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PRIMARY CARE: Denise Kendrick, Katherine Fielding, Elaine Bentley, Robert Kerslake, Paul Miller, and Mike Pringle Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial BMJ 2001; 322: 400-405 [Abstract] [Full text]

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A concern about your recommendations

Robert R Nesbit   (20 February 2001)

Question

E Welch   (21 February 2001)

Are physicans allowed to diagnose?

Sandy Johnston   (24 February 2001)

Agreed! Refrain from lumbar spine x-ray

William Stevenson   (26 February 2001)

Back pain patients' misconceptions of X-rays

Stephen Brealey   (28 February 2001)

Re: A concern about your recommendations

Mark Struthers   (2 March 2001)

Plain x-rays can be cost effective

Ed Charlton   (3 March 2001)

Re: A concern about your recommendations

Denise Kendrick   (7 March 2001)

Re: Question

Denise Kendrick   (7 March 2001)

Re: Back pain patients' misconceptions of X-rays

Denise Kendrick   (7 March 2001)

Re: Plain x-rays can be cost effective

Denise Kendrick   (7 March 2001)

Choices and Dilemmas for GP's

alexander Williams   (10 March 2001)

Interpretation of radiography of the spine in low back pain

Keith A Milligan   (21 March 2001)

Radiography of the Lumbar spine

J F Calder, K A Ajilogba   (6 July 2001)

The importance of spinal imaging in the chronic back pain patient.

Calvin Hargis   (28 September 2001)

A concern about your recommendations 20 February 2001
Robert R Nesbit, Professor Emeritus of Surgery Medical College of Georgia Send response to journal: Re: A concern about your recommendations	I am concerned that a general recommendation against spine films in patients with back pain may lead to failure of early recognition and treatment of metastatic disese to bone - particularly metastatic prostate Ca.
Question 21 February 2001
E Welch Send response to journal: Re: Question	I was very interested in your article and the results that you discovered. I was curious, during the intervention phase, it stated that the patients underwent the normal treatment in the facilities that they were at for their backpain. What was the specific care(treatment) that they underwent.
Are physicans allowed to diagnose? 24 February 2001
Sandy Johnston, Of course this won't be printed because I'm not a doctor just a former patient with an opinion on the difficulties in getting treatment. Send response to journal: Re: Are physicans allowed to diagnose?	Here is yet another study that would seem to be designed to direct physicians not to radiograph patients with back pain. As a former victim of back pain myself, I am appalled at the very thought. It is amazing that in these days of astonishing medical advances physicians are being given yet another excuse to ignore their patients and continue in the non- diagnosed treatments of their patient's complaints. In increasing proportions, physician's no longer test for many illnesses because of the time and/or expense involved and opt to treat as they see fit without definitive proof of the actual problem. In the case of low back pain, there are some substantial reasons to radiograph early and not make patients wait through excrutiating and sometimes inhumane conditions that can deteriorate during this waiting period. Now we have this new study which argues that patients shouldn't recieve radiographs at all. So then, what becomes of the patients with spinal abnormalities, congenital or otherwise. Are they to be given more pills in unending supply so that the physician doesn't have to be bothered with "wasting" their time on these "useless" measures. I myself have a congenital abnormality of the spine and developed and extremely extruded disk as a result of the instability caused by the malformation. My physician DID order radiographs which DIAGNOSED the malformation (though not soon enough). Unfortunatly, he was against doing an MRI. The reasons were similar to the ones produced by your study - too expensive and too time consuming - and you know, "hardly anyone with low back pain has anything really wrong". So I was given pills, many pills of many different types(surprisingly, I emerged later, addiction free). Vicodin, oxymorphone, soma - none were able to supply enough relief to allow me basic living conditions. Unable to walk, unable to stand, I crawled. For two months I was unable to sleep for more than an hour at a time - I simply couldn't lie down. Try imagining the mental stress that can cause. Try also to imagine how dehumanizing it is to be unable to go to the bathroom and having to squat on the floor over a bowl to urinate and defecate. Try to imagine crawling to the car and having someone drive you to the doctor's office; to have two strangers come over to help pull you screaming from the car so that you can be pushed into the doctor's office hunched forward in a wheelchair unable to even sit upright. Imagine again attempting to crawl onto an exam table and have the doctor tell you that he can't examine you because of the position you have to lie in and yet refusing to authorize an MRI because of the expense. "Besides, it'll get better with rest". My surgeon, yes I did have surgery finally after waiting much too long for DIAGNOSTIC testing, was a wonderful doctor who insisted on radiographs each time I returned after the surgery to ensure that no further damage to the disks or bones were taking place. I was further informed by said surgeon that had I not gotten the radiographs and subsequent MRI to DIAGNOSE the actual problem that I would have lost functional control of my bladder and more. Hmmm, imagine, using radiographs just to monitor a potential problem - not even to diagnose a symptom (how wasteful). It's disturbing to read that studies are being done to find more reasons to ignore patients and shuffle them in and out as quickly as possible without ever really addressing their concerns or DIAGNOSE the problem. Yes, maybe only one person in a thousand has a severe problem (many even worse than what I went through). Doesn't a patient deserve the benefit of the doubt? Shouldn't each patient be treated as though they might have a bona fide condition that could need medical attention and not be treated as some whiny, sniveling wastrel that has nothing better to do than to annoy the prescious physician and waste their time. Try doing studies that actually benefit the care of the patients. It sounds as though the majority of the patients in the study approved of being allowed to have radiographs. Maybe we need less studies of the patients and more of the physicians and the rampant apathy that seems status quo in many clinics. We need studies that lead to better treatment not excuses to avoid patients.
Agreed! Refrain from lumbar spine x-ray 26 February 2001
William Stevenson, Consultant Radiologist Burnley Send response to journal: Re: Agreed! Refrain from lumbar spine x-ray	Although the conclusions of this paper are hardly a surprise, the research does provide support for those wishing to discourage the use of this virtually worthless examination which incurs a significant population radiation dose. Although this is not stated explicitly, being disguised as reassurance for patient and doctor, the reason for the lumbar spine x-ray is give the impression to the patient that something is being done and thus remove them from the consultation. It can hardly be a surprise to hospital doctors and GPs that radiography for routine back pain virtually never leads to any benefit to the patient to balance his probable slightly increased risk of cancer. While it is difficult to write down what routine back pain is, we all have a high degree of certainty in knowing it when we see it. It is even hard to conceive of what benefit there could be. Setting aside any nebulous psychological effect, consideration of which should be strongly discouraged, something would have to happen to the back pain sufferer as a result of the x-ray. Whatever one’s views on the relative merits of surgery, pain clinics, aromatherapy etc., it cannot be argued that plain x-ray has any role in the selection of patients for them. Clinical features: yes; x-ray:no. There were 420 patients in the trial; this is only a few months worth of lumbar spines for me, many of which would fit the inclusion criteria. I report over 90% as normal, and the vast majority of the rest as essentially normal. I struggle to think of any occasion when the x-ray affected management.
Back pain patients' misconceptions of X-rays 28 February 2001
Stephen Brealey, Research Fellow Send response to journal: Re: Back pain patients' misconceptions of X-rays	EDITOR Lumbar spine radiographs appear to the patient as an innocuous test but deliver 40 times the radiation of a chest X-ray.1 Radiography and other imaging techniques are also very costly.2 A recent article concludes that primary care patients with low back pain of at least six week's duration who are referred for lumbar spine radiography, are not associated with improved clinical outcomes.3 However, there does not appear to have been any monitoring of the differential use of other diagnostic tests as co-interventions. Is it possible that because doctors were asked not to refer patients for radiography in the control group they were referred for alternative tests like Magnetic Resonance Imaging, Computed Tomography, or Nuclear Medicine? In addition, those in the intervention group may have been referred for other diagnostic tests subsequent to lumbar radiography. This potentially important confounding factor could also have huge cost implications.2 The trial findings, however, are consistent with a recent on-the- street survey of public perceptions of over 500 people who responded to statements based on The Back Book and RCGP guidelines about their expectations and understanding of back pain and its management.4 Forty percent had experienced back pain in the previous year. The survey showed that most people would expect their GP to send them for an X-ray and that the great majority believe that the most important thing the GP can do for them is reassure them and advise them to return to normal activities. In this trial, although those who have not had radiography apparently have better outcomes, 80% of patients still want to have radiography, presumably to provide a diagnostic label. Both the trial findings and survey strongly imply the GP is often not successful in reassuring the patient. This misconception of the usefulness of X-rays needs to be addressed. It is also interesting to note that 88% (421/476) of patients agreed to be randomised accepting they might not have radiography. Furthermore, for only 14% (26/199) of control patients did doctors judge it 'clinically necessary' to request radiography. The challenge is for GPs to match these figures in the clinical setting. Surely similar explanations could be given to the patients and now applied with greater confidence by GPs in the light of these findings. 1. Halpin SF, Yeoman L, Dundas DD. Radiographic examination of the lumbar spine in a community hospital: an audit of current practice. BMJ 1991; 303: 813-815. 2. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000; 84: 95-103. 3. Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ 2001; 322: 400-5. 4. Klaber Moffett JA, Newbronner E, Waddell G, Croucher K, Spears S. Public expectations about Public Perceptions about Low Back Pain and its management: A gap between expectations and reality? Health Expectations 2000; 3: 161-169. Stephen Brealey, research fellow Department of Health Sciences and Clinical Evaluation, University of York, York YO1 5DD E-mail: sb143@york.ac.uk Dr Jennifer Klaber Moffett, reader in rehabilitation Institute of Rehabilitation, University of Hull, Hull HU3 2PG
Re: A concern about your recommendations 2 March 2001
Mark Struthers, GP Leighton Buzzard, Bedfordshire, UK Send response to journal: Re: Re: A concern about your recommendations	Spinal Xrays should be used with some discretion and surely Professor Nesbit in Georgia can diagnose metastatic prostate cancer by other means. X rays can be positively misleading and even delay a serious diagnosis like this. What about the elderly man with upper back pain who is otherwise well and with no urinary symptoms. He is sent for a spinal Xray and the radiologist reports that 'there is a thoracic wedge fracture typical of osteoporosis'. The doctor and patient are happy to have a diagnosis except that it's wrong. A doctor decides to do a 'prostate specific antigen' (PSA) test; the result returns very high and the whole picture changes. The Xray only served to delay the diagnosis and the appropriate treatment. Another disabled man with new thoracic back pain returns a mild anaemia and a raised alkaline phospatase. A subsequent raised PSA avoids a 25 mile ambulance trip for an unnecessary Xray. Bad back pain for weeks, a negative lumbar spine Xray, relief all round. Its just a shame the chest wasn't Xrayed instead and the primary lung cancer found. Another not uncommon scenario. Elderly men with persistent back pain need PSA's not Xrays. With a little thought and lateral thinking unnecessary and wasteful investigation can be avoided and resources freed up for the benefit of all in the NHS. Perhaps the conservation of resources is not so relevant to American society and its health systems today.
Plain x-rays can be cost effective 3 March 2001
Ed Charlton, Consultant in pain management and anaesthesia Royal Victoria Infirmary, Newcastle upon Tyne Send response to journal: Re: Plain x-rays can be cost effective	We know x-rays of the back do not improve clinical outcome. Perhaps the major value of this study is the finding that patients were satisfied with their care. So why do the authors believe that patients should not receive x-rays for reassurance? Smith, in Editor's Choice believes "the challenge for doctors is to reassure patients without recourse to radiography". Low back pain has been estimated to cost the UK £5 billion annually, thus anything that acts as a trigger to get people back to better function is good. The problem with this paper and the comments about it, is that it tries to make the conclusion apply to the entire coalface - not just the bit it looked at. Those taking this view shouldn't underestimate the power of an x-ray to influence change in patient's behaviour and lifestyle. For the average low back loser in the pain management unit, nothing less than a plain x-ray will do, although (shock! horror!) some cases require an advanced form of imaging, completed, of course, at huge expence to the taxpayer. As a physician treating this difficult group of patients and as a taxpayer too, I feel this can be money well spent. The plain x-ray of the back represents a cost effective management tool: one that can lead to a change in activity and behaviour patterns that gets patients out of the sick role and back to productive life. The Primary Care x-ray that they believe is "without benficial clinical outcome" is a bonus for those who work in pain management units. Comparative fiilms demonstrate to the patient that there is little or no disease progression and that they haven't done their back any harm. No amount of "reassurance" has the same power and the challenge to radiology and the editor is to come up with something better - not just to talk about it.
Re: A concern about your recommendations 7 March 2001
Denise Kendrick, senior lecturer in general practice University of Nottingham Send response to journal: Re: Re: A concern about your recommendations	Dear Professor Nesbit We would like to point out that our study specifically excluded patients aged over 55 or those with "red flags" for potentially serious spinal pathology to minimise the chance of failing to detect serious spinal pathology.
Re: Question 7 March 2001
Denise Kendrick, senior lecturer in general practice University of Nottingham Send response to journal: Re: Re: Question	General practitioners were asked to continue to manage participants with low back pain as they had been doing prior to the trial commencing. The management participants recieved in terms of medication and physical therapies are detailed in tables 2-4. We were unable to show any difference in management between the intervention and control groups.
Re: Back pain patients' misconceptions of X-rays 7 March 2001
Denise Kendrick, senior lecturer in general practice University of Nottingham Send response to journal: Re: Re: Back pain patients' misconceptions of X-rays	The general practitioners in our study did not have open access to MRI or CT scans through the NHS. All investigations ordered by hospital consultants were recorded and included in the health economic analysis which we will be presenting seperately. In addition details of private referrals and private investigations have also been recorded, costed and included in the analysis. We were unable to show any difference in out patient referrals (the mechanism through which further investigation would be accessed) between the treatment groups so we consider it unlikley that the provision of alternative imaging may confound our results.
Re: Plain x-rays can be cost effective 7 March 2001
Denise Kendrick, senior lecturer in general practice University of Nottingham Send response to journal: Re: Re: Plain x-rays can be cost effective	The argument that x rays will reassure and lead to improved function in patients with low back pain cannot be supported from our findings. Our study demonstrates that in a primary care population with low back pain of a median duration of 10 weeks, a lumbar spine x ray does not improve function and get people back to work more quickly; if anything those having x-rays report slightly worse function. X rays are not an innocuous test. We need to find ways of reasurring the large number of patients with low back pain who are extremely unlikely to have serious pathology without exposing them to radiation. Unfortunatly we do not seem to be very good at doing this at present. As suggested in our paper further work in this area is required.
Choices and Dilemmas for GP's 10 March 2001
alexander Williams, General Practitioner St Thomas Health Centre Send response to journal: Re: Choices and Dilemmas for GP's	The study by Kendrick (1) and colleagues of the use of radiography of the lumbar spine presents both a challenge and a dilemma to General Practitioners. Whilst there is high patient expectation to be investigated and reassurance of both patients and doctors by radiology there appear to be increaced workload implications.With the advent of Primary Care Trusts difficult decisions will have to be made about the allocation of limited resources. Iwould like to report the results of an audit undertaken by a group of established General Practitioner trainers.The audit looked retrospectively at the number of lumbar spine x-rays requested by the individual practitioner (or their deputy).We then delivered an educational intervention and produced our own recomendations with the advise of one of our consultant radiologists and guidelines from the Royal College of Radiologists(2).In most cases of low back pain plain radiology will only show degenerative changes and exposes the patient to about 50 times the radiation dose of a standard chest x-ray.There may be more appropriate investigations to exclude secondary's(bone scan),a prolapsed disc or cord pathology(MRI)and osteoporosis(bone densiometry. We agreed as a group to follow our guidelines and repeat our audit after 1 year.We set our standard as a 50% reduction in requests.The results showed a reduction in the number of x-rays from 91 to 46 (49.5%). The requests by all participants had fallen (some dramatically so) One suggestion by Kendrick is to increase patient satisfaction without the recourse to radiology but clearly another challenge to General Practitioner's is to use investigations both more appropriately and more cost effectively.The delivery of an educational package may be the way to achieve this. 2 Royal College of Radiologists WP Making the best use of the department of clinical radiology:guidelines for doctors 4th edn:Royal College of Radiologists 1998
Interpretation of radiography of the spine in low back pain 21 March 2001
Keith A Milligan, Clinical Director, Pain Management South Cleveland Hospital Send response to journal: Re: Interpretation of radiography of the spine in low back pain	Dear Sir INTERPRETATION OF RADIOGRAPHY OF THE SPINE IN LOW BACK PAIN Kendrick et al (1) set out to demonstrate that radiography of the lumbar spine is not associated with improved clinical outcomes or satisfaction with care. They conclude that it confers no benefit and indeed patients who have been investigated report a longer duration of pain, more severe pain, reduced functioning and overall poorer health status. They conclude radiography reinforces patients’ beliefs that they are sick. I would agree with this conclusion but feel that the added morbidity may be explained at least in part by the way that the radiography report is interpreted. However, many patients referred to the Pain Management Clinic with low back pain have been told by their General Practitioner that radiography shows that they have ‘arthritis in their spine’, ‘narrowed disc spaces’, a ‘crumbling spine’, ‘bulging discs’, ‘degenerative disc disease’, ‘wear and tear’ etc. I suspect that this labelling of the patient with a ‘negative medical diagnosis’ for their simple low back pain after having radiography contributes greatly to the increase in reported symptoms and development of chronicity in these patients. I feel that Kendrick et al slightly missed the point and in their conclusion should have highlighted the negative effect that primary care interpretation of the radiography has on low back pain. Keith A. Milligan Clinical Director Pain Management Clinic, South Cleveland Hospital, Middlesbrough TS4 3BW doctor@kamilligan.freeserve.co.uk 1. Kendrick D. et al. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ 2001;322:400 -5
Radiography of the Lumbar spine 6 July 2001
J F Calder, (1) Cosultant Radiologist, (2) Spr Radiology X Ray Dept, Victoria Infirmary, Langside Rd, Glasgow, K A Ajilogba Send response to journal: Re: Radiography of the Lumbar spine	Letter to the Editor of the BMJ Dear Sir, Radiography of the lumbar spine Kendrick et al in their article of the 17th, Feb 2001 stated, “in the absence of indications for serious spinal disease, radiography in patients with low back pain was not associated with improved clinical outcome but was associated with increased satisfaction with care” (1). An audit was conducted on the influence of the article on GPs requests for lumbar spine radiography for low back pain six weeks before and after the 28th, Feb 2001. The number of requests increased slightly from 110 before 28/02/01 to 122 after, particularly in the acute (less than six weeks duration) group from 17 before to 27 after the 28th, Feb 2001. This indicates that the article written by primary care physicians has made no impact on the GPs requests for lumbar spine radiography. We are aware of the demands made on GPs by patients and reassurance provided by “normal” radiological reports (2, 3,). However, unnecessary investigations are an inappropriate use of ionising radiation and an inefficient and ineffective use of scarce resource (4). If, as appears, general practitioners are taking no cognisance of numerous articles including a recent one (1) by their own peers, perhaps it is time for radiologists to consider rejecting requests, which do not conform to the Royal College of Radiologists` guideline (4). John F Calder – Consultant Radiologist, Victoria Infirmary, Langside Rd, Glasgow G44 Kaseem A Ajilogba – SpR in Radiology, Victoria Infirmary. Langside Rd, Glasgow G44. 1. Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ 2001 Feb 17; 322(7283): 400-5. 2. Little P, Cantrell T, Roberts L, Chapman J, Langridge J, Pickering. Why do GPs perform investigations? The medical and social agendas of back X rays. Fam Pract. 1998 Jun; 15 (3): 264-5. 3. Ansgar Espeland, Anders Baerheim, Grethe Albrektsen, Knut Korsbrekke, John L Larsen. Patient’s views on Importance and Usefulness of Plain Radiography for Low Back Pain. SPINE 2001; 26:1356-1363. 4. Royal College of Radiologists WP. Making the best use of a department of clinical radiology: guidelines for doctors, 4th ed. London: Royal College of Radiologists.
The importance of spinal imaging in the chronic back pain patient. 28 September 2001
Calvin Hargis Warwick Chiropractic Center, Warwick,NY Send response to journal: Re: The importance of spinal imaging in the chronic back pain patient.	Having lately come to the site for BMJ I am currently researching material for a book. Now and for the past twenty one years I have maintained a busy chiropractic practice, whose patients are composed primarily of back pain sufferers of all ages. In addition to my chiropractic schooling I have a board certification in chiropractic orthopedics. My success rate in treating both acute and chronic patients is quite high. While I would agree that the majority of acute and non reoccurrent back pain sufferers do not require x-ray evaluation, I would strongly disagree that this would apply to the chronic and reoccurrently afflicted patient. The rational for my opinion is based simply on the recognition that the majority of the latter group are plagued by biomechanical errors that stress and injure their spines on a daily basis through the persistent microtrauma of lower extremity, pelvic or spinal imbalances which undermind their spinal health, placing them at a higher risk of exacerbation with even moderate physical endeavors or prolonged static postures. For instance: L.G.F. Giles, M.Sc, D.C.,Ph.D. in, 'Anatomical Basis of Low Back Pain', has demonstrated that a significant group of LBP patients have a leg length discrepancy. Other common mechanical maladies include pronounced pes planus/ankle pronation or genu valgus. Simarly defects of the spine such as sacral dysgenesis, hemi-vertebra, spodylolesthesis and other spinal disorders will promote ongoing decay and injury of spinal components leading to significant impairment and pain to the patient if undetected. Often with properly performed x-rays of the lumbar spine and pelvis in the erect weight bearing position the observant clinition can diagnose and correct such problems. Appropriate shoe lifts, orthotics, exercises or therapeutic modalities are often helpful. Of course as these conditions universally entail damage to soft tissue components, be they discal, ligamentous, joint, nerve or muscle, the correct postures and therapy must be implimented and followed faithfully to ensure appropriate response to therapy and recovery while employing such biomechanical ammendments. Naturally all stretching and massage must be avoided in the early stages of soft tissue trauma. Unfortunately it has been my observation that few practioners are trained to secure such information or to chart a successful course of recovery for their patients. This may be why the UK and US demonstrate poor success in the treatment of their back pain patients. 'Back Pain in Britian', BMJ 2000, Palmer, Walsh, et. al.. If one is simply looking at x-rays to R/O cancer, arthritis or disc desease, not understanding that spinal decay is simply the sequelae of biomechanical issues and not using x-ray to unlock he mysteries of biomechanical dysfunction for the betterment of ones patients x-rays may indeed be of limited value.