Journal of General Internal Medicine

, Volume 16, Issue 1, pp 14–23 | Cite as

Finding cancer in primary care outpatients with low back pain

A comparison of diagnostic strategies
  • Jerry D. Joines
  • Robert A. McNutt
  • Timothy S. Carey
  • Richard A. Deyo
  • Roya Rouhani
Original Articles


OBJECTIVE: To compare strategies for diagnosing cancer in primary care patients with low back pain. Strategies differed in their use of clinical findings, erythrocyte sedimentation rate (ESR), and plain x-rays prior to imaging and biopsy.

DESIGN: Decision analysis and cost effectiveness analysis with sensitivity analyses. Strategies were compared in terms of sensitivity, specificity, and diagnostic cost effectiveness ratios.

SETTING: Hypothetical.

MEASUREMENTS: Estimates of disease prevalence and test characteristics were taken from the literature. Costs were represented by the Medicare reimbursement for the tests and procedures employed.

MAIN RESULTS: In the baseline analysis, using magnetic resonance imaging (MRI) as the imaging procedure prior to a single biopsy, strategies ranged in sensitivity from 0.40 to 0.73, with corresponding diagnostic costs of $14 to $241 per patient with average cost effectiveness ratios of $5,283 to $49,814 per case of cancer found. Incremental cost effectiveness ratios varied from $8,397 to $624,781; five strategies were dominant in the baseline analysis. Use of a higher ESR cutoff point (50 mm/hr) improved specificity and cost effectiveness for certain strategies. Imaging with MRI, or bone scan followed in series by MRI, resulted in fewer unnecessary biopsies than imaging with bone scan alone. Cancer prevalence was an important determinant of cost effectiveness.

CONCLUSIONS: We recommend a strategy of imaging patients who have a clinical finding (history of cancer, age ≥ 50 years, weight loss, or failure to improve with conservative therapy) in combination with either an elevated ESR (≥50 mm/hr) or a positive x-ray, or using the same approach but imaging directly those patients with a history of cancer.

Key words

low back pain decision analysis cost-effectiveness analysis 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine. 1987;12:264–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Lawrence VA, Tugwell P, Gafni A, Kosuwon W, Spitzer WO. Acute low back pain and economics of therapy: the iterative loop approach. J Clin Epidemiol. 1992;45:301–11.PubMedCrossRefGoogle Scholar
  3. 3.
    Deyo RA. Early diagnostic evaluation of low back pain. J Gen Intern Med. 1986;1;328–38.PubMedCrossRefGoogle Scholar
  4. 4.
    Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthop Clin North Am. 1991;22:263–71.PubMedGoogle Scholar
  5. 5.
    Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268:760–65.PubMedCrossRefGoogle Scholar
  6. 6.
    Deyo RA, Diehl AK. Cancer as an cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988;3:230–38.PubMedCrossRefGoogle Scholar
  7. 7.
    Constans JP, DeDivitiis E, Donzelli R, Spaziante R, Meder JF, Haye C. Spinal metastases with neurological manifestations: review of 600 cases. J Neurosurg. 1983;59:111–18.PubMedCrossRefGoogle Scholar
  8. 8.
    Bates DW, Reuler JB. Back pain and epidural spinal cord compression. J Gen Intern Med. 1988;3:191–97.PubMedCrossRefGoogle Scholar
  9. 9.
    Portenoy RK, Lipton RB, Foley KM. Back pain in the cancer patient: an algorithm for evaluation and management. Neurology. 1987;37:134–38.PubMedGoogle Scholar
  10. 10.
    Sorensen PS, Borgesen SE, Rohde K, et al. Metastatic epidural spinal cord compression: results of treatment and survival. Cancer. 1990;65:1502–08.PubMedCrossRefGoogle Scholar
  11. 11.
    O’Rourke T, George CB, Redmond J, et al. Spinal computed tomography and computed tomographic metrizamide myelography in the early diagnosis of metastatic disease. J Clin Oncol. 1986;4:576–83.PubMedGoogle Scholar
  12. 12.
    Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR publication 950642. Rockville, Md: Agency for Health Care Policy and Research, US Dept of Health and Human Services. December; 1994.Google Scholar
  13. 13.
    Kostuik JP. Differential diagnosis and surgical treatment of metastatic spinal tumors. In: Frymoyer JW, ed. The Adult Spine: Principles and Practice. 2nd ed. Philadelphia: Lipincott-Raven Publishers; 1997;989–1014.Google Scholar
  14. 14.
    Li KC, Poon PY. Sensitivity and specificity of MRI in detecting malignant spinal cord compression and in distinguishing malignant from benign compression fractures of vertebrae. Magn Reson Imaging. 1988;6:547–56.PubMedCrossRefGoogle Scholar
  15. 15.
    Godersky JC, Smoker WRK, Knutzon R. Use of magnetic resonance imaging in the evaluation of metastatic spinal disease. Neurosurgery. 1987;21:676–80.PubMedCrossRefGoogle Scholar
  16. 16.
    Sze G. Magnetic resonance imaging in the evaluation of spinal tumors. Cancer. 1991;67:1229–241.PubMedCrossRefGoogle Scholar
  17. 17.
    Pelz DM, Haddad RG. Radiologic investigation of low back pain. CMAJ. 1989;140:289–95.PubMedGoogle Scholar
  18. 18.
    Deyo RA, Bigos SJ, Maravilla KR. Diagnostic imaging procedures for the lumbar spine. Ann Intern Med. 1989;111:865–7.PubMedGoogle Scholar
  19. 19.
    Corcoran RJ, Thrall JH, Kyle RW, Kaminski RJ, Johnson MC. Solitary abnormalities in bone scans of patients with extraosseous malignancies. Radiology. 1976;121:663–7.PubMedGoogle Scholar
  20. 20.
    Pistenma DA, McDougall R, Kriss JP. Screening for bone metastases: are only scans necessary? JAMA. 1975;231:46–50.CrossRefGoogle Scholar
  21. 21.
    Waddell G. An approach to backache. Br J Hosp Med. 1982;28:187–219 passim.PubMedGoogle Scholar
  22. 22.
    Jacobson AF. Musculoskeletal pain as an indicator of occult malignancy: yield of bone scintigraphy. Arch Intern Med. 1997;157:105–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Han LJ, Au-Wong TK, Tong WCM, Chu KS, Szeto LT, Wong CP. Comparison of bone single-photon emission tomography and planar imaging in the detection of vertebral metastases in patients with back pain. Eur J Nucl Med. 1998;25:635–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Avrahami E, Tadmor R, Dally O, Hadar H, Early MR. demonstration of spinal metastases in patients with normal radiographs and CT and radionuclide bone scans. J Comput Assist Tomogr. 1989;13:598–602.PubMedCrossRefGoogle Scholar
  25. 25.
    Gosfield E, Alavi A, Kneeland B. Comparison of radionuclide bone scans and magnetic resonance imaging in detecting spinal metastases. J Nucl Med. 1993;34:2191–8.PubMedGoogle Scholar
  26. 26.
    Mazanec DJ. Low back pain syndromes. In: Black ER, Bordley DR, Tape TG, Panzer RJ, eds. Diagnostic Strategies for Common Medical Problems. 2nd ed. Philadelphia: American College of Physicians; 1999:401–18.Google Scholar
  27. 27.
    Collins JD, Bassett L, Main GD, Kagan C. Percutaneous biopsy following positive bone scans. Radiology. 1979;132:439–42.PubMedGoogle Scholar
  28. 28.
    Schajowicz F, Derqui JC. Puncture biopsy in lesions of the locomotor system: review of results in 4050 cases, including 941 vertebral punctures. Cancer. 1968;21:531–48.PubMedCrossRefGoogle Scholar
  29. 29.
    Fyfe IS, Henry APJ, Mulholland RC. Closed vertebral biopsy. J Bone Joint Surg. 1983;65:140–3.Google Scholar
  30. 30.
    Ackermann W. Application of the trephine for bone biopsy: results in 635 cases. JAMA. 1963;184:11–7.PubMedGoogle Scholar
  31. 31.
    Babu NV, Titus VTK, Chittaranjan S, Abraham G, Prem H, Korula RJ. Computed tomographically guided biopsy of the spine. Spine. 1994;19:2436–442.PubMedCrossRefGoogle Scholar
  32. 32.
    Kornblum MB, Wesolowski DP, Fischgrund JS, Herkowitz HN. Computed tomography guided biopsy of the spine: a review of 103 patients. Spine. 1998;23:81–5.PubMedCrossRefGoogle Scholar
  33. 33.
    Stoker DJ, Kissin CM. Percutaneous vertebral biopsy: a review of 135 cases. Clin Radiol. 1985;36:569–77.PubMedCrossRefGoogle Scholar
  34. 34.
    Moore TM, Meyers MH, Patzakis MJ, Terry R, Harvey JP. Closed biopsy of musculoskeletal lesions. J Bone Joint Surg. 1979;61-A:375–80.Google Scholar
  35. 35.
    Health Care Financing Administration. Medicare Physician Fee Schedule and Clinical Diagnostic Laboratory Fee Schedule. Available at Scholar
  36. 36.
    Eisenberg JM. Clinical economics: a guide to the economic analysis of clinical practices. JAMA. 1989;262:2879–86.PubMedCrossRefGoogle Scholar
  37. 37.
    Detsky AS, Naglie IG. A clinican’s guide to cost effectiveness analysis. Ann Intern Med. 1990;113:147–54.PubMedGoogle Scholar
  38. 38.
    Siegel JE, Weinstein MC, Torrance GW. Reporting cost effectiveness studies and results. In: Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Cost Effectiveness in Health and Medicine. New York: Oxford University Press; 1996:276–303.Google Scholar
  39. 39.
    Brandeau ML, Eddy DM. The workup of the asymptomatic patient with a positive fecal occult blood test. Med Decis Making. 1987;7:32–46.PubMedCrossRefGoogle Scholar
  40. 40.
    Liang M, Momaroff AL. Roentgenograms in primary care patients with acute low back pain: a cost effectiveness analysis. Arch Intern Med. 1982;142:1108–12.PubMedCrossRefGoogle Scholar
  41. 41.
    Frazier LM, Carey TS, Lyles MF, Khayrallah MA, McGaghie WC. Selective criteria may increase lumbosacral spine roentgenogram use in acute low-back pain. Arch Intern Med. 1989;149:47–50.PubMedCrossRefGoogle Scholar
  42. 42.
    Schroth WS, Schectman JM, Elinsky EG, Panagides JC. Utilization of medical services for the treatment of acute low back pain: conformance with clinical guidelines. J Gen Intern Med. 1992;7:486–91.PubMedCrossRefGoogle Scholar
  43. 43.
    Carey TS, Garrett JG, Jackman A, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. N Engl J Med. 1995;333:913–17.PubMedCrossRefGoogle Scholar
  44. 44.
    Evens RG. Diagnostic imaging in cancer care: the role of cost/benefit analysis. Cancer. 1991;67:1245–52.PubMedCrossRefGoogle Scholar
  45. 45.
    Brown ML, Fintor L. Cost effectiveness of breast cancer screening: preliminary results of a systematic review of the literature. Breast Cancer Res and Treat. 1993;25:113–18.CrossRefGoogle Scholar
  46. 46.
    Tatsui H, Onomura T, Morishita S, Oketa M, Inoue T. Survival rates of patients with metastatic spinal cancer after scintigraphic detection of abnormal radioactive accumulation. Spine. 1996;21:2143–48.PubMedCrossRefGoogle Scholar

Copyright information

© Blackwell Science Inc 2001

Authors and Affiliations

  • Jerry D. Joines
    • 6
    • 2
  • Robert A. McNutt
    • 3
  • Timothy S. Carey
    • 1
    • 2
  • Richard A. Deyo
    • 4
  • Roya Rouhani
    • 5
  1. 1.the Cecil G. Sheps Center for Health Services ResearchUSA
  2. 2.the Department of MedicineUniversity of North Carolina at Chapel HillChapel Hill
  3. 3.Department of MedicineCook County HospitalChicago
  4. 4.Department of Medicine, Department of Health Services, and Center for Cost and Outcomes ResearchUniversity of WashingtonSeattle
  5. 5.Center for Distance Learning and TelehealthUniversity of Texas Health Science CenterSan Antonio
  6. 6.Internal Medicine Training ProgramMoses H. Cone Memorial HospitalGreensboro

Personalised recommendations