ARTIGO DO MÊS (12/2009)

Imaging strategies for low-back pain: systematic review and meta-analysis

Kochen, Eva Blozik, Martin Scherer, Jean-François Chenot
The Lancet, Volume 373, Issue 9662, 7 February 2009-13 February 2009, Pages 436-437, Michael M

ABSTRACT

BACKGROUND: Some clinicians do lumbar imaging routinely or in the absence of historical or clinical features suggestive of serious low-back problems. We investigated the effects of routine, immediate lumbar imaging versus usual clinical care without immediate imaging on clinical outcomes in patients with low-back pain and no indication of serious underlying conditions.

METHODS: We analysed randomised controlled trials that compared immediate lumbar imaging (radiography, MRI, or CT) versus usual clinical care without immediate imaging for low-back pain. These trials reported pain or function (primary outcomes), quality of life, mental health, overall patient-reported improvement (based on various scales), and patient satisfaction in care received. Six trials (n=1804) met inclusion criteria. Study quality was assessed by two independent reviewers with criteria adapted from the Cochrane Back Review Group. Meta-analyses were done with a random effects model.

FINDINGS: We did not record significant differences between immediate lumbar imaging and usual care without immediate imaging for primary outcomes at either short-term or long-term follow-up. Other outcomes did not differ significantly. Trial quality, use of different imaging methods, and duration of low-back pain did not affect the results, but analyses were limited by small numbers of trials. Results are most applicable to acute or subacute low-back pain assessed in primary-care settings.

INTERPRETATION: Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.

CONCLUSION: We need to identify back-pain assessment and educational strategies that meet patient expectations and increase satisfaction, while avoiding unnecessary imaging.