Nearly all the patients with low back pain referred by their general practitioner for a lumbar magnetic resonance imaging scan (MRI) had abnormal findings on the imaging, with seven in 10 showing disc herniation, according to a prospective cohort study published in December 8 in Family Practice.
“International and Dutch guidelines recommend the use of imaging only when there is suspicion of serious pathology (fracture, malignancy and discitis) or in patients with severe sciatica for whom surgery is indicated because they fail to respond to conservative care for at least 6–8 weeks,” write Evelien I. T. de Schepper, MD, from Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues. “In the present study, most patients presenting for a lumbar MRI examination as referred by their [general practitioner] reported long-lasting back complaints and high scores on back and leg pain.”
The researchers consecutively recruited all willing adults who were referred by their general practitioner for a lumbar MRI from June 2010 through September 2011. Patients completed questionnaires on basic demographics as well as their history of back pain, its duration and severity, back pain symptoms, their quality of life, and their beliefs regarding back pain. The researchers reviewed MRI data for presence of disc bulging, disc herniation, disc sequestration, nerve root compression, spinal stenosis, spondylolisthesis, and serious pathologies, such as fracture, malignancy, and/or diskettes.
Among the 683 participants, ranging in age from 19 to 80 years, the mean age was 49.9 years, and 70% were employed. Just more than half (53%) were male, and 36% had a low education level.
The average back pain severity score reported by the participants was 6.6 on an 11-point scale from 0 (no pain) to 10 (worst pain ever). Average disability score was 13.5 on the Roland Disability Questionnaire. Two thirds (67%) of the participants reported having chronic low back pain, with 71% of these individuals reporting it had persisted for at least a year.
Two thirds of the participants (66%) reported pain that radiated to the leg below the knee, and the mean score for leg pain severity was 5.6. Just more than half the participants (55%) reported having this pain for at least 6 weeks. In addition, 77% of the patients reported neurological symptoms in the legs.
Nearly all (94%) the patients had abnormal MRI findings, including 72% with disc herniation (more frequently at lower lumbar disc levels), 69% with signs of nerve root compression, 18% with spondylolisthesis (75% of which were grade I), 13% with spinal stenosis, 3% with compression fractures, and 0.3% with discitis. Almost half (46%) the patients had disc herniation at multiple levels.
“Patients without any abnormal MRI findings (6%) were more often female, had a slightly higher [body mass index] and less often reported pain radiating to the leg below the knee and neurological symptoms of the legs, compared with those with specific MRI findings,” that authors report.
“Patients with disc herniation with nerve root compression were younger, more often male, had a slightly higher [body mass index,] and more often reported acute back pain compared with those without.”
All of the 0.7% of patients with malignancy reported that their back pain had started after age of 50 years, a “red flag,” the authors noted, and only two of the five patients had a history of back pain.
“These results could be an indication that [general practitioners] in the Netherlands tend to adhere to their guidelines,” an area requiring research for confirmation, the authors write.