Version May 2024
| Diagnostic imaging techniques | Radiography |
| Computed tomography (CT) | |
| Magnetic resonance imaging (MRI) | |
| Indications for diagnostic imaging | Radiography is recommended in patients with acute low back pain who have major risk factors for cancer (new onset of low back pain with history of cancer, multiple risk factors for cancer, or strong clinical suspicion for cancer). MRI is recommended in patients with acute low back pain who have risk factors for spinal infection (new onset of low back pain with fever and history of intravenous drug use or recent infection), risk factors for or signs of the cauda equina syndrome (new urinary retention, fecal incontinence, or saddle anesthesia), or severe or progressive neurologic deficits. |
| Radiography is recommended after a trial of therapy in patients with minor risk factors for cancer (unexplained weight loss or age >50 years), risk factors for ankylosing spondylitis (morning stiffness that improves with exercise, alternating buttock pain, awakening because of back pain during the second part of the night), risk factors for vertebral compression fracture (history of osteoporosis, glucocorticoid use, significant trauma, or older age [>65 years for men or >75 years for women]). MRI is recommended after a trial of therapy in patients with signs/symptoms of radiculopathy (back pain with leg pain in an L4, L5, or S1 nerve root distribution or positive result on straight leg raise or crossed straight leg raise test) who are candidates for surgery or epidural steroid injection. MRI is also recommended in patients with risk factors for or symptoms of symptomatic spinal stenosis (radiating leg pain, older age, or pseudoclaudication) in patients who are candidates for surgery. | |
| MRI is generally preferred over CT scan for most cases of low back pain. CT scan may help visualize bony abnormalities and is used when patients have a magnetic implant that is not suitable for MRI. | |
| Repeated imaging is only recommended in patients with new or changed low back symptoms. | |
| Evidence that expanding imaging to patients without these indications does not improve outcomes | Randomized trials of routine imaging versus usual care without routine imaging in patients without indications for diagnostic imaging suggest no clinically meaningful benefits on outcomes related to pain, function, quality of life, or mental health. |
| Other supporting evidence includes the weak correlation between most imaging findings and symptoms, the favorable natural history of acute low back pain with or without imaging, the low prevalence of serious or specific underlying conditions, and unclear effects of imaging on treatment decisions. | |
| Harms of unnecessary imaging | Radiation exposure (for lumbar radiography and CT) |
| Labeling | |
| Hypersensitivity reactions and contrast nephropathy (for iodinated contrast with CT) | |
| Potential association with subsequent unnecessary, invasive, and expensive procedures | |
| Approaches to overcome barriers to evidence-based practice | Patient expectations or preferences for routine imaging: Use talking points based on evidence-based guidelines to aid in patient education |
| Time constraints: Use evidence-based online or print education material to supplement face-to-face education | |
| Clinician uncertainty: Recognize the low likelihood of serious conditions in the absence of clinical risk factors and the evidence that shows no benefit associated with routine imaging | |
| Clinician incentives based on patient satisfaction: Advocate for incentives that are based on providing appropriate care | |
| Talking points for clinicians when discussing low back pain imaging with patients | Risk factor assessment can almost always identify patients who require imaging |
| The prevalence of serious underlying conditions is low in patients without risk factors | |
| The natural history of acute low back pain is quite favorable, but patients require reevaluation if they are not better after about one month | |
| Routine imaging does not improve clinical outcomes but increases costs and may lead to potentially unnecessary invasive treatments, such as surgery | |
| Imaging abnormalities are extremely common, especially in older adults, but most are poorly correlated with symptoms | |
| In most cases, treatment plans do not change after imaging studies | |
| Back imaging is associated with radiation exposure, which can increase the risk for cancer in the case of lumbar radiography and CT |
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
