Low back pain is a very common condition. The Need for diagnostic imaging for patients with low
back pain has often been exaggerated. 'Evidence indicates that routine imaging is not associated with
clinically meaningful benefits but can lead to harms', reports
Usually diagnostic imaging in this condition should be
indicated only if low back pain is associated with progressive neurologic
deficits or signs or symptoms that suggest a serious or specific underlying
. This evidence-based recommendations from the American College of
Physicians (ACP) and the American Pain Society (APS) appear to be grossly
neglected. Routine imaging does not seem to improve clinical outcomes and exposes
patients to unnecessary harms.
Overuse of imaging imposes severe financial burden
patients who already suffer lower productivity due to the menacing low back
pain. Reducing unnecessary tests or ineffective treatments decrease the costs
associated with low back pain. In addition to the direct costs imaging also
causes additional expenses by leading to additional tests, follow-up, and
referrals. It may also result in an invasive procedure of limited or
The appropriateness of many of the low back imaging studies
obtained in clinical practice has long been questioned. The ACP/APS low back
pain guideline recommends selective imaging
for patients in whom it is
There are numerous factors
that explain why routine imaging
does not seem beneficial. Most lumbar imaging abnormalities are common in
persons without low back pain and are only loosely associated with back
symptoms. Although advanced imaging can detect more and smaller
abnormalities, these abnormalities are not necessarily clinically relevant
. This means a rapid MRI
need not always be of greater practical value than radiography for evaluating low back pain.
Many abnormalities detected with advanced imaging are so common in
asymptomatic persons that they could be viewed as normal signs of aging
presence of imaging abnormalities need not mean that the abnormalities are
responsible for symptoms.
Acute low back pain has a favourable natural history and the
expected yield of routine imaging is low. Most patients show significant improvements
in pain and function in the first 4 weeks; routine imaging is unlikely to
improve on this. Imaging results rarely affect treatment plans. Thus they often have a
low impact on clinical outcomes.
Routine imaging is associated with potential harms:
• Lumbar radiography and CT contribute to cumulative low-level
radiation exposure. They may promote the development of cancer.
• The use of iodinated contrast in lumbar CT is associated with
hypersensitivity reactions and nephropathy (disease associated with the
• The average radiation exposure from lumbar radiography is 75 times
higher than for chest radiography. This is particularly harmful to young woman
because of the proximity to the gonads (sex glands). The amount of female
gonadal irradiation from lumbar radiography is supposed to tantamount to having
chest radiography daily for several years.
routinely order imaging for all cases of lower back pain even in the
absence of a clear clinical indication though ACP/APS guideline suggests
a trial of management without imaging in adults with no risk factors other than
older age. The use of advanced imaging modalities like MRI and CT scans is
skyrocketing. A large number of clinicians hastily jump to these modalities
irrespective of any guidelines.
Patient expectations and preferences
about diagnostic testing also add
to the cause. They expect a clear diagnosis for their low back pain. Some
attach a clinician's decision to not obtain imaging with low-quality care.
There are patients who think that their pain is not legitimate or important if
the clinician doesn't order for imaging. Wanting diagnostic testing is a
frequent reason for repeated office visits for chronic back pain. There are
ones who insist that they need imaging even after the physician explains that it
would be unnecessary.
The potential solutions include:
• Clinicians should adhere
to the ACP/APS recommendations on
use of imaging so as to reduce overuse. Most patients do not need immediate
imaging, and an initial trial of therapy before imaging is warranted in many
• Advanced imaging should be reserved for serious situations
i.e. only when the results are sure to influence clinical decision making. Conditions
like major trauma, severe neurologic
compromise, or vertebral infection qualify for being imaged using an MRI or CT
scanner. In the absence of strong risk factors for cancer and lack of
neurologic signs, initial imaging with lumbar radiography and evaluation of
erythrocyte sedimentation rate (ESR) is a reasonable approach.
• Patients should be educated
about the pros and cons of
imaging. Face-to-face information with patient hand outs, self-care education
books, online materials, mass media educational campaigns help.
Source: 'Diagnostic Imaging for Low Back Pain: Advice for High-Value Health
Care from the American College of Physicians': Annals of Internal Medicine.