Last year, as part of an initiative of the National Physicians Alliance called “Promoting Good Stewardship in Clinical Practice,” a group of experts developed a list of the top five medical practices by primary care physicians that, if changed, would lead to better patient care and a better use of medical resources.
One of the items on that list was “Don’t do imaging for low back pain within the first six weeks unless red flags are present.”
And by red flags, the experts meant really significant ones — a severe neurological problem, for example, or a serious underlying illness, such as cancer or a bone infection (osteomyelitis).
On Monday, a team of medical experts from around the United States published a paper in the Archives of Internal Medicine’s ongoing (and terrific) “Less Is More” series that offers data to support that recommendation.
After sifting through the best studies to date on the topic, they found that the routine imaging of the spines of people with lower back pain is not only unnecessary, it may actually be harmful.
Several risks
One of those harmful risks is unnecessary radiation, especially from computed tomography (CT) scans. (As I've reported here before, a study published in 2009 estimated that 15,000 people may die from cancer over the next two decades as a direct result of CT scans that were done in 2007 alone.)
Another risk is unnecessary surgery. Research has shown that those areas of the country that have a higher utilization of magnetic resonance imaging (MRI) for low back pain also have higher rates of back surgery.
Yet, as the authors of this paper repeatedly point out, “greater use of imaging is not associated with better patient outcomes.”
Then there’s the problem of “labeling.” More than 85 percent of people who develop symptoms of low back pain have no specific disease or anatomic abnormality that can explain the symptoms. Research has also shown that when the spines of people without symptoms of back pain are scanned and examined, some kind of anatomic abnormality, such as a herniated disc, is often found. This suggests that many of the diagnostic labels given people with back pain may have nothing to do with their symptoms.
People who receive such a label, however, tend to have a diminished sense of well-being. One randomized study found, for example, that people with low back pain who had their spines X-rayed (and were told the results) reported more pain and worse overall health three weeks later than a second group who did not have X-rays.
Driven by patient expectations
Yet, many physicians continue to routinely prescribe X-rays or MRIs or CT scans to their patients who come to them with low back pain.
And this happens despite the fact that guidelines have been recommending against routine imaging for uncompleted low back pain for more than three decades.
Physicians do this, say the authors of the Archives of Internal Medicine, for a number of reasons, including “time pressures (which make it easier to order an imaging procedure than to discuss the condition) and financial incentives.”
The physicians are not entirely to blame, however. They frequently order imaging tests for low back pain because we, their patients, expect it. We may even demand it.
It’s not that we feel physically better after undergoing spinal imaging. In fact, we may actually feel worse because, as just noted, being labeled with some sort of abnormality (whether or not it’s causing our symptoms) is likely to make us worry about our overall health — and/or lead to unnecessary (and painful) surgery.
But the imaging will make us feel better about our physicians.
“In randomized controlled trials, patients with low back pain expressed more satisfaction when they received routine lumbar imaging or advanced imaging, although clinical outcomes were not better than those for patients,” write the authors of the Archives of Internal Medicine paper.
In fact, one-third of physicians surveyed in 2007 said they would order MRIs for uncomplicated acute low back pain if a patient insisted on it even if they themselves thought it was unnecessary.
Needed: ‘a frank and honest discussion’
The authors of the paper call for physicians to have “a frank and honest discussion of the benefits and risks of medical therapy and imaging” with their patients who come to them with complaints of low back pain.
Most cases of low back pain can be treated with over-the-counter pain medications, special exercises and other at-home treatments.
You can learn more about why “less is more” when it comes to imaging for low back pain by reading the Archives of Internal Medicine paper in full on the journal’s website.