No Need For MRI And X-Ray For Lower Back Pain

By Margarita Nahapetyan

Back pain is one of the most common reasons for people to visit a doctor or miss work. About 85 per cent of U.S. population suffer from lower back pain at some point in their lives. Researchers at the Oregon Health and Science University in Portland have revealed that routine use of expensive X-Ray, MRI and CT scans or radiography on patients with lower back pain, do not have any effect on the clinical outcomes.

To reach this conclusion, the researchers examined 6 trials that included more than 1,800 low back pain patients. Lumbar radiography was used in 4 of the trials, and 2 other trials assessed MRI or CT scans. All were done in primary- or urgent-care settings for mainly acute or sub-acute low back pain with duration of the symptoms for less than twelve weeks.

Of all the patients with low back pain but no indications of serious underlying conditions, the proportion with sciatica or radiculopathy generally ranged from 24 per cent to 44 per cent, although these patients were excluded from one of the trials. A meta-analysis of a wide range of outcomes - including pain and function, quality of life, mental health, overall patient-reported improvement, and patient satisfaction - showed no differences between patients who received immediate back imaging and those with standard clinical care.

This means that doctors should not conduct regular medical imaging, CT or radiography unless they see signs of serious underlying conditions causing the pain, such as herniated disks, muscle injuries, arthritis or broken bones, which pose serious complications for back pain, the authors wrote in this week's edition of The Lancet.

The researchers 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."

The frequent use of medical imaging scans by doctors while diagnosing lower back pain in patients is "a waste of health care resources" and carries a big risk for serious, life-threatening side effects, according to the scientists. Women who suffer from lower back pain and often undergo X-ray and CT scans are more likely to face a risk of ovarian cancer due to radiation emitted by the exams.

"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., a lead author of the study; 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.

There are cases when doctors recommend expensive tests for their patients so they can make sure that everything is being done in order to find the source of the pain. However, the study said that there are other much safer and more cost-effective ways to accurately diagnose and treat lower back pain.

And when patients who complain of lower back pain still insist on having an imaging procedure performed, the physicians must inform them about the limited benefits of the tests, the costs, and the risks associated with the exposure of patients to the doses of radiation, the researchers said, citing one study of people with low back pain in which 80 per cent of the participants reported they would have imaging, if given the choice, even without expected benefits.

"We need to identify back-pain assessment and educational strategies that meet patient expectations and increase satisfaction, while avoiding unnecessary imaging," the researchers wrote.

The study was accompanied by comments from Dr. Michael Kochen, of the University of Goettingen in Germany, who wrote: "If there are no warning signs pointing to a serious cause of low back pain, imaging is almost never helpful to guide treatment. Routine imaging of patients with low back pain is a waste of health care resources."

"Meanwhile a promising approach seems to be the way of educating patients in and outside general practitioners surgeries," concluded Michael Kochen and his colleagues.