One question I get asked a lot in my profession is, “Well if you don’t have an image of my low back, then how can you know how to treat it?”
I get it. And I think it is a valid question. In medicine, you don’t treat a blood clot without knowing it's a blood clot. You don’t give antibiotics unless you know you are treating a bacterial infection. So why would you treat back pain without knowing what you have? I promise you, it is not because we want to see you suffer. It’s actually the complete opposite! Like a parent enforcing their child to eat vegetables – we do know what is good for you, even if it does not seem like the case at that time!
But let’s back track a little bit. Low back pain is a particularly difficult topic. It is the second most common complaint in primary care offices. 80% of the population has had or will have a low back problem at some point in their lives. Of that 80%, 70-90% will have recurrent back pain. Luckily, there are some steps individuals can take to reduce this incidence. The good news is, most low back pain is considered non-specific and is not a serious harm to a patient when it occurs.
A 2021 study published by The BMJ states, “Less than 5-10% of all low back pain is due to a specific underlying spinal pathology…” such as infection, malignancy, bone pain or cauda equina syndrome. That means 90-95% of low back pain is treated successfully with proper combination of reassurance, exercise, physical therapy, chiropractic care, cognitive-behavioral therapy and in some cases interventional methods such as pain management with injections or medications.
Therefore, the necessity for imaging should only be considered initially for lower back pain if there is a high clinical suspicion for malignancy, infection, vertebral fracture, spondyloarthritis, or cauda equina syndrome.
To explain further, I want to provide you with my top five reasons for why clinicians should refrain from ordering imaging if there is no clinical suspicion to.
Reason #1: Therapeutic MRI
I think many people believe that if they just have an MRI it will provide peace of mind and that their clinician will have a better idea of how to appropriately treat them. Unfortunately, too early of imaging can actually detriment treatment, confusing both provider and patient. Studies have shown, “Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient's clinical condition.” (Brinjikji, et. al. 2015).
Below is a chart demonstrating abnormal spine findings in ASYMPTOMATIC individuals.
Reason #2: High Cost
Obtaining an MRI immediately after an episode of low back pain can lead to an over diagnosis or misdiagnosis of the problem. Studies have supported this in recent years stating, “Unnecessary imaging can lead to additional tests, follow-up, referrals and may result in an invasive procedure of limited or questionable benefit. Imaging should be delayed for 6 weeks in patients with nonspecific LBP without reasonable suspicion for serious disease.” (Wang et. al 2018). Not only do health care costs go up, but unnecessary procedures may be offered when not needed. “There is moderate-quality evidence (1 RCT, 2 OSs; n = 3897) that performing MRI or imaging (MRI or CT) is associated with an increase in healthcare utilization (e.g., future injections, surgery, medication, etc.).” (Lemmers, et. al., 2019)
Reason #3: Treat the Patient, not the image!
The physical examination is one of the most important tools for deciphering back pain. It helps us understand what is “normal” – although it may not feel that way to the patient, and what is “abnormal” or just doesn’t seem to be adding up. We can also tell through the physical exam if there is any serious damage that WOULD require imaging sooner rather than later. A good history and exam are imperative for assessing treatment moving forward. And for those who are worried that it may be something more ominous, “...[MRIs are] also considered for those patients presenting with suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture and infection. In western country primary care settings, the prevalence has been suggested to be 0.7% for metastatic cancer, 0.01% for spinal infection and 0.04% for cauda equina syndrome. Of the small proportion of patients with any of these conditions, almost all have an identifiable risk factor.” (Wang, et. al. 2018).
Reason #4: Get to the Root Cause
Most low back pain incidences are caused by poor biomechanical imbalance. Some are fairly obvious for the clinician to find, while others may be more subtle, depending on the overall fitness of the patient. You can check out my article on the differences between a rehab, maintenance and progression program here. A proper exercise regimen and exercise dosing can and will make a difference in your low back pain.
Reason #5: Poorer Outcomes
All in all, too early use of diagnostic testing may even contribute to poorer health outcomes. In one study, researchers found that “Use of early diagnostic magnetic resonance imaging (MRI) for low back pain (LBP) contributes to increasing health care costs but may not lead to better outcomes than delayed imaging.” (Graves, Jarvik & Franklin, 2012). Furthermore, “Of 1226 participants, 18.6% received early MRI. Most (77.9%) had mild/major sprains and 22.1% had radiculopathy. Participants with early MRI differed significantly at baseline in pain, function, and psychosocial variables. After adjusting for covariates, early imaging was not associated with substantial differences in 1-year health outcomes for sprains or radiculopathy” (Graves, Jarvik & Franklin, 2012).
Takeaway Points:
Although MRIs will be able to clearly view spinal pathology, such as disc pathology, arthropathy, and canal narrowing, these findings are found in asymptomatic individuals (particularly as a person ages) and do not necessarily help the clinician come to a definitive diagnosis.
Imaging prior to at least six weeks from onset of non-specific low back pain without adequate treatment first can lead to high costs for healthcare and patients.
90-95% of low back pain is treated successfully with proper combination of reassurance, exercise, physical therapy, chiropractic care, cognitive-behavioral therapy and in some cases interventional methods such as pain management with injections or medications
Studies show that early diagnostic testing in low back pain actually contributes to poorer health outcomes in patients
References
Lemmers GPG, van Lankveld W, Westert GP, van der Wees PJ, Staal JB. Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. Eur Spine J. 2019 May;28(5):937-950. doi: 10.1007/s00586-019-05918-1. Epub 2019 Feb 22. PMID: 30796513.
Wáng YXJ, Wu AM, Ruiz Santiago F, Nogueira-Barbosa MH. Informed appropriate imaging for low back pain management: A narrative review. J Orthop Translat. 2018 Aug 27;15:21-34. doi: 10.1016/j.jot.2018.07.009. PMID: 30258783; PMCID: PMC6148737.
Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Early imaging for acute low back pain: one-year health and disability outcomes among Washington State workers. Spine (Phila Pa 1976). 2012 Aug 15;37(18):1617-27. doi: 10.1097/BRS.0b013e318251887b. PMID: 22415000.
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797.
Hall AM, Aubrey-Bassler K, Thorne B, Maher CG. Do not routinely offer imaging for uncomplicated low back pain. BMJ. 2021 Feb 12;372:n291. doi: 10.1136/bmj.n291. PMID: 33579691; PMCID: PMC8023332
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