Don't do imaging for low back pain within the first six weeks, unless red flags are present. (Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected.)
Low back pain is the fifth most common reason for all physician visits. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs.
Sources: Agency for Health Care Research and Policy (AHCPR), Cochrane Reviews
Low back pain is one of the most common reasons for an outpatient visit. The evaluation for low back pain should include a complete, focused medical history looking for red flags, which include, but are not limited to: severe or progressive neurologic deficits (e.g., bowel or bladder function), fever, sudden back pain with spinal tenderness, trauma, and indications of a serious underlying condition (e.g., osteomyelitis, malignancy). It is also important to rule out nonspinal causes of back pain, such as pyelonephritis, pancreatitis, penetrating ulcer disease or other gastrointestinal causes, and pelvic disease. Fractures are an uncommon cause of back pain; they are associated with risk factors such as osteoporosis and steroid use. (1,2,3,4)
Most patients with radicular symptoms will recover within several weeks of onset.(5) The majority of disc herniations will regress or reabsorb within eight weeks of onset. In the absence of progressive neurologic deficits or other red flags, there is strong evidence to avoid CT/MRI imaging in patients with non-specific low back pain. (6,7)
For Your Patients
Clinical Preventive Service Recommendation
Studies have shown that patients with no back pain often show anatomic abnormalities on imaging.(8) Risks associated with routine imaging include unnecessary radiation exposure and patient labeling.(9) The labeling phenomenon of patients with low back pain has been studied and shown to worsen patients’ sense of well-being.(10) In addition studies have linked the increase rate of imaging with the increase rate of surgery. (9) A study by Webster et al showed that patients with occupation-related back pain who had early magnetic resonance imaging (MRI) had an eightfold increased risk of surgery.(11) A study by Jarvik et al showed that patients with low back pain who had an MRI were more than twice as likely to undergo surgery compared with patients who had plain film imaging.(12)
A meta-analysis by Chou et al found no clinically significant difference in patient outcomes between those who had immediate lumbar imaging versus usual care.(7) The imaging of the lumbar spine before 6 weeks does not improve outcomes, but it does increase costs. In general, imaging should be saved for patients for whom noninvasive, conservative regimens have failed and surgery or therapeutic injection are being considered.
Watch the video as Dr. LeFevre talks with a patient who requests an imaging test for her acute low back pain.
This recommendation is provided solely for informational purposes and is not intended as a substitute for consultation with a medical professional. Patients with any specific questions about this recommendation or their individual situation should consult their physician.
The Choosing Wisely®(www.choosingwisely.org) campaign was created as an initiative of the American Board of Internal Medicine (ABIM) Foundation(www.abimfoundation.org) to improve health care quality. More than 70 specialty societies have identified commonly used tests or procedures within their specialties that are possibly overused.
Learn more about the AAFP support of the Choosing Wisely® campaign.
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Imaging for Low Back Pain