Strong evidence that routine imaging for low- back pain is not beneficial to patients


Researchers recommend that physicians should refrain from routine, immediate imaging, unless they observe features of a serious underlying condition.

The routine use of radiography, MRI or CT scans in patients with low back pain but no indication of a serious underlying condition does not improve clinical outcomes, finds a recent study published in The Lancet.

Roger Chou, MD, of the Oregon Health and Science University in Portland, one of the researchers, told Spinal News International, “The results are important because they are based on the strongest kind of evidence-randomised trials, most of high quality, that compared patient outcomes associated with routine imaging versus not performing routine imaging.”

This was a unique situation, he said because, “Most studies of imaging focus on things like sensitivity or specificity. The trials we review actually looked at patient outcomes from routine imaging versus no routine imaging and found no benefits with routine imaging on pain, function, anxiety, or quality of life, and if anything some trends towards slightly worse outcomes in the group that received routine imaging.”

Recommendations about not performing routine imaging can therefore now be based on strong evidence that there is no beneficial effect on patient outcomes.

Chou said, “Routine imaging is quite common, though estimates vary across settings. I have heard estimates of around 30-40% of patients with acute low back pain receiving some kind of imaging test (x-ray or MRI) within the first 6 weeks without any clear indication for it.”

Part of the reason for immediate imaging, he says, is because patients seem to expect this. Which is why, “It is often perceived as easier to just get the test than to explain why it is unnecessary. ” Doctors may also order tests for defensive reasons, because they are afraid they will miss something serious. However, says Chou, “This did not happen in any of the patients enrolled in the trials we reviewed, or in other large observational studies with thousands of patients.”

Chou maintains that here is also a natural human inclination to want to pinpoint the source of the back pain-to say it is a degenerated disc, or a facet joint. “But imaging studies can be very misleading since many asymptomatic patients have these kinds of findings, and there is no reliable way to distinguish asymptomatic from symptomatic imaging findings. Finally, there is no financial or other disincentive to getting the studies, meaning that in most cases there is nothing to stop doctors from ordering the tests and people from getting them done,” he said.

The study

Investigators carried out a meta-analysis of randomised, controlled trials comparing immediate back imaging – using either radiography, MRI or CT – with clinical care that did not entail imaging first.
Investigators included six trials that involved more than 1,800 patients and reported a range of outcomes, including pain and function, quality of life, mental health, overall patient-reported improvement and patient satisfaction. The researchers did not find significant differences between immediate imaging and usual clinical care in their meta-analysis.

Limitations of the study

• The number of trials, at six, was relatively small, though nearly 2000 patients were enrolled.

• Most of the trials focused on acute or subacute back pain, so there is not much information on what to do for chronic low back pain (back pain present > three months).

• There is not much data on patients with radiculopathy, so more evidence is needed there as well.
• More research is needed to understand whether there are certain subgroups of patients who would, in fact, benefit from routine imaging.