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



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

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Fig. 1


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Correspondence to G. P. G. Lemmers.

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Appendix: search strategy

Appendix: search strategy

  1. #1

    ((“Low Back pain”[mesh] OR “Diskectomy”[mesh] OR “Spinal diseases”[mesh] OR “back injuries”[mesh] OR “spinal fusion”[mesh] OR “sciatica”[mesh] OR “Sciatic Neuropathy”[mesh] OR backpain*[tiab] OR lumbar pain*[tiab] OR lumbar back pain*[tiab] OR lumbar backach*[tiab] OR lumbar spine pain*[tiab] OR lbp[tiab] OR sacral pain*[tiab] OR dorsalgia[tiab] OR backach*[tiab] OR back ach*[tiab] OR back pain*[tiab] OR radicular pain*[tiab] OR herniated dis*[tiab] OR slipped dis*[tiab] OR Lumbago*[tiab] OR back disorder*[tiab] OR back injur*[tiab] OR spinal fusion*[tiab] OR postlaminectomy*[tiab] OR post laminectomy*[tiab] OR arachnoiditis[tiab] OR failed back*[tiab] OR spondylit*[tiab] OR spondylosis[tiab] OR sciatic*[tiab] OR discitis[tiab] OR Radicular syndrom*[tiab] OR Radicular pain*[tiab] OR Spondylolisthes*[tiab] OR scoliosis[tiab] OR spinal stenosis[tiab] OR root stenosis[tiab] OR spine stenosis[tiab] OR degeneration dis*[tiab] OR degenerative dis*[tiab] OR displaced dis*[tiab] OR Disc problem*[tiab] OR disk problem*[tiab] OR back disab*[tiab] OR Piriformis Syndrome[tiab]) OR ((“pain”[mesh] OR “Pain Measurement”[Mesh] OR “Hernia”[mesh] OR pain[tiab] or ache*[tiab] OR aching*[tiab] OR Physical Suffering*[tiab] OR hernia*[tiab] OR Analges*[tiab] OR Nociception*[tiab]) AND (“Spine”[mesh] OR “back”[mesh] OR “spinal nerves”[mesh] OR “Intervertebral Disc”[mesh] OR spine*[tiab] OR spinal[tiab] OR Intervertebral Disk*[tiab] OR Lumbar Vertebra*[tiab] OR sacrum*[tiab] OR Cauda Equina*[tiab] OR facet joint*[tiab] OR coccyx[tiab] OR coccydynia[tiab] OR Ventral Root*[tiab] OR Dorsal Root*[tiab] OR anterior root*[tiab] OR posterior root*[tiab])))

  2. #2

    (“Magnetic Resonance Imaging”[mh] OR “magnetic resonance spectroscopy”[mh] OR magnetic resonance[tiab] OR NMR[tiab] OR MR[tiab] OR MRI[tiab] OR MRIs[tiab] OR mrs[tiab] OR MRSI[tiab] OR fMRI[tiab] OR fMRIs[tiab] OR fcmri[tiab] OR cmr[tiab] OR MRA[tiab] OR diffusion weighted[tiab] OR perfusion weighted[tiab] OR diffusion tensor[tiab] OR tractography[tiab] OR magnetization transfer*[tiab] OR zeugmatograph*[tiab] OR echo-planar[tiab] OR echoplanar[tiab] OR proton spin tomograph*[tiab] OR 1H-MR*[tiab] OR 1HMR*[tiab] OR H-MR*[tiab] OR HMR*[tiab] OR tesla[tiab] OR DWI[tiab] OR DTI[tiab] OR arterial spin labelling[tiab] OR arterial spin labeling[tiab] OR current density imag*[tiab] OR MP-RAGE[tiab] OR MPRAGE[tiab] OR turbo spin echo*[tiab] OR T1weighted[tiab] OR T2weighted[tiab] OR T1-weighted[tiab] OR T2-weighted[tiab] OR t2 star[tiab] OR t2-map*[tiab] OR t2-value*[tiab] OR t2-relax*[tiab] OR t1-map*[tiab] OR t1-value*[tiab] OR t1-relax*[tiab] OR dgemric[tiab] OR ASL[tiab] OR imaging[tiab] OR “Radiography”[Mesh] OR radiograph*[tiab] OR Roentgenograph*[tiab] OR Tomography[mesh] OR tomograph*[tiab] OR “Diagnostic Imaging”[Mesh:NoExp] OR “Diagnostic Imaging”[SH] OR “Tomography, X-Ray Computed”[Mesh] OR ct[tiab] OR cts[tiab] OR cat scan*[tiab] OR catscan*[tiab] OR x ray*[tiab] OR xray*[tiab] OR scan*[tiab] OR photograph*[tiab] OR photo[tiab] OR photos[tiab] OR radiolog*[tiab] OR ACR[tiab])

  3. #3

    (“costs and cost analysis”[mesh] OR “cost of illness”[mesh] OR “Health Care Costs”[Mesh] OR “Insurance”[Mesh] OR “Referral and Consultation”[Mesh] OR Budget control*[tiab] OR Budget saving*[tiab] OR Care budget*[tiab] OR care expen*[tiab] OR Care expen*[tiab] OR Care fund*[tiab] OR Care spend*[tiab] OR champus[tiab] OR Claim analysis[tiab] OR Claim review*[tiab] OR Claims Analysis[tiab] OR Claims Review*[tiab] OR Coinsurance*[tiab] OR Competitive Health Plan*[tiab] OR Competitive Medical Plan*[tiab] OR control cost*[tiab] OR Cost allocat*[tiab] OR Cost analy*[tiab] OR Cost apportionment*[tiab] OR Cost benefit*[tiab] OR Cost compar*[tiab] OR Cost contain*[tiab] OR Cost control*[tiab] OR Cost effective*[tiab] OR Cost Efficien*[tiab] OR Cost evaluat*[tiab] OR Cost increase*[tiab] OR Cost manag*[tiab] OR Cost minimi*[tiab] OR Cost reduc*[tiab] OR Cost reduction[tiab] OR Cost saving*[tiab] OR Cost sharing[tiab] OR Cost shifting*[tiab] OR Costeffect*[tiab] OR Cost minimisation[tiab] OR Cost minimization[tiab] OR Deductible*[tiab] OR direct cost*[tiab] OR Economic evaluat*[tiab] OR Health Benefit Plan*[tiab] OR Health budget*[tiab] OR health care cost*[tiab] OR Health care saving*[tiab] OR health care spending[tiab] OR health care system*[tiab] OR health cost*[tiab] OR health expen*[tiab] OR health expenditure*[tiab] OR Health fund*[tiab] OR Health spend*[tiab] OR health spending*[tiab] OR Healthcare budget*[tiab] OR Healthcare cost*[tiab] OR healthcare expen*[tiab] OR Healthcare fund*[tiab] OR Healthcare savings[tiab] OR Healthcare spend*[tiab] OR healthcare spending*[tiab] OR healthcare system*[tiab] OR High cost*[tiab] OR High spend*[tiab] OR Increasing cost*[tiab] OR insuran*[tiab] OR Low cost*[tiab] OR managed car*[tiab] OR Medical budget*[tiab] OR Medical Care Cost*[tiab] OR medical cost*[tiab] OR Medical expen*[tiab] OR Medical fund*[tiab] OR medical saving*[tiab] OR Medical saving*[tiab] OR Medical spend*[tiab] OR medicare[tiab] OR Preferred provider*[tiab] OR Reducing cost*[tiab] OR Reimburs*[tiab] OR Rising cost*[tiab] OR Saving cost*[tiab] OR societal cost*[tiab] OR Third-Party Pay*[tiab] OR Treatment Cost*[tiab] OR Usage reduction*[tiab] OR Value Based Purchas*[tiab] OR Worker Compensation*[tiab] OR Worker s compensation*[tiab] OR Workers compensation*[tiab])

  4. #4

    (“Health Services Misuse”[Mesh] OR appropriateness criteria[tiab] OR overus*[tiab] OR over us*[tiab] OR overutili*[tiab] OR over utili*[tiab] OR misuse*[tiab] OR mis use[tiab] OR Unnecessary Surgery[tiab] OR Unnecessary procedur*[tiab] OR Unnecessary treat*[tiab] OR Unnecessary medic*[tiab] OR Overdiagno*[tiab] OR Over diagno*[tiab] OR Overmedication*[tiab] OR Over medication*[tiab] OR Misdiagnosi*[tiab] OR Mis diagnosi*[tiab] OR Unwanted Medical Car*[tiab] OR Overtreat*[tiab] OR over treat*[tiab] OR inappropriate[tiab] OR Justif*[tiab])

  5. #5

    (“absenteeism”[mesh] OR “Sick leave”[mesh] OR “Return to work”[mesh] OR work absen*[tiab] OR work disabilit* OR absenteeism[tiab] OR sick leav*[tiab] OR sick day*[tiab] OR sickness absen*[tiab] OR disability leav*[tiab] OR Illness Day*[tiab] OR absenteeism[tiab] OR absentism[tiab] or return to work[tiab] OR returning to work[tiab] OR absence from work*[tiab] OR away from work[tiab] OR employee performance[tiab] OR job performance[tiab] OR lost work day*[tiab] OR lost work*[tiab] OR missed work*[tiab] OR missing work[tiab] OR presenteeism[tiab] OR work ability[tiab] OR work attend*[tiab] OR work day*[tiab] OR work impairment*[tiab] OR workday*[tiab] OR work performance*[tiab] OR work productivity*[tiab] OR work loss*[tiab])

  6. #6

    #3 OR #4 OR #5

  7. #7

    #1 AND #2 AND #6

  8. #8

    Routine diagnostic imaging[tiab] OR Unnecessary scan*[tiab] OR Unnecessary mri*[tiab] OR Unnecessary radiograph*[tiab] OR Unnecessary imag*[tiab] OR Unnecessary x ray* OR acr appropriateness criteria*[tiab] OR choosing wisely[tiab] OR Mri utiliz*[tiab] OR MRI use[tiab] OR MRI usage[tiab] OR CT utiliz*[tiab] OR CT use[tiab] OR CT usage[tiab] OR image utiliz*[tiab] OR image use[tiab] OR scan utiliz*[tiab] OR scan use[tiab] OR scan usage[tiab] OR x ray utiliz*[tiab] OR x ray use[tiab] OR x ray usage[tiab] OR radiography use[tiab] OR radiography utiliz*[tiab] OR Early mri*[tiab] OR early x ray*[tiab] OR early imag*[tiab] OR early radiograph*[tiab]

  9. #9

    #1 AND #8

  10. #10

    #7 OR #9

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Lemmers, G.P.G., van Lankveld, W., Westert, G.P. et al. Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. Eur Spine J 28, 937–950 (2019).

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  • Low back pain
  • Imaging
  • Costs
  • Healthcare utilization
  • Absence from work