Appropriateness of Referrals From Primary Care for Lumbar MRI

Abstract Background: A number of papers highlight the extent to which low back pain (LBP) is generally mismanaged, especially regarding overuse of magnetic resonance imaging (MRI). International guidelines do not recommend routine imaging, including MRI, and seek to guide clinicians only to refer for imaging based on specific indications. Despite this, several studies show an increase in the use of MRI among patients with LBP and an imbalance between appropriate versus inappropriate use of MRI for LBP. This study aimed to investigate to what extent referrals from general practice for lumbar MRI complied with clinical guideline recommendations in a Danish setting.Materials and methods: From 2014-2018, all referrals for lumbar MRI were included from general practitioners in the Central Denmark Region for diagnostic imaging at a public regional hospital. A modified version of the American College of Radiology Imaging Appropriateness Criteria for LBP was used to classify referrals as appropriate or inappropriate, based on the unstructured text in the GPs’ referrals. Appropriate referrals included fractures, cancer, symptoms persisting for more than 6 weeks of non-surgical treatment, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals were sub-classified as lacking information about previous non-surgical treatment and duration. Results: Of the 3,772 retrieved referrals for MRI of the lumbar spine, 55% were selected and a total of 2,051 referrals were categorised. Approximately one quarter (24.5%) were categorised as appropriate, and 75.5% were deemed inappropriate. 51% of the inappropriate referrals lacked information about previous non-surgical treatment, and 49% had no information about the duration of non-surgical treatment. Apart from minor yearly fluctuations, there was no change in the distribution of appropriate and inappropriate MRI referrals from 2014 to 2018.Conclusion:The majority of lumbar MRI referrals (75.5%) from general practitioners for lumbar MRI did not fulfil the ACR Imaging Appropriateness Criteria for LBP based on the unstructured text of their referrals. There is a need for referrers to include all guideline-relevant information in referrals for imaging. More research is needed to determine whether this is due to patients not fulfilling guideline recommendations or simply the content of the referrals.

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BENIGN TUMORS BREAST GLASS

Clinical Medicine and Pharmacology ◽

10.12737/2409-3750-2021-7-2-2-11 ◽

2021 ◽

Vol 7 (2) ◽

pp. 2-11

Author(s):

Arif Guseynov ◽

T. Guseynov ◽

V. Odincov

Keyword(s):

Surgical Treatment ◽

General Practitioners ◽

Clinical Picture ◽

Relevant Information ◽

Diagnostic Methods ◽

Diagnosis And Treatment ◽

Differential Diagnostics ◽

Benign Tumors

The lecture provides relevant information for doctors of various specialties: oncologists, surgeons, mammologists, general practitioners on the problems of diagnosis and treatment of benign breast formations. The issues of etiology and pathogenesis, classification and clinical picture of various formations are highlighted, diagnostic methods, differential diagnostics, treatment tactics and methods of surgical treatment are described in detail.

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Non-surgical Treatment for Cauda Equina Syndrome after Lumbar Epidural Block

Asian Journal of Pain ◽

10.35353/ajp.3.2.36 ◽

2017 ◽

Vol 3 (2) ◽

pp. 36-38

Author(s):

Jin-Woo Park ◽

Junseok W Hur ◽

Jang-Bo Lee ◽

Jung-Yul Park

Keyword(s):

Surgical Treatment ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

Epidural Block ◽

Non Surgical Treatment

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Conservative Treatment for Giant Lumbar Disc Herniation: Clinical Study in 409 Cases

January 2018 - Pain Physician ◽

10.36076/ppj.2021.24.e639 ◽

2021 ◽

pp. E639-E648

Keyword(s):

Surgical Treatment ◽

Chinese Medicine ◽

Treatment Group ◽

Conservative Treatment ◽

Lumbar Disc Herniation ◽

Disc Herniation ◽

Lumbar Disc ◽

Cauda Equina ◽

Bull's Eye ◽

Non Surgical Treatment

BACKGROUND: There have been several recent reports of lumbar disc herniation (LDH) resorption; however, large sample studies are lacking, and the mechanism(s) underlying this phenomenon is unclear. OBJECTIVES: To explore the feasibility and clinical outcomes of conservative treatment for giant LDH and to analyze the factors affecting the resorption of giant LDH. STUDY DESIGN: Observational study and original research. SETTING: This work was performed at a University Hospital of Traditional Chinese Medicine, Nanjing University of Traditional Chinese Medicine. METHODS: From January 2008 to December 2019, 409 patients with giant LDH who initially underwent nonsurgical treatment in our hospital were followed for 1–12 years to analyze the rate of surgical intervention, calculate the rate of resorption of protrusions, and the rate of excellent clinical outcomes. RESULTS: Eighty-nine of the 409 patients (21.76%) underwent surgery, while the remaining 320 patients (78.24%) constituted the non-surgical treatment group. The Japanese Orthopaedic Association (JOA) score in the 320 patients changed from 10.22 ± 3.84 points to 24.88 ± 5.69 points after treatment, and the rate of excellent outcomes was 84.06%. Among the 320 patients in the non-surgical treatment group, the protrusion percentage decreased from 70.08±30.95% to 31.67 ± 24.42%. One-hundred and eighty-nine patients (59.06%) had > 30% resorption of protrusions, and 81 patients (25.31%) had a significant resorption of protrusions of > 50%. Among 189 patients with resorption, the shortest resorption interval was 1 month, and the longest was 8 years, with 77 patients (40.74%) showing resorption within 6 months, 51 (26.98%) within 6–12 months, and 61 patients (32.28%) after 12 months. LIMITATION: The main limitations are that all patients were from the same site, and there was a lack of multicenter randomized controlled trials with which to compare data. CONCLUSIONS: Patients with giant LDH are less likely to develop progressive nerve injury and cauda equina syndrome if their clinical symptoms improve after treatment. As long as there is no progressive nerve injury or cauda equina syndrome, conservative treatment is preferred for giant disc herniation. Resorption is more likely with greater disc protrusions in the spinal canal. A ring enhancement bull’s eye sign) around a protruding disc on enhanced magnetic resonance imaging is an important indicator of straightforward resorption. KEY WORDS: Lumbar disc herniation, conservative treatment, giant, resorption, bull’s eye sign

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Categorisation of lumbar spine MRI referrals in Denmark as compliant or non-compliant to international imaging guidelines: an inter-rater reliability study

Chiropractic & Manual Therapies ◽

10.1186/s12998-021-00370-9 ◽

2021 ◽

Vol 29 (1) ◽

Author(s):

Susanne Brogaard Krogh ◽

Tue Secher Jensen ◽

Nanna Rolving ◽

Malene Laursen ◽

Janus Nikolaj Laust Thomsen ◽

...

Keyword(s):

Surgical Treatment ◽

Lumbar Spine ◽

Pairwise Comparisons ◽

Kappa Statistics ◽

Reliability Study ◽

Appropriateness Criteria ◽

Rater Reliability ◽

Senior Clinician ◽

Spine Mri ◽

Non Surgical Treatment

Abstract Background Managing low back pain (LBP) often involves MRI despite the fact that international guidelines do not recommend routine imaging. To allow us to explore the topic and use this knowledge in further research, a reliable method to review the MRI referrals is needed. Consequently, this study aimed to assess the inter-rater reliability of a method evaluating lumbar spine MRI referrals’ appropriateness. Methods Four inexperienced students (chiropractic master’s students) and a senior clinician (chiropractor) were included as independent raters in this inter-rater reliability study. Lumbar spine MRI referrals from primary care on patients (> 18 years) with LBP with or without leg pain were included. The referrals were classified using a modified version of the American College of Radiology (ACR) imaging appropriateness criteria for LBP. Categories of appropriate referrals included; fractures, cancer, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals included lacking information on previous non-surgical treatment, no word on non-surgical treatment duration, or “other reasons” for inappropriate referrals. After two rounds of training and consensus sessions, 50 lumbar spine MRI referrals were reviewed independently by the five raters. Inter-rater reliability was quantified using unweighted Kappa statistics, and the observed agreement was calculated with both a pairwise comparison and an overall five-rater comparison. Results Inter-rater reliability was substantial, with a Kappa value for appropriate vs. inappropriate referrals of 0.76 (95% CI: 0.55–0.89). When six and eight subcategories were evaluated, the Kappa values were 0.77 (95% CI: 0.58–0.91) and 0.82 (95% CI: 0.72–0.92), respectively. The overall percentage of agreement for appropriate and inappropriate referrals was 92% and ranged from 88 to 98% for the pairwise comparisons of the five raters’ results. For the six and eight subcategories, the overall agreement was 92 and 88%, respectively, ranging from 88 to 98% and 84–92%, respectively, for the pairwise comparisons. Conclusion The inter-rater reliability of the evaluation of the appropriateness of lumbar spine MRI referrals, according to the modified ACR-appropriateness criteria, was found to range from substantial to almost perfect and can be used for research and quality assurance purposes.

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