Application of “Less Is More” to Low Back Pain

Abstract

An initiative of the National Physicians Alliance, the project titled "Promoting Good Stewardship in Clinical Practice," developed a list of the top 5 activities in primary care for which changes in practice could lead to higher-quality care and better use of finite clinical resources. One of the top 5 recommendations was "Don't do imaging for low back pain within the first 6 weeks unless red flags are present." This article presents data that support this recommendation. We selectively reviewed the literature, including recent reviews, guidelines, and commentaries, on the benefits and risks of routine imaging in low back pain. In particular, we searched PubMed for systematic reviews or meta-analyses published in the past 5 years. We also assessed the cost of spine imaging using data from the National Ambulatory Medical Care Survey. One high-quality systematic review and meta-analysis focused on clinical outcomes in patients with low back pain and found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging vs usual care. Published data also document harms associated with early imaging for low back pain, including patient "labeling," unneeded follow-up tests for incidental findings, irradiation exposure, unnecessary surgery, and significant cost. Routine imaging should not be pursued in acute low back pain. Not imaging patients with acute low back pain will reduce harms and costs, without affecting clinical outcomes.

Radiograph utilization and demographics in a chiropractic college teaching clinic

“…[4][5][6][7][8] In addition to the direct costs involved with obtaining radiographs, indirect costs are incurred from incidental findings on the images as the health care provider attempts to further clarify the nature of the finding. Radiographic imaging exposes the patient to low levels of potentially harmful radiation, the risk of which should be balanced against the benefit of the information that might be obtained from the images.…”

Neurology Choosing Wisely recommendations

“…7 Likewise, high and rising neuroimaging utilization has been reported for patients with low back pain with high resulting costs. 8,9 Neuroimaging for headache and low back pain are ideal intervention candidates as multiple societies and guidelines have recommended against their use and the costs of guideline discordant care are known to be high. 10,11 Future studies are needed to probe the costs of the other 64 items, and cost estimates should be provided with all future Choosing Wisely items.…”

Spine surgeons’ requirements for imaging at the time of referral: a survey of Canadian spine surgeons

“…16 Reasons for high rates of inappropriate spine-related imaging are not clear; however, it appears to be a com bination of patient demand owing to the persistent and often recurrent nature of degenerative spinal disorders [17][18][19][20][21] as well as the limited confidence that many primary care physicians have in assessing and managing patients with chronic musculoskeletal complaints. [22][23][24] This may drive referrals for both imaging and surgical consultation owing to concerns over further management needs or missing important findings.…”