Informed appropriate imaging for low back pain management: A narrative review

Abstract

Most patients with acute low back pain (LBP), with or without radiculopathy, have substantial improvements in pain and function in the first 4 weeks, and they do not require routine imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their LBP. It is also considered for those patients presenting with suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture and infection. In western country primary care settings, the prevalence has been suggested to be 0.7% for metastatic cancer, 0.01% for spinal infection and 0.04% for cauda equina syndrome. Of the small proportion of patients with any of these conditions, almost all have an identifiable risk factor. Osteoporotic vertebral compression fractures (4%) and inflammatory spine disease (<5%) may cause LBP, but these conditions typically carry lower diagnostic urgency. Imaging is an important driver of LBP care costs, not only because of the direct costs of the test procedures but also because of the downstream effects. Unnecessary imaging can lead to additional tests, follow-up, referrals and may result in an invasive procedure of limited or questionable benefit. Imaging should be delayed for 6 weeks in patients with nonspecific LBP without reasonable suspicion for serious disease.The translational potential of this article: Diagnostic imaging studies should be performed only in patients who have severe or progressive neurologic deficits or are suspected of having a serious or specific underlying condition. Radiologists can play a critical role in decision support related to appropriateness of imaging requests, and accurately reporting the potential clinical significance or insignificance of imaging findings.

Low back pain should be considered a health and research priority in Brazil: Lost productivity and healthcare costs between 2012 to 2016

“…We found more than 880,000 routine diagnostic imaging procedures were performed between 2012-2016 during inpatient and outpatient care, with a ratio of approximate 10 images per 1000 individuals affected by LBP in Brazil. Inappropriate use of routine diagnostic imaging for LBP is being widely discussed [14,[42][43][44][45]. Previous studies demonstrated frequent referral for diagnostic imaging, despite the absence of red flags, such as infection, progressive neurologic deficits, or underlying pathologies [44,46].…”

“…Inappropriate use of routine diagnostic imaging for LBP is being widely discussed [14,[42][43][44][45]. Previous studies demonstrated frequent referral for diagnostic imaging, despite the absence of red flags, such as infection, progressive neurologic deficits, or underlying pathologies [44,46]. However, current recommendations rather discourage imaging as part of early management of LBP, because of harms such as unnecessary exposition to radiation, patient fear and sense of fragility, and use of additional procedures resulting in overmedicalization [14,44].…”

“…Previous studies demonstrated frequent referral for diagnostic imaging, despite the absence of red flags, such as infection, progressive neurologic deficits, or underlying pathologies [44,46]. However, current recommendations rather discourage imaging as part of early management of LBP, because of harms such as unnecessary exposition to radiation, patient fear and sense of fragility, and use of additional procedures resulting in overmedicalization [14,44]. Nonetheless, a systematic review [45] found a 53% relative increase in diagnostic imaging use (e.g., CT-scans) for LBP in primary and emergency care, from 1995 to 2015, despite guidelines advice and campaigns otherwise [47].…”

Primary cardiac undifferentiated pleomorphic sarcoma: an alarming cause of lower back pain

“…Usually, the first complaint is a symptom of heart failure such as dyspnoea 4 ; lower back pain as the first manifestation is extremely rare and reported in few previous case reports. [5][6][7] Although lower back pain itself is a common manifestation caused by nonserious orthopaedic diseases, some serious medical disorders such as malignancies could be its cause, 8 and 'red flag' signs are essential to determine whether presenting back pain is serious. 9 Our patient had three red flags, namely, unintentional weight loss, pain without improvement by resting in the supine position and neurological deficits, 10 leading us to perform a meticulous physical examination, which resulted in finding signs of cardiac abnormalities and timely echocardiography, to make a correct diagnosis.…”

Anti-inflammatory effects of Jingshu Keli capsule and its components on human synoviocyte MH7A cells

“…It is characterized by circumferential narrowing of the cervical foramen and subsequent neural compression [3]. During the process of cervical radiculopathy, inflammation mediators were released [4,5]. Neurogenic inflammation caused by mechanical compression of the cervical nerve root was reported to be the main cause of spastic pain [6][7][8].…”