European Spine Journal

, Volume 28, Issue 5, pp 937–950 | Cite as

Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work

  • G. P. G. LemmersEmail author
  • W. van Lankveld
  • G. P. Westert
  • P. J. van der Wees
  • J. B. Staal
Review Article



Imaging (X-ray, CT and MRI) provides no health benefits for low back pain (LBP) patients and is not recommended in clinical practice guidelines. Whether imaging leads to increased costs, healthcare utilization or absence from work is unclear. Therefore, this study systematically reviews if imaging in patients with LBP leads to an increase in these outcomes.


We searched PubMed, CINAHL, EMBASE, Cochrane Library and Web of Science until October 2017 for randomized controlled trials (RCTs) and observational studies (OSs), comparing imaging versus no imaging on targeted outcomes. Data extraction and risk of bias assessment was performed independently by two reviewers. The quality of the body of evidence was determined using GRADE methodology.


Moderate-quality evidence (1 RCT; n = 421) supports that direct costs increase for patients undergoing X-ray. Low-quality evidence (3 OSs; n = 9535) supports that early MRI may lead to an increase in costs. There is moderate-quality evidence (1 RCT, 2 OSs; n = 3897) that performing MRI or imaging (MRI or CT) is associated with an increase in healthcare utilization (e.g., future injections, surgery, medication, etc.). There is low-quality evidence (5 OSs; n = 15,493) that performing X-ray or MRI is associated with an increase in healthcare utilization. Moderate-quality evidence (2 RCTs; n = 667) showed no significant differences between X-ray or MRI groups compared with non-imaging groups on absence from work. However, low-quality evidence (2 Oss; n = 7765) did show significantly greater mean absence from work in the MRI groups in comparison with the non-imaging groups.


Imaging in LBP may be associated with higher medical costs, increased healthcare utilization and more absence from work.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Low back pain Imaging Costs Healthcare utilization Absence from work 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest

Supplementary material

586_2019_5918_MOESM1_ESM.pptx (288 kb)
Supplementary material 1 (PPTX 288 kb)


  1. 1.
    Becker A, Held H, Redaelli M et al (2010) Low back pain in primary care. Spine (Phila Pa 1976) 35:1714–1720. CrossRefGoogle Scholar
  2. 2.
    Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WDCT (2009) The rising prevalence of chronic low back pain. Med Arch Intern 169:8–9. CrossRefGoogle Scholar
  3. 3.
    Manchikanti L, Benyamin RM, Falco FJE, Hirsch JA (2013) Recommendations of the Medicare Payment Advisory Commission (MEDPAC) on the health care delivery system: the impact on interventional pain management in 2014 and beyond. Pain Physician 16:419–440PubMedGoogle Scholar
  4. 4.
    Vos T, Flaxman AD, Naghavi M et al (2012) Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380:2163–2196. CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Dagenais S, Caro J, Haldeman S (2008) A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 8:8–20. CrossRefPubMedGoogle Scholar
  6. 6.
    Lin C-WC, Li Q, Williams CM et al (2018) The economic burden of guideline-recommended first line care for acute low back pain. Eur Spine J 27(1):109–116. CrossRefPubMedGoogle Scholar
  7. 7.
    Ma VY, Chan L, Carruthers K (2015) The incidence, prevalence, costs and impact on disability of common conditions requiring rehabilitation in the US: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back. Pain 95:986–995. CrossRefGoogle Scholar
  8. 8.
    Martin BI, Deyo RA, Mirza SK et al (2008) Expenditures and health status among adults with back and neck problems. JAMA 299:656–664. CrossRefPubMedGoogle Scholar
  9. 9.
    Lambeek LC, Van Tulder MW, Swinkels ICS et al (2011) The trend in total cost of back pain in the netherlands in the period 2002 to 2007. Spine (Phila Pa 1976) 36:1050–1058. CrossRefGoogle Scholar
  10. 10.
    Hartvigsen J, Hancock MJ, Kongsted A et al (2018) What low back pain is and why we need to pay attention. Lancet 391(10137):2356–2367. CrossRefPubMedGoogle Scholar
  11. 11.
    Dagenais SHS (2012) Evidence-based management of low back pain. In: Dagenais S, Haldeman S (eds) Evidence-based management of low back pain. Mosby, St Louis, pp 1–12Google Scholar
  12. 12.
    Foster N, Anema J, Cherkin D et al (2018) Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 391(10137):2368–2383. CrossRefPubMedGoogle Scholar
  13. 13.
    Stochkendahl MJ, Kjaer P, Hartvigsen J et al (2018) National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 27:60–75. CrossRefPubMedGoogle Scholar
  14. 14.
    Koes BW, van Tulder MW, Ostelo R et al (2001) Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine (Phila Pa 1976) 26:2504CrossRefGoogle Scholar
  15. 15.
    Verhagen AP, Downie A, Maher CG, Koes BW (2017) Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain 158(10):1860–1868. CrossRefPubMedGoogle Scholar
  16. 16.
    Hanney WJ, Masaracchio M, Liu X, Kolber MJ (2016) The influence of physical therapy guideline adherence on healthcare utilization and costs among patients with low back pain: a systematic review of the literature. PLoS ONE 11:1–18. CrossRefGoogle Scholar
  17. 17.
    Jenniskens K, de Groot JAH, Reitsma JB et al (2017) Overdiagnosis across medical disciplines: a scoping review. BMJ Open 7:e018448. CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS (1994) Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 14;331(2):69–73CrossRefGoogle Scholar
  19. 19.
    Boden SD, Davis DO, Dina TS et al (1990) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 72:403–408CrossRefPubMedGoogle Scholar
  20. 20.
    Van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM (1997) Spinal radiographic findings and nonspecific low back pain: a systematic review of observational studies. Spine (Phila Pa 1976) 22:427–434CrossRefGoogle Scholar
  21. 21.
    Brinjikji W, Luetmer PH, Comstock B et al (2015) Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 36(4):811–816. CrossRefGoogle Scholar
  22. 22.
    Jarvik JG, Deyo RA (2002) Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med 137:586–597CrossRefPubMedGoogle Scholar
  23. 23.
    Steffens D, Hancock MJ, Maher CG et al (2014) Does magnetic resonance imaging predict future low back pain? A systematic review. Eur J Pain 18:755–765. CrossRefPubMedGoogle Scholar
  24. 24.
    Pham HH, Landon BE, Reschovsky JD et al (2009) Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med 169:972–981. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Webster BS, Cifuentes M (2010) Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med 52:900–907. CrossRefPubMedGoogle Scholar
  26. 26.
    Dagenais S, Galloway EK, Roffey DM (2014) A systematic review of diagnostic imaging use for low back pain in the United States. Spine J 14:1036–1048. CrossRefPubMedGoogle Scholar
  27. 27.
    Mafi J, McCarthy EP, Davis RB, Landon BE (2013) Worsening trends in the management and treatment of back pain. JAMA 173:1573–1581. CrossRefGoogle Scholar
  28. 28.
    Lurie JD, Birkmeyer NJ, Weinstein JN (2003) Rates of advanced spinal imaging and spine surgery. Spine (Phila Pa 1976) 28:616–620. CrossRefGoogle Scholar
  29. 29.
    Chou R, Fu R, Carrino JA, Deyo RA (2009) Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 373:463–472. CrossRefPubMedGoogle Scholar
  30. 30.
    Jarvik JG, Gold LS, Comstock BA et al (2015) Association of early imaging for back pain with clinical outcomes in older adults. JAMA 313:1143–1153. CrossRefPubMedGoogle Scholar
  31. 31.
    Sox HCJ, Margulies I, Sox CH (1981) Psychologically mediated effects of diagnostic tests. Ann Intern Med 95:680–685CrossRefPubMedGoogle Scholar
  32. 32.
    Verbeek J, Sengers M-J, Riemens L, Haafkens J (2004) Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine (Phila Pa 1976) 29:2309–2318CrossRefGoogle Scholar
  33. 33.
    Wilson IB, Dukes K, Greenfield S et al (2001) Patients’ role in the use of radiology testing for common office practice complaints. Arch Intern Med 161:256–263CrossRefPubMedGoogle Scholar
  34. 34.
    Blank L, Baxter S, Woods HB et al (2014) Referral interventions from primary to specialist care: a systematic review of international evidence. Br J Gen Pract 64:e765–e774. CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Blank L, Baxter S, Woods HB et al (2015) What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis. Health Serv Deliv Res 3:1–430. CrossRefGoogle Scholar
  36. 36.
    Itz CJ, Ramaekers BL, van Kleef M, Dirksen CD (2017) Medical specialists care and hospital costs for low back pain in the Netherlands. Eur J Pain (United Kingdom) 21:705–715. CrossRefGoogle Scholar
  37. 37.
    Karel YHJM, Verkerk K, Endenburg S et al (2015) Effect of routine diagnostic imaging for patients with musculoskeletal disorders: a meta-analysis. Eur J Intern Med 26:585–595. CrossRefPubMedGoogle Scholar
  38. 38.
    Vrabel M (2015) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Oncol Nurs Forum 42:552–554. CrossRefPubMedGoogle Scholar
  39. 39.
    Higgins J (2008) Cochrane handbook for systematic reviews of interventions version 5.0.0. Cochrane CollaborationGoogle Scholar
  40. 40.
    Institute. NHL and B (2014) Quality assessment tool for observational cohort and cross-sectional studies—NHLBI, NIH. National Institutes of Health, Bethesda, MDGoogle Scholar
  41. 41.
    Canfield SE, Dahm P (2011) Rating the quality of evidence and the strength of recommendations using GRADE. World J Urol 29:311–317. CrossRefPubMedGoogle Scholar
  42. 42.
    Baker A, Young K, Potter J, Madan I (2010) A review of grading systems for evidence-based guidelines produced by medical specialties. Clin Med 10:358–363. CrossRefGoogle Scholar
  43. 43.
    Djulbegovic B, Trikalinos TA, Roback J et al (2009) Impact of quality of evidence on the strength of recommendations: an empirical study. BMC Health Serv Res 9:120. CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Schünemann H, Brożek J, Guyatt G, Oxman A E (2013) GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working GroupGoogle Scholar
  45. 45.
    Guyatt GH, Oxman AD, Vist GE et al (2009) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 336:924–926. CrossRefGoogle Scholar
  46. 46.
    Huguet A, Hayden JA, Stinson J et al (2013) Judging the quality of evidence in reviews of prognostic factor research: adapting the GRADE framework. Syst Rev 2:71. CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Shamliyan TA, Staal JB (2014) Epidural steroid injections for radicular lumbosacral pain: a systematic review. Phys Med Rehabil Clin N Am 25:471–489CrossRefPubMedGoogle Scholar
  48. 48.
    Ryan R, Santesso N, Hill S (2016) Preparing Summary of Findings (SoF) tables. Cochrane Consumers and Communication Group, available at Version 2.0 December 2016
  49. 49.
    Glenton C, Santesso N, Rosenbaum S et al (2010) Presenting the results of cochrane systematic reviews to a consumer audience: a qualitative study. Med Decis Making 30:566–577. CrossRefPubMedGoogle Scholar
  50. 50.
    Cohen SP, Gupta A, Strassels SA, Christo PJ, Erdek MA, Griffith SR, Kurihara C, Buckenmaier CC III, Cornblath D, Vu T-N (2012) Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections. Arch Intern Med 172:134. CrossRefPubMedGoogle Scholar
  51. 51.
    Ash LM, Modic MT, Obuchowski NA et al (2008) Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol 29:1098–1103. CrossRefPubMedGoogle Scholar
  52. 52.
    Miller P, Kendrick D, Bentley E, Fielding K (2002) Cost-effectiveness of lumbar spine radiography in primary care patients with low back pain. Spine (Phila Pa 1976) 27:2291–2297. CrossRefGoogle Scholar
  53. 53.
    Kendrick D, Fielding K, Bentley E et al (2001) Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ 322:400–405. CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Kerry S, Hilton S, Dundas D et al (2002) Radiography for low back pain: a randomised controlled trial and observational study in primary care. Br J Gen Pract 52:469–474PubMedPubMedCentralGoogle Scholar
  55. 55.
    Gilbert FJ, Grant AM, Gillan MG et al (2004) Does early imaging influence management and improve outcome in patients with low back pain? A pragmatic randomised controlled trial. Health Technol Assess 8:iii, 1–131CrossRefPubMedGoogle Scholar
  56. 56.
    Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM (2014) Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Serv Res 49:645–665. CrossRefPubMedGoogle Scholar
  57. 57.
    Webster BS, Bauer AZ, Choi Y et al (2013) Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine (Phila Pa 1976) 38:1939–1946. CrossRefGoogle Scholar
  58. 58.
    Webster BS, Choi Y, Bauer AZ et al (2014) The cascade of medical services and associated longitudinal costs due to nonadherent magnetic resonance imaging for low back pain. Spine (Phila Pa 1976) 39:1433–1440. CrossRefGoogle Scholar
  59. 59.
    Aaronson EL, Yun BJ, Mort E et al (2017) Association of magnetic resonance imaging for back pain on seven-day return visit to the emergency department. Emerg Med J. CrossRefPubMedGoogle Scholar
  60. 60.
    Fritz JM, Brennan GP, Hunter SJ (2015) Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges. Health Serv Res 50:1927–1940. CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Carey M, Turon H, Goergen S et al (2015) Patients’ experiences of the management of lower back pain in general practice: use of diagnostic imaging, medication and provision of self-management advice. Aust J Prim Health 21:342–346. CrossRefPubMedGoogle Scholar
  62. 62.
    Oliveira CB, Maher CG, Pinto RZ et al (2018) Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J 27:1–13. CrossRefGoogle Scholar
  63. 63.
    Doniselli FM, Zanardo M, Manfrè L et al (2018) A critical appraisal of the quality of low back pain practice guidelines using the AGREE II tool and comparison with previous evaluations: a EuroAIM initiative. Eur Spine J 27:2781–2790. CrossRefPubMedGoogle Scholar
  64. 64.
    Jenkins HJ, Downie AS, Maher CG et al (2018) Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. Spine J 18:2266–2277. CrossRefPubMedGoogle Scholar
  65. 65.
    Wong JJ, Cote P, Sutton DA et al (2017) Clinical practice guidelines for the noninvasive management of low back pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain 21:201–216. CrossRefPubMedGoogle Scholar
  66. 66.
    Bernstein IA, Malik Q, Carville S, Ward S (2017) Low back pain and sciatica: summary of NICE guidance. BMJ 356:i6748. CrossRefPubMedGoogle Scholar
  67. 67.
    Qaseem A, Wilt TJ, McLean RM, Forciea MA (2017) Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 166:514–530. CrossRefPubMedGoogle Scholar
  68. 68.
    Rizzardo A, Miceli L, Bednarova R et al (2016) Low-back pain at the emergency department: still not being managed? Ther Clin Risk Manag 12:183–187. CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Rosenberg A, Agiro A, Gottlieb M et al (2015) Early trends among seven recommendations from the Choosing Wisely Campaign. JAMA Intern Med 175:1913–1920. CrossRefPubMedGoogle Scholar
  70. 70.
    Werner EL, Ihlebaek C (2012) Primary care doctors’ management of low back pain patients-ten years after. Tidsskr Nor Laegeforen 132:2388–2390. CrossRefPubMedGoogle Scholar
  71. 71.
    Baker SR, Rabin A, Lantos G, Gallagher EJ (1987) The effect of restricting the indications for lumbosacral spine radiography in patients with acute back symptoms. Am J Roentgenol 149:535–538. CrossRefGoogle Scholar
  72. 72.
    Eccles M, Steen N, Grimshaw J et al (2001) Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial. Lancet (London, England) 357:1406–1409. CrossRefGoogle Scholar
  73. 73.
    Riis A, Jensen CE, Bro F et al (2016) A multifaceted implementation strategy versus passive implementation of low back pain guidelines in general practice: a cluster randomised controlled trial. Implement Sci 11:1–10. CrossRefGoogle Scholar
  74. 74.
    Jensen CE, Riis A, Petersen KD et al (2017) Economic evaluation of an implementation strategy for the management of low back pain in general practice. Pain 158:891–899. CrossRefPubMedGoogle Scholar
  75. 75.
    Suman A, Dikkers MF, Schaafsma FG et al (2016) Effectiveness of multifaceted implementation strategies for the implementation of back and neck pain guidelines in health care: a systematic review. Implement Sci 11:126. CrossRefPubMedPubMedCentralGoogle Scholar
  76. 76.
    Graves JM, Fulton-kehoe D, Jarvik JG, Franklin GM (2018) Impact of an advanced imaging utilization review program on downstream health care utilization and costs for low back pain. Med Care 56:520–528. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Fysius Back ExpertsNijverdalThe Netherlands
  2. 2.Radboud Institute for Health Sciences, IQ HealthcareRadboud University Medical CenterNijmegenThe Netherlands
  3. 3.Research Group Musculoskeletal RehabilitationHAN University of Applied SciencesNijmegenThe Netherlands

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