Are we still imaging low back pain to much ?

February 25, 2022
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Niseko Chiropractic research update:

 

There have been some amazing improvements over the last few decades in imaging for lower back pain. most notably the MRI scan ( considered the gold standard ) has the ability to clearly show soft tissues such as discs, ligaments and muscles as well as give an overview of bones. There has also been crazy advances in CT imaging such as the gap is now a lot more narrow.

But with the advance comes another problem.

Over imaging.

Counter- intuitively getting an image taken is often associated with poorer outcomes for our patients due to some of the psychological reasons associated with seeing your insides less than perfect  and also reinforcement from our treating Dr’s that we are truly broken. Early MRI in patients with non-specific LBP has been shown to result in more back surgery, increased use of opioids and a higher pain score (1)

That’s not to say that imaging is not vitally important and necessary in many circumstances. It’s just that we need to make sure the image is ordered in the appropriate conditions.

A recent study looking at over 4000 referrals from Denmark looked at problem and concluded that 75% of MRI imaging referrals for lower back were either inappropriate or did not contain enough information to make a call (2)  Only 25% of imaging referrals meet the standards of appropriate lower back imaging referral as agreed by the Nice imaging guidelines. This is is keeping with other research which also finds similar rates of over-imaging (3) As clinicians we need to do better  !

The final decision for image should really be up to your treating Dr to decide and there is often things happening we may not be aware of but it is important to remember that most instances of lower back pain get better within 4 weeks so just having a sore back is not reason enough alone to order imaging.

For imaging to recommended early before 6 weeks of symptoms we are really looking for other ” red flags” such as neurological symptoms, rapidly worsening symptoms or suspicion of fracture or serious injury to warrant an image at early stage.

So if your primary care physician has decided not to order an image they may be not slack or not thorough they might just be following best practise ! That being said if you feel something is not right you should always go with your gut and mention it to your Dr.

 

References

 

  1. Jenkins, H.J., Kongsted, A., French, S.D. et al. What are the effects of diagnostic imaging on clinical outcomes in patients with low back pain presenting for chiropractic care: a matched observational study. Chiropr Man Therap 29, 46 (2021). https://doi.org/10.1186/s12998-021-00403-3

 

2. Krogh, S.B., Jensen, T.S., Rolving, N. et al. Appropriateness of referrals from primary care for lumbar MRI. Chiropr Man Therap 30, 9 (2022). https://doi.org/10.1186/s12998-022-00418-4

3. Jenkins HJ, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ. Imaging for low back pain: Is clinical use consistent with guidelines? A systematic review and meta-analysis. Spine J. 2018;18:2266–77.

 





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