Informed Imaging for Low Back Pain

Wang, Yi Xiang J. et al. Informed appropriate imaging for low back pain management: A narrative review. Journal of Orthopaedic Translation: 2018
  • Lumbar imaging are common in people without low back pain and are only loosely associated with symptoms. It is an important driver of LBP costs, not only directly, but also because of direct downstream effects like additional tests and procedures,and sometimes treatments of questionable benefit.
  • The American College of Physicians, American Pain Society, and American College of Radiology recommend selective criteria for imaging: LBP > 6 weeks AFTER having completed a course of conservative management, persistent radiculopathic symptoms, pts w/ severe neurological deficits, or signs and symptoms of a serious condition
  • Serious conditions include cancer (0.7% of pts with LBP in primary care setting), 0.01% have spinal infection, 0.04% have cauda equina. Osteoporotic compression fractures (4%) and inflammatory disorders (<0.5%) may cause LBP but all these conditions have many other identifiable risk factors
  • A recent systematic review provides strong evidence that most episodes of LBP improve substantially within 6 weeks. Most cases of disc herniation resorb or regress by 8 weeks after symptom onset. There is also not a significant correlation with morphological changes on radiography and clinical improvement
  • “Degenerative spine disease” is common in asymptomatic individuals and increases with age. Imaging findings are not associated with presence or degree of LBP. However, very specific types of changes are more likely to correlate with LBP: Modic Type 1 changes and zygapophyseal edematous changes. Modic Type 1 changes have been shown in 20-50% of persons w/ LBP but also can be found in 10-25% of people w/o LBP
  • Disc herniation along with inflammation is the most common cause of radiculopathy and radicular pain. However, disc herniations are also common in asymptomatic individuals. Size and type of herniation and the location or presence of nerve root compression, are not related to patient outcome.
  • In one trial, pts w/ LBP of 6 wk duration who had radiography were more likely to report more pain and worse overall health status after three months compared with people who did not have radiography performed
  • Telling pts they have a spine imaging abnormality can result in unintended harms related to labelling and can hinder recovery by causing pts to worry more, focus excessively on minor symptoms, avoid exercise or other recommended activities b/c of fear that they could cause more damage.
  • There is strong evidence that routine spine imaging is not associated with a clinically meaningful benefit on patient outcomes. Studies should be performed only in selected, higher-risk patients who have severe or progressive neurologic deficits or are suspected of having a serious specific underlying condition