Low-Back Pain Imaging Without Indication of Underlying Conditions Does Not Improve Clinical Outcomes

The routine use of radiography, magnetic resonance imaging (MRI), or computed tomography (CT) scans in patients with low-back pain but no indication of a serious underlying condition has been shown to not improve clinical outcomes, according to recent research. Therefore, physicians should refrain from routine, immediate scanning unless they observe features of a serious underlying condition.

These are the conclusions of Roger Chou, M.D., from the Oregon Health and Science University (Portland, OR, USA), and colleagues who published their findings in this February 9, 2009, issue of the journal The Lancet. The researchers performed a meta-analysis of randomized controlled trials that compared immediate back imaging--using one of the aforementioned three scanning types--with typical clinical care that does not involve immediate imaging. Six trials covering more than 1,800 patients were included, reporting a variety of outcomes including pain and function, quality of life, mental health, overall patient-reported improvement, and patient satisfaction. The analysis revealed no significant differences between immediate imaging and usual clinical care. The investigators reported that the results are most applicable to acute or sub-acute low-back pain of the type assessed in primary-care setting, such as at the patient's family doctor.

The researchers reported in their article, "Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.”

The investigators also reported that since the rates of utilization of lumbar MRI are increasing, and implementation of diagnostic-imaging guidelines for low-back pain remains a challenge. However, clinicians are more likely to stick to guideline recommendations about lumbar imaging now that these are supported by consistent evidence from higher-quality randomized controlled trials. Patient expectations and preferences about imaging should also be addressed, because 80% of patients with low-back pain in one trial would undergo radiography if given the choice, in spite of no advantages with routine imaging.

The researches go on to report that educational interventions could be useful for reducing the amount of patients with low-back pain who believe that regular imaging should be done. They need to identify back-pain evaluation and educational strategies that meet patient expectations and increase satisfaction, while avoiding unnecessary imaging.

In an accompanying editorial in the same issue of The Lancet, Prof. Michael M. Kochen, from the department of general practice, University of Gottingen (Germany), and colleagues discussed how certain factors could hinder doctors changing practice to avoid immediate imaging, "such as patients' expectations about diagnostic testing, reimbursement structures providing financial incentives, or the fear of missing relevant pathology. Meanwhile, a promising approach seems to be the way of educating patients in and outside general practitioners surgeries.”

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