Routine scans for low-back pain do not improve outcomes, researchers say

Physicians should not immediately order routine radiography, MRI or CT scans for low-back pain unless they observe features of a serious underlying condition, according to a 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, lead author of the report and scientific director of the Oregon Evidence-Based Practice Center at Oregon Health & Science University.

"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," he added.

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Chou and colleagues conducted an analysis of randomized controlled trials that compared immediate back imaging -- using one of the three scanning types (radiography, MRI or CT scans) -- 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 researchers said 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.

"Rates of utilization of lumbar MRI are increasing, and implementation of diagnostic-imaging guidelines for low-back pain remains a challenge," Chou said. "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."

The researchers also said that patient expectations and preferences about imaging should also be addressed. The study found that 80 percent of patients with low-back pain in one trial said they would undergo radiography if given the choice despite the fact that researchers found no benefits with routine imaging. The study urged the use of educational interventions for reducing the proportion of patients with low-back pain who believe that routine imaging should be conducted.

April 30, 2009

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