Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 3: Spinal Disorders

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Abstract

Purpose

To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for spinal disorders.

Methods

A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research were invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer reviewed by practicing chiropractors, and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence.

Results

Recommendations for diagnostic imaging guidelines of adult spine disorders are provided, supported by more than 385 primary and secondary citations. The overall quality of available literature is low, however. On average, 45 Delphi panelists completed 1 of 2 rounds, reaching more than 85% agreement on all 55 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. Dissemination and implementation strategies are discussed.

Conclusions

The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

Section snippets

Reporting of Topics Included in the Development of the Diagnostic Imaging Practice Guidelines1

An initial literature review considered 10 clinical questions pertaining to imaging of musculoskeletal conditions to evaluate the pertinence of developing diagnostic imaging guidelines. This initial review led to a research project divided into 9 phases: (1) literature search; (2) independent literature assessment; (3) guideline development specific recommendations; (4) first external review; (5) consensus panel (modified Delphi); (6) public website; (7) second external review; (8) final draft

Methods for Synthesizing Evidence

  • (a)

    Literature search and independent literature assessment of spinal disorders: Quality of diagnostic accuracy studies (QUADAS),3 Appraisal of Guidelines Research and Evaluation (AGREE),4 and Stroke Prevention and Educational Awareness Diffusion (SPREAD).5

  • (b)

    Initial draft: template based on European Commission classification (2001).6

  • (c)

    Expert consensus: a 2-round modified Delphi process was used to generate consensus among an international panel of more than 60 experts in musculoskeletal disorders.

What Is the Role of These Guidelines?

These evidence-based diagnostic imaging practice guidelines are intended to assist primary care providers and students in decision making regarding the appropriate use of diagnostic imaging for specific clinical presentations. The guidelines are intended to be used in conjunction with sound clinical judgment and experience. For example, other special circumstances for radiographic imaging studies may include: patient unable to give a reliable history; crippling cancer phobia focused on back

Are There Potential Risks Associated With Conventional Radiographs?

Although somewhat controversial,20, 21, 22, 23 it is important to remember that health hazards of all forms of radiation are cumulative.23, 24, 25, 26, 27, 28, 29, 30 The Biological Effects of Ionizing Radiation (BEIR) 2005 report released by the National Academy of Sciences adds further support to the “linear-no-threshold” model of cancer risk from ionizing radiation exposure.31 In summary, this report concludes that ionizing radiation is dangerous even at low doses and that there are no safe

Acknowledgment

We appreciate the efforts of the many people who assisted in this process, listed in Appendix G.

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