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Prevalence rates of all tested demographic and clinical characteristics in the subgroups of MRI findings. (PDF 92 kb)

Reasoning underpinning the selection of clinical and demographic characteristics. (PDF 97 kb)

Background The routine use of radiology is normally discouraged in patients with low back pain (LBP). Magnetic Resonance Imaging (MRI) provides clinicians and patients with detailed knowledge of spinal structures and has no known physical side effects. It is possible that insight into the pathological changes in LBP patients could affect patient management. However, to our knowledge, this has never been tested. Until June 2006, all patients at our specialised out-patient public clinic were referred for MRI on the basis of clinical indications, economic constraints, and availability of MRI (the "needs-based MRI" group). As a new approach, we now refer all patients who meet certain criteria for routine up-front MRI before the clinical examination (the "routine MRI" group). Objectives The aims of this study were to investigate if these two MRI approaches resulted in differences in: (1) duration of treatment, (2) number of contacts with clinicians, and (3) referral for surgery. Design Comparison of two retrospective clinical cohorts. Method Files were retrieved from consecutive patients in both groups. Criteria for referral were: (1) LBP or leg pain of at least 3 on an 11-point Numeric Rating Scale, (2) duration of present symptoms from 2 to12 months and (3) age above 18 years. A comparison was made between the "needs-based MRI" and "routine MRI" groups on the outcomes of duration of treatment and use of resources. Results In all, 169 "needs-based MRI" and 208 "routine MRI" patient files were identified. The two groups were similar in age, sex, and severity of LBP. However, the median duration of treatment for the "needs-based MRI" group was 160 versus 115 days in the "routine MRI" group (p = 0.0001). The median number of contacts with clinicians for the "needs-based MRI" group was 4 versus 3 for the "routine MRI" group (p = 0.003). There was no difference between the two approaches in frequency of referral for back surgery (p = 0.81). When the direct clinical costs were compared, the "routine MRI" group was less costly but only by €11. Conclusion In our clinic, the management strategy of routinely performing an up-front MRI at the start of treatment did reduce the duration of treatment and number of contacts with clinicians, and did not increase the rate of referral for back surgery. Also, the direct costs were not increased.

Baggrund 50 % af den voksne befolkning oplever hvert år smerter i nakke, lænd, torakale afsnit eller måske i flere af ryggens regioner samtidigt. Rygsymptomer er altså et særdeles hyppigt fænomen, som i hovedparten af tilfældene er af uspecifik oprindelse, og som i de fleste tilfælde har ganske god prognose. Hos 10-20% af patienterne fortsætter smerterne imidlertid i måneder eller år trods relevante behandlingsforsøg. Udredning af såvel akutte (varighed < 3 mdr.) som kroniske (varighed > 3 mdr.) tilstande foregår gennem en diagnostisk triage: • Først afklares det, om der er red flags til stede, som kræver hurtig indsats. • Herefter vurderes om smerterne skyldes mulige specifikke diagnoser. • Er patienten i restgruppen, foretages en bredere udredning for at afdække eventuelle behandlingsmuligheder og prognose. Væsentlige kliniske karakteristika RED FLAGS Enhver førstegangsudredning af patienten med rygsmerter indledes ved klinisk at udpege de få alvorlige diagnoser, som kræver akut eller hurtig indsats: Sphinctersymptomer eller abnorme sensibilitets-/refleksforhold af perineum giver mistanke om cauda equina-syndrom. Progredierende parese af over- eller underekstremiteter eller paralyse er ofte tegn på truende incarceration af nerverod. L’Hermittes tegn, bilaterale UE-symptomer, hyperrefleksi eller Babinskis tåfænomen. Tænk begyndende medullært tværsnitssyndrom. Almensymptomer med fx vægttab, træthed og feber, tidligere cancersygdom, +50 år. Tænk andre red flags som infektion, systemsygdom eller cancer. Background Every year, 50% of the adult population experiences pain in the neck, low back pain, thoracic pain. Low Back pain is a very frequent phenomenon, which in most cases is of non-specific origin and which in most cases has a good prognosis. However, in 10-20% of patients, the pain persists for months or years despite relevant treatment trials. Both acute (duration 3 months) conditions are investigated through a diagnostic triage: • First, it is clarified whether red flags are present that require prompt action. • Thereafter, we assess whether the pain is due to possible specific diagnoses. • If the patient is in the residual group, a broader assessment is made to identify any treatment options and prognosis. Essential clinical characteristics RED FLAGS Any initial assessment of the patient with back pain is initiated by clinically identifying the few serious diagnoses that require urgent or urgent action: Sphincter symptoms or abnormal sensitivity / reflex conditions of the perineum cause cauda equina syndrome. Progressive palsy of upper or lower extremities or paralysis is often indicative of threatening nerve root incarceration. L’Hermitte’s signs, bilateral UE symptoms, hyper-reflex or Babinski’s toe phenomenon. Think incipient medullary cross-sectional syndrome. Common symptoms with eg weight loss, fatigue and fever, previous cancer disease, +50 years. Think of other red flags like infection, system disease or cancer.