Most back pain patients don't need diagnostic imaging

The American College of Physicians wants doctors to stop and think before ordering diagnostic imaging for patients with low back pain.

Such tests are recommended only for those with severe or progressive neurologic deficits or signs of "a serious or specific underlying condition," according to ACP clinical guidance in the Feb. 1 Annals of Internal Medicine.

Research shows that unnecessary diagnostic imaging drives up health care costs and has little value for most patients. The tests might cause harm through unnecessary radiation exposure and lead to more tests or invasive procedures that fail to ease symptoms.

"They do not improve patient outcomes and may increase the risk of cancer, especially in women," said Amir Qaseem, MD, PhD, the paper's co-author and director of clinical policy with the ACP's medical education division.

Low back pain is one of the most common reasons patients visit physicians. Studies have shown that about a quarter of adults report experiencing back pain for one day in the last three months, Dr. Qaseem said.

"Not a new message"

The ACP and the American Pain Society have recommended selective use of diagnostic imaging -- such as lumbar radiography, computed tomography and magnetic resonance imaging -- since 2007, said Roger Chou, MD, the paper's co-author and director of the APS' clinical practice guidelines program.

"It's not a new message. Unfortunately, it's been hard to get people to change their behaviors," said Dr. Chou, associate professor of internal medicine at Oregon Health & Science University.

The average annual cost per patient with back and neck problems increased 65% from $4,795 in 1997 to $6,096 in 2005, after being adjusted for inflation. Despite that increase, adults with spine pain reported similar or worse scores when evaluated for mental health, physical functioning, work or school limitations and social limitations from 1997 to 2005, the paper said.

The clinical guidelines were issued to help reduce direct costs from the tests as well as costs from follow-up visits, additional tests, referrals and invasive procedures that have questionable benefit, Dr. Qaseem said.

"The key is to reduce unnecessary costs in the health care system," he said.

Physicians often feel compelled to recommend diagnostic imaging because of patient pressure, the expectation of a clear diagnosis, excessive precaution due to medical liability concerns or financial considerations because of high reimbursements for such tests, Dr. Chou said.

One survey found that more than a third of physicians said they would order an imaging test if a patient insisted on it. If physicians take time to explain why such tests are not recommended in the majority of cases, most patients would prefer not to undergo a test that could be potentially harmful, Dr. Qaseem said.

The paper's authors analyzed six randomized trials that included 1,804 patients who had primarily acute or subacute low back pain and no evidence of an underlying condition.

They found no difference in pain, function, quality of life or overall improvement between patients who underwent imaging tests and those who did not. There was no difference in patients who received radiography versus advanced imaging tests such as MRI and CT scans.

The studies showed no psychological benefit for patients who underwent the tests, despite a general belief that undergoing the tests helps to relieve patient anxiety. In fact, most patients' symptoms subsided on their own within four weeks.

"There continues to be this perception that if you just knew what was causing the back pain that you can do something about it," Dr. Chou said. "Unfortunately, it has been shown that that just isn't the case."