Routine scans for low-back pain do not improve outcomes

OHSU researchers find regular MRI, CT, radiography scans unnecessary unless a significant underlying condition is first identified

08 feb 2009--Physicians should not immediately order routine scans for low-back pain unless they observe features of a serious underlying condition, researchers in the Oregon Evidence-Based Practice Center at Oregon Health & Science University report. Their findings are published in this week's edition of the The Lancet.

The regular use of radiography, MRI or CT scans in patients with low-back pain but no indication of a significant underlying condition does not improve their outcome, the researchers report.

"Our study shows that performing routine X-rays or MRIs for patients with low-back pain does not lead to improved pain, function or anxiety level, and there were even some trends toward worse outcomes," said Roger Chou, M.D., lead author; scientific director of the Oregon Evidence-Based Practice Center at OHSU; and associate professor of medical informatics and clinical epidemiology, and medicine (general internal medicine and geriatrics) in the OHSU School of Medicine.

"Clinicians may think they are helping patients by doing routine X-rays or MRIs, but these diagnostic tests increase medical costs, can result in unnecessary surgeries or other invasive procedures, and may cause patients to stop being active — probably the best thing for back health — because they are worried about common findings such as degenerated discs or arthritis, not understanding that these are very weakly associated with back pain."

To reach this conclusion, Chou and colleagues conducted a meta-analysis of randomized controlled trials that compared immediate back imaging — using one of the three scanning types above — with usual clinical care that does not involve immediate imaging. Six trials covering more than 1,800 patients were included, reporting a range of outcomes including pain and function, quality of life, mental health, overall patient-reported improvement, and patient satisfaction.

The analysis found no significant differences between immediate imaging and usual clinical care. The authors say that the results are most applicable to acute or sub-acute low-back pain of the type assessed in a primary care setting with the patient's family doctor.

The authors report that 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.

They added: "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 adhere 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 percent of patients with low-back pain in one trial would undergo radiography if given the choice, despite no benefits with routine imaging, the reporters report. They indicated educational interventions for reducing the proportion of patients with low-back pain who believe that routine imaging should be done.

Other investigators who participated in this study include: Rick Deyo, M.D., M.P.H., Kaiser Permanente Professor of Evidence-Based Family Medicine, OHSU School of Medicine, Oregon Evidence-Based Practice Center; and Rochelle Fu, Ph.D., assistant professor of public health and preventive medicine, OHSU School of Medicine.

In an accompanying comment, Michael M. Kochen, Department of General Practice, University of Göttingen, Germany, and colleagues discuss how certain factors could hamper 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." They conclude: "Meanwhile a promising approach seems to be the way of educating patients in and outside general practitioners surgeries."

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