Primary care Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial

Objective To test the hypothesis that radiography of the lumbar spine in patients with low back pain is not associated with improved clinical outcomes or satisfaction with care. Design Randomised unblinded controlled trial. Setting 73 general practices in Nottingham, north Nottinghamshire, southern Derbyshire, north Lincolnshire, and north Leicestershire. 52 practices recruited participants to the trial. Subjects 421 patients with low back pain of a median duration of 10 weeks. Intervention Radiography of the lumbar spine. Main outcome measures Roland adaptation of the sickness impact profile, visual analogue scale for pain, health status, EuroQol, satisfaction with care, use of primary and secondary care services, and reporting of low back pain at three and nine months after randomisation. Results The intervention group were more likely to report low back pain at three months (relative risk 1.26, 95% confidence interval 1.00 to 1.60) and had a lower overall health status score and borderline higher Roland and pain scores. A higher proportion of participants consulted their doctor in the three months after radiography (1.62, 1.33 to 1.97). Satisfaction with care was greater in the group receiving radiography at nine but not three months after randomisation. Overall, 80% of participants in both groups at three and nine months would have radiography if the choice was available. An abnormal finding on radiography made no difference to the outcome, as measured by the Roland score. Conclusions Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks’ duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography. Introduction Low back pain is a common condition in primary care, with 7% of the adult population consulting for this condition each year. Radiography of the lumbar spine is the most usual investigation for back pain in primary care and accounts for 5% of all radiographic examinations in NHS hospitals. Despite this, the yield of findings that alter clinical management is low. One survey found that more than 80% of doctors would always or sometimes refer patients with recurrent low back pain for radiography, and more than 70% would always or sometimes refer those with a first episode of low back pain lasting for more than one month. When asked about reasons for requesting radiography, 88% said they did so to reassure patients and 78% said they did so to reassure themselves. In addition, many patients with low back pain believe they need radiography. 8 Conflicting findings have been found concerning patient satisfaction and referral for radiography, 5 8 and one study found that providing a patient with a diagnostic label increased patient satisfaction. A small UK trial of radiography of the lumbar spine at presentation for new episodes of low back pain in primary care found small improvements in psychological wellbeing in the group of patients receiving radiography. Current guidelines for managing low back pain give conflicting advice regarding radiography of the lumbar spine. Guidelines from the Agency for Health Care Policy and Research suggest radiography if the patient is not improving after four weeks, the Clinical Standards Advisory Group suggest considering radiography after six weeks if there is no improvement, the Royal College of General Practitioners suggest radiography is not indicated in acute back pain of less than four weeks’ duration, and the Royal College of Radiologists suggest radiography is not routinely indicated in patients with acute low back pain without indicators for serious spinal disease. In the light of this conflicting advice, we aimed to test the hypothesis that radiography of the lumbar spine in patients in primary care with low back pain of at least six weeks’ duration is not associated with improved clinical outcomes or satisfaction with care. We therefore tested the effect of radiography of the lumbar spine on patient outcomes rather than its utility as a diagnostic test. Division of General Practice, School of Community Health Sciences, University Park, Nottingham NG7 2RD Denise Kendrick senior lecturer Mike Pringle professor Division of Public Health Medicine and Epidemiology, Queens Medical Centre, Nottingham NG7 2UH Katherine Fielding lecturer in statistics Elaine Bentley research assistant Paul Miller lecturer in health economics Imaging Centre, Queens Medical Centre Robert Kerslake consultant radiologist Correspondence to: D Kendrick denise.kendrick@ nottingham.ac.uk