Imaging should not generally be recommended at initial visit for low back pain
Unless there are certain red flags, imaging is not recommended in the assessment of acute low back pain that is non-specific or associated with radiculopathy or spinal stenosis, according to evidence-based guidelines published in the October issue of the Journal of the American College of Radiology.

Provided within the article, written by Scott E. Forseen, MD, of Georgia Health Sciences University in Augusta, and Amanda S. Corey, MD, of Emory University Hospital in Atlanta, are templates designed to aid in the creation of clinical decision support tools.

“These templates may be reasonably expected to improve patient care, decrease inappropriate imaging utilization, reduce the inappropriate use of steroids and narcotics, and potentially decrease the number of inappropriate invasive procedures,” wrote the authors. They added that the templates could be helpful for providers regardless of whether they intend to meet federal standards for use of computerized physician order entry.

The guidelines called for patients to be categorized into one of three groups—non-specific low back pain, low back pain associated with radiculopathy or spinal stenosis or low back pain potentially associated with a specific underlying cause—based on assessment of patient history and physical examination at the initial visit.

Red flags for underlying conditions include recent serious trauma, immunosuppression, intravenous drug use, advanced age exceeding 70 years and osteoporosis, according to the authors. For this group, MRI is considered the imaging modality of choice, though CT, radiography and 99mTc bone scans could be considered for certain patients.

For patients with non-specific low back pain or pain associated with radiculopathy or spinal stenosis, however, imaging is not recommended at the initial evaluation, according to Forseen and Corey.

They wrote that evidence supports the use of self-care techniques for patients with non-specific low back pain, such as remaining active and applying heat. Acetaminophen is considered the first-line medication due to its limited side effects, but severe pain could be treated with opioids and tramadol. There is less evidence on self-care for patients with radiculopathy or spinal stenosis, but the authors noted that strategies used for non-specific low back pain could be used safely in this group.

If there is no improvement at a follow-up of four weeks for patients with non-specific pain, radiculopathy or spinal stenosis, then imaging could be considered, according to the authors.

Low back pain is one of the most common reasons for outpatient visits to physicians, wrote Forseen and Corey. Medical costs related to low back pain have increased disproportionately to the prevalence of the condition, with no associated improvement in outcomes. Total costs related to back pain, including imaging, are estimated at $100 billion per year in the U.S., according to the authors.

“The evidence-based order templates we have presented are designed to assist practitioners with the sometimes confusing process of managing patients with acute low back pain. We have presented a logical method of choosing, developing, and implementing [clinical decision support] interventions that is based on the best available evidence…Ideally, these templates could also be used to develop transparent criteria for payer coverage determinations with regard to imaging, medications, procedures and surgical interventions.”