title: Imaging studies in patients with spinal pain:   Practice audit evaluation of Choosing Wisely Canada recommendations.
abstract: OBJECTIVE
  To evaluate an a priori threshold for advanced imaging in patients with spinal pain.
  
  
  METHODS
  Patients with spinal pain in any region for 6 to 52 weeks were assessed to determine if radiologic studies beyond x-ray scans were indicated, including magnetic resonance imaging (MRI), computed tomography (CT), and radionuclide bone scans. An a priori threshold was set before MRI, CT, or bone scans would be considered. Those who did not have MRI, CT, or bone scans ordered were followed for at least 1 year to determine if any of them went on to be diagnosed with a more serious spinal disorder (eg, infection, fracture, spondylitis, tumour, neurologic compression).
  
  
  METHODS
  Four large primary care clinics in Edmonton, Alta.
  
  
  METHODS
  A total of 1003 consecutively presenting patients with symptoms suspected to be related to the spine (for a duration of generally 6 to 52 weeks) who had not already undergone advanced imaging and did not have a diagnosis of nonbenign back pain.
  
  
  METHODS
  Number of cases of nonbenign spinal disorder in participants who underwent advanced imaging and participants who did not undergo advanced imaging (ie, did not have any red flags).
  
  
  RESULTS
  There were 399 women (39.8%) and 604 men (60.2%). The mean (SD) age of the group was 47.2 (14.6) years. The mean (SD) duration of symptoms was 15.1 (8.6) weeks. Of the 1003 participants, 110 met an a priori threshold for undergoing at least 1 of MRI, CT, or bone scan. In these 110 participants, there were newly diagnosed cases of radiculopathy (n = 12), including a case of cauda equina syndrome; spondyloarthropathy (n = 6); occult fracture (n = 2); solitary metastasis (n = 1); epidural lipomatosis (n = 1); osteomyelitis (n = 1), and retroperitoneal hematoma (n = 1), each of which was considered likely to be the cause of the patient's spinal symptoms. The remaining 893 participants were followed for at least 1 year and none showed evidence of a nonbenign cause of his or her spinal pain.
  
  
  CONCLUSIONS
  In the evaluation of nonspecific spinal pain and symptoms, setting and following an a priori threshold for ordering MRI, CT, or bone scans in the spirit of the current Choosing Wisely Canada recommendations has a very low risk of missing a case of a serious cause of back pain.
authors.forename: Robert
authors.initials: R
authors.lastname: Ferrari
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta; D001416:Back Pain / Q000175:diagnosis*; D003952:Diagnostic Imaging / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D013122:Spinal Diseases / Q000175:diagnosis*; D019564:Unnecessary Procedures / Q000191:economics*; D055815:Young Adult