Low back pain is one of the most common reasons for patients to see physicians. Many who suffer from low back pain receive routine imaging (performed without a clear clinical indication). Routine imaging, however, has not been shown in randomized trials to improve patient outcomes when compared with usual care without routine imaging. In addition, routine imaging can lead to unnecessary additional tests, interventions, follow-ups, and referrals. In some cases, imaging tests may even be harmful. Nonetheless, use of imaging tests, particularly MRI, for low back pain continues to increase.
To address this issue, the Clinical Guidelines Committee of the American College of Physicians (ACP) released recommendations for diagnostic imaging for low back pain. Published in the February 1, 2011Annals of Internal Medicine, these guidelines are the first in a series to help physicians and patients identify potentially misused medical treatments and to practice high-value healthcare.
Important New Recommendations for Low Back Pain
A key theme of the ACP guideline is that routine imaging for low back pain does not appear to improve patient health. This is based on evidence that the use of diagnostic imaging in patients without indications offers little or no benefit. The vast majority of imaging findings do not correlate well with the presence or severity of symptoms, and do not affect initial management. Randomized trials comparing routine imaging with usual care without imaging suggest there is no clinically meaningful benefit on outcomes of pain, function, quality of life, or mental health.
The guideline recommends immediate imaging for patients with acute low back pain who have the following:
Major risk factors for cancer (personal history of cancer or strong clinical suspicion).
Risk factors or signs of spinal infection.
Signs of cauda equina syndrome.
Severe or progressive neurological deficits.
Imaging after a trial of treatment is recommended for patients who have the following:
Minor risk factors for cancer.
Risk factors or signs of inflammatory back disease.
Risk factors or signs of vertebral compression fracture.
Persistent signs or symptoms of radiculopathy.
Persistent symptoms of spinal stenosis.
Repeated imaging is recommended only in patients with new or changed low back symptoms.
Reducing Routine Imaging for Low Back Pain
Efforts to reduce the routine use of imaging in individuals with low back pain will be most effective if they address clinician behaviors, patient expectations, and financial incentives. Clinicians may be uncertain about the need for imaging, but can be reassured with these guidelines. Clinician incentives should be based on providing appropriate care, not necessarily on patient satisfaction—which may be at odds with the evidence.
Education is needed to inform patients of current and effective standards of care; patients must be educated on the potential benefits and harms of diagnostic imaging modalities so that expectations can be appropriately managed. To overcome patient barriers to evidence-based practices on the use of imaging for low back pain, the ACP recommends using talking points based on the guidelines. The use of online or print education materials could supplement face-to-face interactions with patients, easing time constraints for busy clinicians and patients.
Readings & Resources (click to view)
Chou R, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154:181-189. Available athttp://www.annals.org/content/154/3/181.full.pdf+html.
Webster BS, Courtney TK, Huang YH, Matz S, Christiani DC. Physicians’ initial management of acute low back pain versus evidence-based guidelines. Influence of sciatica. J Gen Intern Med. 2005;20:1132-1135.
Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463-472.