Low back pain: influence of early MR imaging or CT on treatment and outcome--multicenter randomized trial

To establish whether early use of magnetic resonance (MR) imaging or computed tomography (CT) influences treatment and outcome of patients with low back pain (LBP) and whether it is cost-effective.

In a multicenter randomized study, two imaging policies for LBP were compared in 782 participants with symptomatic lumbar spine disorders who were referred to orthopedists or neurosurgeons. Participants were randomly allocated to early (393 participants; mean age, 43.9 years; range, 16-82 years) or delayed selective (389 participants; mean age, 42.8 years; range, 14-82 years) imaging groups. Delayed selective imaging referred to imaging restricted to patients in whom a clear clinical need subsequently developed. Main outcome measures were Aberdeen Low Back Pain (ALBP) score, Short Form 36 (SF-36) score (for multidimensional health status), EuroQol (EQ-5D) score (for quality-adjusted life-year [QALY] estimates), and healthcare resource use at 8 and 24 months after randomization. Data were evaluated with analysis of covariance, ordinal logistic regression analysis, and chi(2) and Mann-Whitney tests.

Both groups showed improvement in ALBP score, but this was greater in the early group (adjusted mean difference between groups, -3.05 points [95% CI: -5.16, -0.95; P =.005] and -3.62 points [95% CI: -5.92, -1.32; P =.002] at 8 and 24 months, respectively). Scores for SF-36 (bodily pain domain) and EQ-5D were also significantly better at 24 months. Clinical treatment was similar in both groups. Differences in total costs reflected cost of imaging. Imaging provided an adjusted mean additional QALY of 0.041 during 24 months at a mean incremental cost per QALY of $2,124.

Early use of imaging does not appear to affect treatment overall. Decisions about the use of imaging depend on judgments concerning whether the small observed improvement in outcome justifies additional cost.