Clinical Pain Medicine
ISSUE: JULY 2015 | VOLUME: 13(7)
Early diagnostic imaging for new-onset back pain in older adults is costly and not associated with better outcomes, according to a new study.
While early imaging (prior to six weeks after an index visit) in younger adults is discouraged by evidence-based guidelines, the timing of imaging in older adults is “controversial,” according to Jeffrey G. Jarvik, MD, MPH, lead author of the study (JAMA 2015;313:1143-1153).
“Many guidelines allow early imaging in older patients to detect potential underlying serious conditions,” said Dr. Jarvik, professor of radiology and neurological surgery at the University of Washington, in Seattle. “Although older patients do have more serious conditions, prevalence of incidental findings is higher, leading to a cascade of unnecessary additional studies and interventions. We wanted to investigate whether early imaging indeed led to superior outcomes in this age group.”
Dr. Jarvik said one of the motivations for imaging older adults is to detect underlying cancer. However, “only one patient in our cohort over 12-month follow-up had a cancerous tumor identified on imaging study.” He said potential fracture in osteoporosis is another concern, but is unnecessary because “the vast majority of spontaneous osteoporotic fractures heal on their own.”
The researchers studied 5,239 patients aged 65 years or older with a new primary care visit for back pain. Controls were matched on a 1:1 ratio, based on demographic and clinical characteristics such as diagnosis, pain severity, pain duration, functional status and prior resource use. Diagnostic imaging included plain films, computed tomography (CT) and magnetic resonance imaging (MRI) of the lumbar and thoracic spine.
At 12 months, neither the early radiograph group nor the early MRI/CT group differed significantly from controls, based on the Roland-Morris Disability Questionnaire, a measure of physical limitations due to back pain.
The mean score for patients who underwent early radiography was 8.54 versus 8.74 for the control group (difference, –0.10; 95% confidence interval [CI], –0.71 to 0.50; mixed model, P=0.36). The mean score for the early MRI/CT group was 9.81 versus 10.50 for the control group (difference, –0.51; 95% CI, –1.62 to 0.60; mixed model, P=0.18).
Dr. Jarvik said the findings are “immediately translatable in daily clinical practice” and that older patients with back pain should not be treated differently from young adults. He said the key is to take a careful history.
“See where the pain occurs and what exacerbates it. It is concerning when pain worsens at night or wakes the patient while sleeping,” Dr. Jarvik said. “Getting an ESR [erythrocyte sedimentation rate] test is important. An abnormal ESR can suggest something more serious, such as an infection or tumor.”
Some pain experts, such as Lynn Webster, MD, vice president of scientific affairs at PRA Health Sciences, Salt Lake City, and immediate past president of the American Academy of Pain Medicine, were not surprised by the results,
“Most low back pain is self-limited regardless of the patient’s age, so a conservative approach is appropriate,” he said.
Dr. Webster, a member of the Pain Medicine News editorial advisory board, said symptoms consistent with nerve impingement by a herniated disk should also receive early imaging.
—Batya Swift Yasgur, MA, LMSW