357:1406–1409.
30.
RosenkrantzABMarieKDoshiA.Assessing the appropriateness of outpatient abdominopelvic CT and MRI examinations using the American College of Radiology Appropriateness criteria.Acad Radiol2015;
22:158–163.
31.
DeyoRADiehlAK.Lumbar spine films in primary care: Current use and effects of selective ordering criteria.J Gen Intern Med1986;
1:20–25.
32.
KoSBLeeSW.Prevalence of spondylolysis and its relationship with low back pain in selected population.Clin Orthop Surg2011;
3:34–38.
33.
KalichmanLKimDHLiL, et al.
Spondylolysis and spondylolisthesis: Prevalence and association with low back pain in the adult community-based population.Spine (Phila Pa 1976)2009;
34:199–205.
34.
BeutlerWJFredricksonBEMurtlandA, et al.
The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine (Phila Pa 1976)2003;
28:35; discussion 1035.
35.
MohriakRVargas SilvaPDTrandafilovMJr, et al.
Spondylolysis and spondylolisthesis in young gymnasts.Rev Bras Ortop2015;
45:79–83.
36.
United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and effects of ionizing radiation; UNSCEAR 2000 report to the general assembly, with scientific annexes. vol II: Effects.
New York:
United Nations, 2000.
37.
ClarkeJCCranleyKKellyBE, et al.
Provision of MRI can significantly reduce CT collective dose.Br J Radiol2001;
74:926–931.
38.
SodhiKSKrishnaSSaxenaAK, et al.
Clinical application of ‘justification’ and ‘optimization’ principle of ALARA in pediatric CT imaging: “How many children can be protected from unnecessary radiation?”Eur J Radiol2015;
84:1752–1757.
39.
RemediosDHierathMAshfordN, et al.
Imaging referral guidelines in Europe: Now and in the future-EC referral guidelines workshop proceedings.Insights Imaging2014;
5:9–13.
40.
Perez MdelR.Referral criteria and clinical decision support: Radiological protection aspects for justification.Ann ICRP2015;
44:276–287.
41.
European Society of Radiology, (ESR).
Summary of the proceedings of the international forum 2016: “Imaging referral guidelines and clinical decision support - how can radiologists implement imaging referral guidelines in clinical routine?”Insights Imaging2017;
8:1–9.
42.
AppariAJohnsonMEAnthonyDL.Health IT and inappropriate utilization of outpatient imaging: A cross-sectional study of U.S. hospitals.Int J Med Inform2018;
109:87–95.
43.
BlackmoreCCMecklenburgRSKaplanGS.Effectiveness of clinical decision support in controlling inappropriate imaging.J Am Coll Radiol2011;
8:19–25.
44.
SistromCLDangPAWeilburgJB, et al.
Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: Seven-year time series analysis.Radiology2009;
251:147–155.
45.
CartonMAuvertBGueriniH, et al.
Assessment of radiological referral practice and effect of computer-based guidelines on radiological requests in two emergency departments.Clin Radiol2002;
57:123–128.
46.
MinAChanVWYAristizabalR, et al.
Clinical decision support decreases volume of imaging for low back pain in an urban emergency department.J Am Coll Radiol2017;
14:889–899.
