A Stronger Case for Less Imaging in Back Pain

Few health problems are as frustrating as back pain. Americans spend an estimated $73 billion every year seeking relief from their aching backs, and any disorder as common and intractable as that is ripe for abuse.

We’ve written about the less-is-more approach to back surgery, a notion recently reinforced by a study published in the Archives of Internal Medicine.

As part of an initiative of the National Physicians Alliance, a project called “Promoting Good Stewardship in Clinical Practice” compiled the top 5 activities in primary care for which changes in clinical practice could lead to higher-quality care and better use of resources. Included in those five recommendations was “Don’t do imaging for low back pain within the first six weeks unless red flags are present.”

According to the American Academy of Family Physicians, those flags include a history of trauma, fever, incontinence, unexplained weight loss, cancer, long-term steroid use, and intense localized pain. And even then, the first treatment usually consists of nonsteroidal anti-inflammatory agents or acetaminophen and a gradual return to usual activities.

The stewardship project reviewed medical literature, guidelines and commentaries about the benefits and risks of routine imaging, such as MRI and CT scan, in low back pain. It also assessed the cost of spine imaging using data from the National Ambulatory Medical Care Survey. One high-quality review focused on outcomes in patients with low back pain and found no significant difference in pain or function between patients who got immediate lumbar spine imaging versus less aggressive care.

Plus, the data documented certain harms from such early imaging, including patient “labeling.” Anyone can have an anatomical abnormality that shows up on a screening test but that, in fact, has nothing to do with the reason the person went to the doctor in the first place. That’s labeling, and it prejudices future diagnoses and care, prompting unneeded follow-up tests for minor findings, exposure to radiation, unnecessary surgery and significant cost.

“Routine imaging should not be pursued in acute low back pain,” was the project’s categoric conclusion. “Not imaging patients with acute low back pain will reduce harms and costs, without affecting clinical outcomes.”

Writing in the September newsletter of his Patient Safety America movement, John James, a Ph.D. scientist, applauds this conclusion. He advises anyone who shares his back-pain experience to question any medical provider who advises an imaging test as a first-response to diagnosing and alleviating pain. It’s difficult to do nothing, but sometimes that’s the best medicine. And the best use of health-care resources.

One-third of Medicare patients with low back pain receive diagnostic imaging within a month of the initial complaint, James reports. The use of MRI imaging for low back pain in Medicare patients increased more than 300 percent in the decade from 1994 to 2005. That doesn’t signify too many people lifting boxes improperly as much as it does inflated treatment for a common malady.

James notes that, according to the stewardship project, if no scanning were done because medical recommendations were being followed, $140 million would be saved. And if unnecessary MRI and CT scanning were eliminated, the additional savings would be $160 million. And that doesn’t even include the additional costs associated with unnecessary surgery.

“As a patient,” James writes, “you have a critical role in helping physicians with good stewardship. If a physician suggests that you wait for your acute back pain to resolve before he makes images of your back, then go along with that recommendation. In the process, you might be avoiding some potentially harmful treatments.”

And be careful, he adds, about the potential for overusing pain medication.

To learn more about the risks of back and spine surgery, read our backgrounder.

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