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      Informed appropriate imaging for low back pain management: A narrative review

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          Abstract

          Most patients with acute low back pain (LBP), with or without radiculopathy, have substantial improvements in pain and function in the first 4 weeks, and they do not require routine imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their LBP. It is also considered for those patients presenting with suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture and infection. In western country primary care settings, the prevalence has been suggested to be 0.7% for metastatic cancer, 0.01% for spinal infection and 0.04% for cauda equina syndrome. Of the small proportion of patients with any of these conditions, almost all have an identifiable risk factor. Osteoporotic vertebral compression fractures (4%) and inflammatory spine disease (<5%) may cause LBP, but these conditions typically carry lower diagnostic urgency. Imaging is an important driver of LBP care costs, not only because of the direct costs of the test procedures but also because of the downstream effects. Unnecessary imaging can lead to additional tests, follow-up, referrals and may result in an invasive procedure of limited or questionable benefit. Imaging should be delayed for 6 weeks in patients with nonspecific LBP without reasonable suspicion for serious disease.

          The translational potential of this article: Diagnostic imaging studies should be performed only in patients who have severe or progressive neurologic deficits or are suspected of having a serious or specific underlying condition. Radiologists can play a critical role in decision support related to appropriateness of imaging requests, and accurately reporting the potential clinical significance or insignificance of imaging findings.

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          Most cited references 128

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          Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care.

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            Exposure to low-dose ionizing radiation from medical imaging procedures.

            The growing use of imaging procedures in the United States has raised concerns about exposure to low-dose ionizing radiation in the general population. We identified 952,420 nonelderly adults (between 18 and 64 years of age) in five health care markets across the United States between January 1, 2005, and December 31, 2007. Utilization data were used to estimate cumulative effective doses of radiation from imaging procedures and to calculate population-based rates of exposure, with annual effective doses defined as low ( 3 to 20 mSv), high (> 20 to 50 mSv), or very high (> 50 mSv). During the study period, 655,613 enrollees (68.8%) underwent at least one imaging procedure associated with radiation exposure. The mean (+/-SD) cumulative effective dose from imaging procedures was 2.4+/-6.0 mSv per enrollee per year; however, a wide distribution was noted, with a median effective dose of 0.1 mSv per enrollee per year (interquartile range, 0.0 to 1.7). Overall, moderate effective doses of radiation were incurred in 193.8 enrollees per 1000 per year, whereas high and very high doses were incurred in 18.6 and 1.9 enrollees per 1000 per year, respectively. In general, cumulative effective doses of radiation from imaging procedures increased with advancing age and were higher in women than in men. Computed tomographic and nuclear imaging accounted for 75.4% of the cumulative effective dose, with 81.8% of the total administered in outpatient settings. Imaging procedures are an important source of exposure to ionizing radiation in the United States and can result in high cumulative effective doses of radiation. 2009 Massachusetts Medical Society
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              Acute low back pain: systematic review of its prognosis.

              To describe the course of acute low back pain and sciatica and to identify clinically important prognostic factors for these conditions. Systematic review. Searches of Medline, Embase, Cinahl, and Science Citation Index and iterative searches of bibliographies. Pain, disability, and return to work. 15 studies of variable methodological quality were included. Rapid improvements in pain (mean reduction 58% of initial scores), disability (58%), and return to work (82% of those initially off work) occurred in one month. Further improvement was apparent until about three months. Thereafter levels for pain, disability, and return to work remained almost constant. 73% of patients had at least one recurrence within 12 months. People with acute low back pain and associated disability usually improve rapidly within weeks. None the less, pain and disability are typically ongoing, and recurrences are common.
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                Author and article information

                Contributors
                Journal
                J Orthop Translat
                J Orthop Translat
                Journal of Orthopaedic Translation
                Chinese Speaking Orthopaedic Society
                2214-031X
                2214-0328
                27 August 2018
                October 2018
                27 August 2018
                : 15
                : 21-34
                Affiliations
                [a ]Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region
                [b ]Department of Spine Surgery, Zhejiang Spine Surgery Centre, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children's Hospital of the Wenzhou Medical University, The Second School of Medicine Wenzhou Medical University, The Key Orthopaedic Laboratory of Zhejiang Province, Wenzhou, China
                [c ]Department of Radiology, Hospital of Traumatology, Carretera de Jaen SN, Granada, Spain
                [d ]Department of Radiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
                Author notes
                []Corresponding author. Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region. yixiang_wang@ 123456cuhk.edu.hk
                Article
                S2214-031X(18)30088-3
                10.1016/j.jot.2018.07.009
                6148737
                © 2018 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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                Review Article

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