The Royal Australian and New Zealand College of Radiologists
Recommendations from the Royal Australian and New Zealand College of Radiologists on imaging for ankle trauma, deep venous thrombosis (DVT), pulmonary embolism, low back pain, whole breast radiation therapy, prostate cancer, bone metastases, brain radiation therapy & locoregional therapy. RANZCR is a non-profit association that delivers skills, knowledge, and insight to promote the science and practice of the medical specialties of clinical radiology (diagnostic and interventional) and radiation oncology.
Don't perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
Low back pain (LBP) is extremely common, being the third most common health complaint seen by Australian general practitioners.
A simple classification places patients into one of three categories:
- LBP associated with sciatica or spinal canal stenosis
- Serious spinal pathology (such as cancer, infection, fracture, and cauda equina syndrome) comprises 1% of GP presentations with LBP
- Non-specific low back pain (90% of presentations)
When evaluating patients with acute LBP, one of the key issues to be addressed is whether or not the patient should be investigated using imaging to confirm or refute the presence of an underlying/associated condition that would change the subsequent medical treatment or investigation of the patient.
Age over 70 years, trauma, corticosteroid therapy, and female gender are risk factors for fracture and previous or current cancer significantly increases the likelihood of cancer related back pain. At least one of fever, systemic symptoms, recent invasive procedure or sepsis, or elevated CRP are seen in most but not all patients with discitis or epidural abscess. New lower limb or bladder motor dysfunction increase the likelihood of cauda equina syndrome in a patient with LBP and are indications for emergency MRI.
Recommendation released April 2015
- Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ (Clinical Research Ed). 2008; 337: a171.
- Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J and Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010.
- Henschke N, Maher C, Refshauge K, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009; 60: 3072-80.
- Chou R, Qaseem A, Owens DK and Shekelle P. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med. 2011; 154: 181-9.
- Williams CM, Henschke N, Maher CG, et al. Red flags to screen for vertebral fracture in patients presenting with low back pain. Cochrane Database Syst Rev 2013. 2013.
- Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P and Irwig L. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev 2013. 2013; 2.
- Henschke N, Maher C and Refshauge K. Screening for malignancy in low back pain patients: a systematic review. Eur Spine J. 2007; 16: 1673-9.
Clinical radiology recommendations 1-6 (April 2015)
A team of five Lead Radiologists were nominated to guide RANZCR's Choosing Wisely contribution. These Lead Radiologists analysed previous work completed by RANZCR, in particular a series of Education Modules for Appropriate Imaging Referrals.
These modules had been developed from an extensive evidence base and with multiple stakeholder input. Using the evidence from the Education Modules, the Lead Radiologists developed a draft recommendations list, which was then further developed and endorsed by RANZCR's Quality and Safety Committee, before being circulated to the RANZCR membership for consultation with a request for alternative recommendations. Member feedback was reviewed by the Lead Radiologists prior to ratification of the final recommendations by the Faculty of Clinical Radiology Council. The final six items selected were those that were felt to meet the goals of Choosing Wisely, i.e. those which are frequently requested or which might expose patients to unnecessary radiation.
Due to the fundamental role of diagnostic imaging in supporting diagnosis across the healthcare system, RANZCR worked closely with other Colleges throughout the project via the Advisory Panel. Following identification of two common recommendations with the Australasian College for Emergency Medicine, it was agreed by both Colleges to present these items jointly.
Radiation oncology recommendations 7-12 (October 2016)
Recommendations relating to radiation oncology from the Choosing Wisely and Choosing Wisely Canada were circulated around the Faculty of Radiation Oncology Council to determine which recommendations were applicable to the Australian and New Zealand context. The selected recommendations were then put to the Quality Improvement Committee and the Economics and Workforce Committee, with each being asked to rank the recommendations.
The five highest ranked recommendations were then put to the radiation oncology membership for consultation prior to being formally approved by the Faculty of Radiation Oncology Council.
Recommendations 7-10 are adapted from the American Society for Radiation Oncology (ASTRO) 2013 and 2014 lists. Recommendation 11 is adapted from Choosing Wisely Canada’s Oncology list. Each organisation was approached for—and subsequently granted—approval to adapt these recommendations as part of the Choosing Wisely Australia campaign.
- 1 Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules).
- 2 Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells Score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D dimer assay is positive.
Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.
- 4 Don't perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
- 5 Don't request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- 6 Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.
- 7 Don’t initiate whole-breast radiation therapy as a part of breast conservation therapy in women age ≥50y with early-stage invasive breast cancer without considering shorter treatment schedules.
- 8 Don’t initiate management of low risk prostate cancer without discussing active surveillance.
- 9 Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases.
- 10 Don't routinely add adjuvant whole-brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
- 11 Don’t routinely use extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumour.