Low back pain. 80% of us will experience it at some point in our lives. It is scary. It is debilitating, and it is painful. It is often so painful, in fact, that it is easy to believe that something truly terrible must be taking place inside our bodies. When this happens it is quite natural to want to know what is wrong and how can we fix it? Our first thought? Let’s take a look! MRIs, CT scans, x-rays - one of these dazzling diagnostic tools must be able to show us the answer.
Unfortunately low back pain is a little elusive when it comes to diagnosis and cause. It likes to be mysterious and keeps you guessing. For many people there is no obvious trauma, no memorable moment when you can think “that’s what happened!”. Low back pain tends to sneak up on us, waking us up in the morning with the unexpected inability to stand up properly. It surprises us on the 9th hole at golf when our usual swing gives a startling stabbing pain that wasn’t there before. It hides under boxes - waiting for us to pick things up poorly .
So we head off to the doctor or emergency room to see if they can see what is wrong with us and tell us how to heal. Low back pain is also one of the most common causes for disability-lost work days - and no one has time for that. We want answers and we want results. We want to get back to living as quickly as possible.
As many as 1 in 5 people with low back pain will receive an MRI for their back pain, despite the fact that there is little evidence to support the use of diagnostic imaging for this condition in the majority of cases.
Americans spend more than $100 billion on different diagnostic imaging tests each year, much of which is both harmful and unnecessary. When MRIs and CT scans (computed tomography) first came to the market in the 1970s, doctors were excited to be able to use the technology to make a diagnosis for a difficult to diagnose condition. It became the default for diagnosing low back pain, but it was never intended for this purpose - only to confirm, or refute, other conditions that may affect low back pain.
How To Diagnose And Treat Low Back Pain
When it comes to the diagnosis and treatment of low back pain the answer is often not one that people want to hear: wait it out. In the vast majority of low back pain cases international guidelines and medical associations all agree that those suffering from the condition need to wait and let the issue resolve on its own. This is not easy to hear, especially when the pain is intense and we don’t feel well enough to work. Staying active, limiting bed rest, and using over the counter pain relievers (sparingly) are the best ways to manage this condition.
When Should You Have Imaging For Low Back Pain?
Medical guidelines around this matter are very clear about when you should use diagnostic imaging for low back pain. Unless there are specific symptoms (red flags) that could indicate the presence of something more serious underlying the back pain, there should be no imaging within the first 6 weeks of the onset of low back pain.
Both the American College Of Physicians (ACP) and the American Pain Society (APS) recommend that imaging is only used for patients with severe or progressive neurologic deficits, or other red flags that could indicate a serious underlying condition.
Concerns With Unnecessary Medical Imaging
Research has found that not only is routing imaging such as X-rays, MRIs, and CT scans not beneficial for low back pain, but it can expose patients to unnecessary radiation, doing more harm than good. Routine imaging has no positive effect on pain, function, or quality of life and it is a colossal waste of time and money.
Routine imaging is a significant driver of costs associated with low back pain treatment. Not only are there the direct costs of the imaging, but it can also lead to follow-ups, referrals, and further tests that are often just as inconclusive. Tests can tell you what back pain is not, rather than what it is. Of further concern is the fact that the rate of spinal MRIs increased at the same time as lumbar surgeries soared, causing many healthcare professionals to be troubled by the apparent correlation with the increase in invasive procedures.
MRIs are an incredible invention that allows doctors to see inside the body in a way that we have never been able to before. They help doctors to diagnose diseases in a non-invasive way that has enormous benefits to the patient. Unfortunately there is a tendency to over-rely on this technology and use it even when there isn’t a clear benefit, such as with low back pain.
New research conducted by professor Gary Young, from Northeastern University, shows that increasingly, doctors feel pressured to prescribe unnecessary MRIs to increase hospital billings and profitability. Young’s team looked at all commercial health insurance claims in Massachusetts between 2009 and 2016. This yielded 30 million imaging procedures for them to study. The team then developed an algorithm that could determine the appropriateness of the MRI prescription.
One example that they looked at was in the area of low back pain. Guidelines clearly recommend that patients suffering from low back pain should not have an MRI as a first resort. “You don’t refer them for an MRI because the likelihood that the MRI is going to reveal anything that’s going to be clinically informative is very, very low,” Young says. “What you should do for lower back pain is have them do physical therapy, home-based exercise, and rest. If the pain persists beyond physical therapy, beyond bed rest, then an MRI may become warranted. But the first step should not be an expensive MRI.”
Young’s research found that when doctors moved from being independent practitioners to being employed by hospitals, they began to refer more MRIs overall, especially inappropriate MRIs such as those used in managing low back pain.
The overuse of imaging is contributing significantly to the growing costs associated with the treatment and management of low back pain. In 1998 total US health care expenses for low back pain were estimated to be around $90 billion. Current estimations put these costs well above the $100 billion mark now, not including the cost to companies for missed work days. If we can reduce the number of unnecessary and ineffective tests and treatments for this condition we can ultimately save on both time spent on having these tests, and the money that it costs to run them.
Current international guidelines recommend " history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors". Healthcare professionals recommend keeping up with routine activities and avoiding bed rest, along with psychosocial interventions such as meditation, relaxation, deep breathing, biofeedback, and stress management.
When diagnosing low back pain it is extremely hard to pinpoint one specific incident or injury that can be treated. This challenge is acknowledged through the adoption of the biopsychosocial approach to treating chronic lower back pain. This model recognizes that low back pain is often caused by a combination of things, including stress, diet, physical strength/fitness, as well as lifestyle factors.
Lower back pain isn't a broken bone that just needs resetting and time to heal. Without proper lifestyle changes, many individuals with chronic low back pain will have subsequent flare ups throughout their lives. Imaging can be useful in some cases of lower back pain, but for the majority of individuals it will be time and money that is better spent elsewhere.