Abstract
BackgroundLow back pain is one of the most common and disabling health problems in Canada and internationally. In most cases, low back pain is a benign, self-limiting condition that can be managed with little diagnostic investigation or treatment. Yet contrary to clinical practice guideline recommendations, diagnostic imaging (here meaning X-ray, MRI, CT) is commonly used in the assessment of low back pain. Diagnostic imaging is of limited value in most cases, exposing patients to unnecessary radiation and leading to increased health services use and worse patient health outcomes. The Choosing Wisely campaign has highlighted the need to reduce diagnostic imaging for low back pain; however, no clinical decision rules are available.MethodsThis project will develop a clinical decision support tool for appropriate use of diagnostic imaging for patients with low back pain in the emergency department. We will conduct a prospective cohort study at five Canadian emergency departments. The study will follow recommendations for prediction model development and testing. The study population will be 4000 patients presenting to the emergency department with low back pain. We will assess potential clinical indications of emergent-cause (i.e., “red flag” items), including clinical characteristics and past history. Our outcome, emergent-cause for low back pain such as fracture, cancer, infection, or cauda equina syndrome, will be assessed at discharge and at 1-, 3-, and 12-month follow-up periods using information from self-report and health administrative data. We will construct and assess the performance of a multivariable prediction model that has strong measurement properties, presented as a clinical decision support tool acceptable to knowledge users.DiscussionPractice guidelines describe “red flags” for which diagnostic imaging is likely appropriate. However, recommendations across guidelines are discordant, and few studies have evaluated these criteria to determine which characteristics best predict emergent etiology that warrant diagnostic imaging. A clinical decision support tool, that recommends diagnostic imaging where appropriate, has the potential to improve clinical care and patient outcomes and reduce costs associated with managing low back pain patients.
Highlights
Low back pain is one of the most common and disabling health problems in Canada and internationally
Numerous systematic reviews and practice guidelines support the limited use of diagnostic imaging for the investigation and treatment of non-specific low back pain [8,9,10,11], recommending plain-film X-ray, MRI, or CT only in special circumstances for patients with low back pain when there are “red flag” indications [8]
Study sample size The target sample of 4000 patients was calculated to have appropriate statistical power based on 10 events per variable for the outcome of interest, emergent-cause low back pain [42, 47], assuming 3–6% of participants experience the outcome event [35, 51, 52], and an analysis of 10 independent variables in our prediction model, accounting for 20% attrition at 12 months
Summary
Low back pain is one of the most common and disabling health problems in Canada and internationally. Low back pain is a benign, self-limiting condition that can be managed with little diagnostic investigation or treatment. Almost every Canadian suffers from low back pain at some point in their lives [1] It is a leading cause of disability nationally and globally (the number one cause in 2015 [2]) and results in enormous direct health care and lost productivity costs [3,4,5,6]. Low back pain is non-specific, that is, it is a benign, self-limiting condition that can be managed with little diagnostic investigation or treatment. Red flags are clinical characteristics suggestive of underlying emergent cause, including potential fracture, cancer, infection, or cauda equina syndrome These diagnoses are rare, occurring in less than 10% of low back pain cases [12, 13]
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