Low back pain is an extremely common condition that affects individuals worldwide. It is estimated that 80% of the population will experience a significant bout of low back pain at some time during the life span, and approximately 25% of adults in the United States will likely have had one entire day of low back pain in the last three months. Low back pain is the most common disorder managed in outpatient physical therapy, accounting for 50% of all referrals. A common question asked by patients with low back pain is, “do I need an X-ray or MRI of my low back?”
The simple answer is that in most cases of low back pain, imaging of the spine – either radiographs (X-ray), computed tomography (CT) or magnetic resonance imaging (MRI) – is not necessary, and as indicated in recent research studies, may even be detrimental to patients. According to several leading medical organizations, including the American College of Physicians, the American College of Radiology, and the Department of Defense/Veterans Administration, current practice guidelines support avoiding imaging of the spine in the routine evaluation of acute low back pain within the four to six weeks of symptoms, unless certain red flags are present, including:
- recent significant trauma (at any age)
- recent mild trauma (over the age of 50)
- over the age of 70
- history of prolonged steroid use or osteoporosis
- severe progressive neurologic deficits, such as recent loss of muscle strength or bowel/bladder function
- clinical signs indicating spinal infection or a history of cancer with new onset of low back pain.
Contrary to common thought, in the case of acute non-specific low back pain, imaging of the spine does not equate to improved care. Two important factors contribute to this finding:
- A large percentage of asymptomatic individuals (those without low back pain), especially over the age of 60, demonstrate what is considered to be significant pathology, or damage, of the spine. These findings suggest that similar degenerative changes upon imaging in those with acute low back pain may not be clinically relevant.
- Imaging of the spine, prior to conservative care (eg, physical therapy, education), frequently will not impact the plan of care for those with low back pain, as most cases of low back pain will improve with non-surgical treatment. In fact, some findings suggest that those individuals undergoing early imaging of the lumbar spine experience a higher rate of surgery, with no significant change in outcomes. In most cases, imaging should be reserved for those patients with persistent low back pain in which findings would help the physician plan the appropriate intervention (surgery vs. epidural steroid injection).
While prudent diagnostic imaging can be beneficial, recent studies estimate that over a quarter of medical imaging of the low back as inappropriate, often exposing the patient to unnecessary risk, such as radiation (x-ray and CT scans), as well as frequently burdening the patient with excessive medical costs (MRI).
A thorough examination by your physician and/or physical therapist, with an appropriate plan of care, including exercise, manual techniques and modalities as indicated – has been shown to effectively manage low back pain in the majority of individuals. For those with low back pain, the good news is that with early referral and access to physical therapy services, most cases of low back can be resolved in a relatively short period of time, without costly or invasive procedures. Contact a ProActive Physical Therapy and Sports Medicine office today if you have questions regarding the treatment of your low back pain!
Reference: Flynn et al, JOSPT ‘11 “Appropriate Use of Diagnostic Imaging In Low Back Pain: A Reminder That Unnecessary Imaging May Do As Much Harm as Good”