Avoid XRAY In Back Pain

Avoid XRAY In Back Pain

Back pain is one of the most common emergency department presenting complaints, evaluating back pain , treating patients’ symptoms and to diagnose potentially life- or limb-threatening causes not always an easy task.

Usually in Emergency Department , we do require for radiological imaging despite the fact that imaging is not associated with improvement in clinical outcomes. 

A  through clinical history and exam in patients with no history of major trauma can identify many patients for whom imaging can be avoided. Important high-risk findings of bowel or bladder incontinence, significant or evolving motor and/or sensory deficit, IV drug abuse or unexplained fever, history of cancer, and advanced age (typically >70 years) are reasons to obtain imaging for low-back pain.

High-Risk History and Physical Examination Findings Warranting Further Workup

Otherwise, imaging rarely alters management, and the emphasis should be on treatment, reassurance, and education. This is supported by guidelines from both the American College of Radiology and the American College of Physicians. 

Which patients can be safely evaluated without imaging?

1. Patients with nonspecific back pain for less than six weeks and normal neurologic examination without high-risk findings can be safely discharged with reassurance and outpatient primary-care follow-up. Patients who are able to identify acute inciting event without direct trauma are much more likely to have musculoskeletal causes of back pain.
   
   
2. Patients with back pain and radiculopathy corresponding to L4–L5 or L5–S1 nerve roots (90 percent of disc herniations) are also candidates for outpatient follow-up without ED imaging. A positive straight leg raise is 91 percent sensitive and crossed straight leg raise is 88 percent specific for herniated discs. Patients with signs consistent with lumbar radiculopathy should not routinely undergo MRIs in the ED. While MRI is sensitive for the disc disease, identifying herniated discs doesn’t alter ED management. One study of asymptomatic patients demonstrated that 64 percent had abnormal discs, 52 percent had bulging discs, and 31 percent had disc protrusion!4 MRI is an outpatient preoperative test for patients with persistent symptoms less than six weeks who may be candidates for spinal injections or surgery. Indications for surgery include failure of conservative therapy after four to six weeks and neurologic deficit causing disability.
   
   
3. The majority of patients in both groups will improve with conservative management within four to six weeks; emergent imaging does not alter clinical outcomes.

The next time you see a patient with back pain with no high-risk findings, spend a few minutes discussing the diagnosis and plan with the patient. Reassurance and an outpatient regimen of over-the-counter analgesia and supportive care can reduce cost and length of stay—and, more important, are clinically effective.



Source : www.acepnow.com

             www.ncbi.nlm.nih.gov
             www.painscience.com