Appropriateness of Imaging in Chronic Low Back Pain

  • Amir Qaseem
  • Erik Van de Kelft


The majority of the patients suffering low back pain will receive routine spinal imaging (lumbar radiography, computed tomography [CT], or magnetic resonance imaging [MRI]) as part of the initial management program. However, the American College of Physicians (ACP) and the American Pain Society (APS) recommend only to perform imaging for patients who have severe or progressive neurologic deficits or signs or symptoms suggesting a serious underlying condition. These recommendations can be justified by the fact that routine imaging does not seem to improve clinical outcomes, exposes patients to unnecessary harms, and increases the cost of low back pain management. Diagnostic studies and specifically imaging studies should address a number of questions with regard to the technical efficacy, the diagnostic accuracy, the therapeutic impact, and the clinical efficacy.


Spinal Stenosis Cauda Equina Syndrome Routine Imaging Progressive Neurologic Deficit American Pain Society 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Di Iorio D, Henley E, Doughty A (2000) A survey of primary care physician practice patterns and adherence to acute low back problem guidelines. Arch Fam Med 9:1015–1021CrossRefPubMedGoogle Scholar
  2. 2.
    Webster BS, Courtney TK, Huang YH, Matz S, Christiani DC (2005) Physicians’ initial management of acute low back pain versus evidence-based guidelines. Influence of sciatica. J Gen Intern Med 20:1132–1135CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK, Clinical Efficacy Assessment Subcommittee of the American College of P, American College of P, American Pain Society Low Back Pain Guidelines P (2007) Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 147:478–491CrossRefPubMedGoogle Scholar
  4. 4.
    Chou R, Fu R, Carrino JA, Deyo RA (2009) Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 373:463–472CrossRefPubMedGoogle Scholar
  5. 5.
    Lurie JD, Birkmeyer NJ, Weinstein JN (2003) Rates of advanced spinal imaging and spine surgery. Spine (Phila Pa 1976) 28:616–620Google Scholar
  6. 6.
    ACoRA (2008) Appropriateness criteria. Low back pain. American College of Radiology, RestonGoogle Scholar
  7. 7.
    Fryback DG, Thornbury JR (1991) The efficacy of diagnostic imaging. Med Decis Making 11:88–94CrossRefPubMedGoogle Scholar
  8. 8.
    Guyatt GH, Tugwell PX, Feeny DH, Haynes RB, Drummond M (1986) A framework for clinical evaluation of diagnostic technologies. CMAJ 134:587–594PubMedPubMedCentralGoogle Scholar
  9. 9.
    Sackett DL, Haynes RB (2002) The architecture of diagnostic research. BMJ 324:539–541CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Schunemann HJ, Oxman AD, Brozek J, Glasziou P, Jaeschke R, Vist GE, Williams JW Jr, Kunz R, Craig J, Montori VM, Bossuyt P, Guyatt GH, Group GW (2008) Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ 336:1106–1110CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R (2001) Implementation barriers for general practice guidelines on low back pain a qualitative study. Spine (Phila Pa 1976) 26:E348–E353CrossRefGoogle Scholar
  12. 12.
    Owens D, Qaseem A, Snow V et al (2010) High value, cost conscious care: concepts for clinicians to evaluate benefits, harms, and costs of medical interventions. Ann Intern Med 154:174–180CrossRefGoogle Scholar
  13. 13.
    Department of Clinical Epidemiology and Biostatistics, McMaster University Health Sciences Centre (1984) How to read clinical journals: VII. To understand an economic evaluation. Can Med Assoc J 130:1542–1549Google Scholar
  14. 14.
    van Tulder MW, Assendelft WJ, 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
  15. 15.
    Jarvik JG, Hollingworth W, Martin B, Emerson SS, Gray DT, Overman S, Robinson D, Staiger T, Wessbecher F, Sullivan SD, Kreuter W, Deyo RA (2003) Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA 289:2810–2818CrossRefPubMedGoogle Scholar
  16. 16.
    Jarvik JJ, Hollingworth W, Heagerty P, Haynor DR, Deyo RA (2001) The longitudinal assessment of imaging and disability of the back (LAIDBack) study: baseline data. Spine (Phila Pa 1976) 26:1158–1166CrossRefGoogle Scholar
  17. 17.
    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 331:69–73CrossRefPubMedGoogle Scholar
  18. 18.
    Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas N (1984) A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine (Phila Pa 1976) 9:549–551CrossRefGoogle Scholar
  19. 19.
    Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW (1990) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 72:403–408PubMedGoogle Scholar
  20. 20.
    Carragee E, Alamin T, Cheng I, Franklin T, van den Haak E, Hurwitz E (2006) Are first-time episodes of serious LBP associated with new MRI findings? Spine J 6:624–635CrossRefPubMedGoogle Scholar
  21. 21.
    Nachemson A (1976) The lumbar spine: an orthopaedic challenge. Spine 1:59–71CrossRefGoogle Scholar
  22. 22.
    Halpin SF, Yeoman L, Dundas DD (1991) Radiographic examination of the lumbar spine in a community hospital: an audit of current practice. BMJ 303:813–815CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Rockey PH, Tompkins RK, Wood RW, Wolcott BW (1978) The usefulness of x-ray examinations in the evaluation of patients with back pain. J Fam Pract 7:455–465PubMedGoogle Scholar
  24. 24.
    Gillan MG, Gilbert FJ, Andrew JE, Grant AM, Wardlaw D, Valentine NW, Gregori AC, Scottish Back Trial G (2001) Influence of imaging on clinical decision making in the treatment of lower back pain. Radiology 220:393–399CrossRefPubMedGoogle Scholar
  25. 25.
    Fazel R, Krumholz HM, Wang Y, Ross JS, Chen J, Ting HH, Shah ND, Nasir K, Einstein AJ, Nallamothu BK (2009) Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med 361:849–857CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Berrington de Gonzalez A, Mahesh M, Kim KP, Bhargavan M, Lewis R, Mettler F, Land C (2009) Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 169:2071–2077CrossRefPubMedGoogle Scholar
  27. 27.
    Fisher ES, Welch HG (1999) Avoiding the unintended consequences of growth in medical care: how might more be worse? JAMA 281:446–453CrossRefPubMedGoogle Scholar
  28. 28.
    Ash LM, Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN (2008) Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol 29:1098–1103CrossRefPubMedGoogle Scholar
  29. 29.
    Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M (2001) Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ 322:400–405CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Rhodes LA, McPhillips-Tangum CA, Markham C, Klenk R (1999) The power of the visible: the meaning of diagnostic tests in chronic back pain. Soc Sci Med 48:1189–1203CrossRefPubMedGoogle Scholar
  31. 31.
    Verrilli D, Welch HG (1996) The impact of diagnostic testing on therapeutic interventions. JAMA 275:1189–1191CrossRefPubMedGoogle Scholar
  32. 32.
    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 52:900–907CrossRefPubMedGoogle Scholar
  33. 33.
    Verbeek J, Sengers MJ, 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
  34. 34.
    McPhillips-Tangum CA, Cherkin DC, Rhodes LA, Markham C (1998) Reasons for repeated medical visits among patients with chronic back pain. J Gen Intern Med 13:289–295CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Davis PC, Wippold FJ 2nd, Brunberg JA, Cornelius RS, De La Paz RL, Dormont PD, Gray L, Jordan JE, Mukherji SK, Seidenwurm DJ, Turski PA, Zimmerman RD, Sloan MA (2009) ACR appropriateness criteria on low back pain. J Am Coll Radiol 6:401–407CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of Clinical PolicyAmerican College of PhysiciansPhiladelphiaUSA
  2. 2.Department of NeurosurgeryAZ NikolaasSint NiklaasBelgium

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