Clinical Question: When should be diagnostic imaging be used for patients with low-back pain?

Bottom Line: X-rays and magnetic resonance imaging (MRI) for patients with low-back pain are associated with increased cost, poorer health in recipients, and an increased risk for surgery. Routine imaging of back patients is not warranted and, moreover, the indications for imaging are few: major risk factors for cancer, signs of cauda equina syndrome, and severe neurologic deficits. Radiography recommendations after a trial of therapy include weak risk factors for cancer, signs of ankylosing spondylitis in young patients, or vertebral fracture risk factors in older people. MRI should be limited to patients with radiculopathy or symptoms of spinal stenosis who don't respond to therapy. Using diagnostic tests for a putative therapeutic effect does not decrease patients' anxiety. (Level of Evidence: 1a)

Reference: Chou R, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011;154(3):181-189.

Study Design: Practice guideline

Funding Source: Foundation

Setting: Various (guideline)

Synopsis: These guidelines are based on a systematic review and meta-analysis of research investigating the usefulness of various imaging studies in patients with low-back pain. Based on a meta-analysis of 6 studies, routine imaging with x-ray, MRI, or computed tomography in patients without underlying conditions does not have any effect on pain, function, quality of life, or patient-rated improvement, and, contrary to common wisdom, does not alleviate patients' anxieties about back pain. These studies were done in patients with and without radiculopathy. Several studies have demonstrated that patients who had routine imaging will have more pain and worse overall health status. That's not to say that imaging won't pick up abnormalities; herniated or bulging discs and spinal stenosis are commonly found in asymptomatic patients, as well as in those with back pain, with up to 90% of asymptomatic individuals older than 60 years having a degenerated or bulging disc. Abnormal findings can lead to surgery that will not be effective since the exposed abnormality is simply coincident to the real cause of the pain. The guidelines suggest plain films, along with erythrocyte sedimentation rate determination for patients with major risk factors for cancer, and MRI for patients at risk for spinal infection (low-back pain, fever, intravenous drug use), signs of cauda equina syndrome, or severe neurologic deficits, such as progressive weakness or motor deficits at multiple neurologic levels.