Evidence-Based Recommendations for Spine Surgery Alexander R. Vaccaro, MD, PhD; Charles G. Fisher, MD; Peter G. Whang, MD; Alpesh A. Patel, MD; Srinivas K. Prasad, MD; Peter D. Angevine, MD, MPH; Kishore Mulpari, MBBS, MHSc; Ken C. Thomas, MD, MHSc Imaging strategies for low-back pain: systematic review and meta-analysis. Chou R, Fu R, Carrino JA, et al. Lancet 2009;373:463–72. STUDY SUMMARY L umbar spinal imaging is commonly utilized in the evaluation of low back pain. The rationale for imag- ing, either plain radiographs, computed tomography (CT), or magnetic resonance imaging (MRI), is primarily based on identifying anatomical sources of pain. Unfortunately, the correlation between findings on im- aging and clinical symptoms can be limited. A number of studies have been preformed to elucidate the value of spinal imaging in the setting of acute back pain. The defi- nition of “value”, however, varies from study to study. Investigations have focused separately on diagnostic infor- mation, treatment interventions, patient outcomes, or patient satisfaction. Additionally, the inclusion and ex- clusion criteria for these studies have not been uniform. Specifically the definition of “red flags” for serious dis- ease (fevers, weight loss, neurological deficits, etc.) are subjective and, in some instances, not defined. Nonethe- less the clinical question remains: is immediate routine lumbar spine imaging more effective than usual care without imaging in patients with low back pain and no suggestion of “red flags.” Chou et al. used methods of systematic review and meta-analysis to address this question. METHODOLOGICAL REVIEW The authors conducted a systematic review and meta- analysis with sound and reproducible methodology. The methods used to select articles were well described with clear inclusion and exclusion criteria. Relevant outcome measures formed part of the inclusion criteria. Random- ized controlled trials that compared immediate lumbar imaging to routine care for low back pain patients with- out indication of serious underlying conditions were considered. Trials were included if their outcomes re- ported on pain, function, mental health, quality of life, patient satisfaction and overall patient reported im- provement. Two reviewers independently assessed titles and abstract for study inclusion. Two reviewers ab- stracted data from included papers and ranked each pa- per as higher or lower quality according to accepted and pre-specified criteria. Two primary outcomes were iden- tified: pain and function. Secondary outcomes included mental status, quality of life, patient satisfaction and overall improvement. Outcomes were categorized as short-term (3 months), long-term (3– 6 months) and extended (1 year). Given that different trials used dif- ferent scales for measurement of specific outcomes, out- come scores were standardized to allow for pooling. The authors defined clinically important differences in outcome measures a priori, diminishing the likelihood of bias. Point estimates and their confidence intervals were reported using a random effects model. Meta-regression was performed for pain and function using duration of pain, imaging tech- nique and trial quality as independent variables. Peter G. Whang, MD, Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA Alpesh A. Patel, MD, Departments of Orthopaedic Surgery and Neurosurgery, University of Utah, Salt Lake City, UT, USA Alexander R. Vaccaro, MD, PhD, Srinivas K. Prasad, MD, Departments of Orthopaedic Surgery and Neurological Surgery, Thomas Jefferson University and The Rothman Institute, Philadelphia, PA, USA Peter D. Angevine, MD, MPH, Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA Kishore Mulpari, MBBS, MHSc, British Columbia Childrens Hospital, Vancouver, BC, Canada Ken C. Thomas, MD, MHSc, Division of Spine, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada Charles G. Fisher, MD, Departments of Orthopaedic Surgery and Neurological Surgery, Thomas Jefferson University and The Rothman Institute, Philadelphia, PA Corresponding Author: Alexander R. Vaccaro, Department of Orthopaedic Surgery and the Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Phildelphia, PA 19107, USA. Phone: (215) 955-3458; E-mail: alexvaccaro3@aol.com Spine E178 SPINE  Volume 35  Number 6  2010