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Influence of Imaging on Clinical Decision Making in the Treatment of Lower Back Pain¹

¹ From the Department of Radiology (M.G.C.G., F.J.G.), the Health Services Research Unit (M.G.C.G., J.E.A., A.M.G.), and the Department of Orthopaedic Surgery (D.W.), University of Aberdeen, Foresterhill, AB25 2ZD, Scotland; the Department of Orthopaedic Surgery, Ninewells Hospital, Dundee, Scotland (N.W.V.); and the Department of Orthopaedics, Hairmyres Hospital, Glasgow, Scotland (A.C.G.). From the 2000 RSNA scientific assembly. Received October 13, 2000; revision requested November 26; revision received January 31, 2001; accepted March 2. Supported by the NHS Research & Development Health Technology Assessment Programme. The Health Services Research Unit is funded by the Chief Scientist Office, Scottish Executive Health Department. Address correspondence to M.G.C.G. (e-mail: m.g.gillan@abdn.ac.uk).

PURPOSE: To assess the impact of cross-sectional imaging with magnetic resonance (MR) imaging or computed tomography (CT) on clinical decision making for patients with lower back pain (LBP).

MATERIALS AND METHODS: A randomized controlled before-and-after study was performed in 145 patients who had symptomatic lumbar spinal disorders and had been referred to orthopedists or neurosurgeons. Participants were a subgroup within a multicenter pragmatic randomized comparison of two imaging policies on LBP treatment: "imaging" versus "no imaging," unless a clear indication developed. Paired assessments were made of diagnosis, diagnostic confidence, proposed treatment, treatment confidence at trial entry and follow-up, and expectations of imaging. Data were analyzed according to the groups as randomized.

RESULTS: At follow-up, there were no statistically significant differences between the groups with respect to diagnosis or treatment plans. Significant increases in diagnostic and therapeutic confidence between trial entry and follow-up were observed for both groups, with a significantly greater increase in diagnostic confidence (P = .01) in the imaging group.

CONCLUSION: Imaging may increase diagnostic confidence but has minimal influence on diagnostic or therapeutic decisions for patients with LBP. The results highlight the need for evidence-based guidelines for imaging in LBP treatment.

Index terms: Efficacy study • Spine, abnormalities, 30.1211, 30.1214 • Technology assessment

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