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A new meta-analysis of randomized trials have suggested that  clinicians must not go for routine immediate lumbar imaging for patients presenting with acute and sub acute low back pain, unless there are indications of some serious underlying causes.

The study was conducted by Dr. Roger Chua and colleagues. They systematically conducted a meta-analysis of six randomised controlled studies comparing immediate lumbar imaging (radiography, MRI, or CT) vs. usual clinical care without immediate imaging for low back pain. 1804 patients with back pain were included from the 6 trials. Short term (up to 3 months) and long term (6-12months) primary outcomes were not significantly different in the two groups. For pain, standardized mean difference at 3 months was 0.19 (95% confidence interval [CI], –0.01 to 0.39) and for function, 0.11 (95% CI, –0.29 to 0.50), with negative values favouring routine imaging.  Primary outcomes were also not significantly different between groups in the long term (6 - 12 months, –0.04; 95% CI, –0.15 to 0.07 for pain and 0.01; 95% CI, –0.17 to 0•19 for function). Other outcomes did not differ significantly. The study was funded by the American Pain University.

The authors of a related editorial in the Lancet opined that various studies had suggests immediate imaging is not necessary for acute or sub acute onset of low back ache mainly because of the following reasons;
•    Most cases are due to non serious causes like strain, inappropriate posture etc
•    Most short duration back pain recover spontaneously or with supportive measures
•    There is not much correlation between the treatments given and the radiology results
•    the imaging findings might point to findings which may not be the cause of the pain and lead to unnecessary treatments and surgical interventions

The exception to this recommendation was in patients with "red flags," the authors note; that is, historical or clinical features suggestive of serious underlying conditions, such as cancer, infection, or cauda equine syndrome.

The authors say that inspite of all the recommendations, the physicians still routinely resort to imaging in back pain, the reasons of which includes;
•    reassuring their patients and themselves
•    patient expectations about diagnostic testing
•    reimbursement structures that provide incentives for imaging
•    fear of missing relevant pathology
•    patients with low back pain are an "interesting market" for poorly evaluated spinal interventions, including implantation of intervertebral devices or "so-called" dynamic stabilization systems

The best approach against this trend, they write, is educating the patient is educating patients both inside and outside of general practitioners' offices.

Source: The Lancet