About 25% of adults report having low back pain lasting at least 1 whole day in the preceding 3 months. Imaging for acute low back pain is common, with a reported 42% of patients receiving imaging within 1 year, mostly plain radiography. Studies, however, indicate that lumbar imaging for low back pain without indications of serious underlying conditions does not improve clinical outcomes. More than 85% of patients seen in primary care have low back pain that cannot be attributed to specific disease or anatomic abnormalities.
Refrain From Low Back Imaging Within First 6 Weeks
In 2012, the National Physicians Alliance launched the initiative “Promoting Good Stewardship in Clinical Practice,” in which a list of the top five activities for primary care was developed to foster higher-quality care and better use of finite clinical resources. One of the top recommendations was to not perform imaging for low back pain within the first 6 weeks unless red flags are present. In the Archives of Internal Medicine, my colleagues and I had a study published in which we selectively researched benefits and risks of routine imaging in low back pain.
The available studies suggest that there is no clinically significant difference in low back pain or function between those who receive immediate lumbar spine imaging and those receiving usual care. Published data also document harms associated with early imaging for low back pain, including patient labeling, unneeded follow-up tests for incidental findings, radiation exposure, unnecessary surgery, and significant cost. By not routinely imaging patients with acute low back pain, there is potential to reduce harms and costs without affecting clinical outcomes. Routine low back imaging provides no benefit to patients, except perhaps to increase a sense of patient satisfaction with their healthcare.
Overcoming Medicolegal Concerns Surrounding Imaging
Ample evidence supports the National Physicians Alliance recommendation that imaging is not warranted in acute low back pain of less than 6 weeks duration in the absence of red flag symptoms. Guidelines have recommended against routine imaging in these patients for almost 30 years, but surveys of physicians consistently show that more than one-third would order lumbar MRI for uncomplicated acute low back pain if patients insisted on it. Physicians must overcome medicolegal concerns, patient preferences, time pressures, and financial incentives to shift the paradigm to one of patient advocacy.
“By not routinely imaging patients with acute low back pain, there is potential to reduce harms and costs without affecting clinical outcomes.”
Multifaceted physician education interventions, computer-based feedback, and consultation with other specialists may be effective in reducing inappropriate imaging for low back pain. Physicians also need to be frank and honest when discussing benefits and risks of medical therapy and imaging for low back pain. With greater support, education, and research, it’s hoped that adherence to the National Physicians Alliance’s Good Stewardship recommendation on low back pain will improve care, reduce harm, and decrease overall medical costs.
Readings & Resources (click to view)
Srinivas SV, Deyo RA, Berger ZD. Application of “less is more” to low back pain. Arch Intern Med. 2012;172:1016-1020. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1213846.
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.
Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine. 2006;31:2724-2727.
Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463-472.
Khorasani R. Can radiology professional society guidelines be converted to effective decision support? J Am Coll Radiol. 2010;7:561-562.
Schectman JM, Schroth WS, Verme D, Voss JD. Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain. J Gen Intern Med. 2003;18:773-780.
Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289:2810-2818.