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Lower back pain: best left unimaged

Michael Daubs, MD, Board Certified Orthopedic Surgeon, Southwest Medical Associates

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Southwest Medical, part of OptumCare, is one of Nevada’s largest multi-specialty medical groups. We’ve been caring for southern Nevadans since 1972. We have decades of experience and a drive to better our patients' lives. 

By combining technology and information, we give our patients the right care in the right setting. We provide primary, specialty, urgent, senior, OB-GYN, pediatric, and convenient care. 

Among primary care clinicians and specialists dealing with conditions of the spine, the path of a patient suffering with lower back pain is a familiar one.

The patient begins to experience back pain, a symptom he or she has in common with 84% of people worldwide over the course of a lifetime.1  

If the pain sticks around or does not relent with common over-the-counter remedy, the patient visits their primary care clinician seeking some relief.

Conservative options

Depending on patient characteristics and duration and level of pain experienced, the primary care clinician likely begins treatment with an NSAID, rest, heat and ice. 

Yet, when the patient regularly returns with exacerbations of back pain, and conservative lines of treatment are exhausted, the clinician, in an effort to better understand what underlying mechanism may be responsible, orders imaging.

Where does the pain come from?

This is the point at which back pain, which is a symptom, is at risk of conflation with the evidence of spine degeneration on the image. 

As we continue to further study best practices for diagnosis and management of an epidemic of pain responsible for the greatest amount of disability across the globe,2 the evidence against imaging as a diagnostic tool in axillary lower back pain has come clear. 

In fact, regardless of incidence of pain the prevalence of degenerative changes of the spine tracks at about 30% for people in their 30s, 40% for people in their 40s, and so forth, making the likelihood of finding a flawless spine increasingly small with time.3 

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Strong evidence

A 2009 meta-analysis assessed for quality by the Cochrane Back Review Group looked at six studies containing the images of 1,804 patients in an effort to show correlation between changes on a CT or MRI and incidence of lower back pain. 

The study could not correlate irregular CT or MRI with incidence or severity of back pain, and advised that “Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. 

Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.

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The power of a picture

When presented with a picture and radiology report confirming disc bulges or degenerative change, a patient’s perception of their condition may change from a person with pain, a symptom, to a person with disc disease, a diagnosis. 

Moving from symptomatic to diseased is a powerful shift, and most normal patients can’t be faulted in expecting the next logical thing: a cure.

A patient seeking a cure for degenerative changes of the spine can become understandably attached to their status as a sufferer of an operable ailment. With the evidence of an image, the context of their back pain may change from transient symptom to persistent spinal problem. 

For some patients this can cause anxiety, known to increase the perception of pain, and further disability.

Best coping

At this step and when face-to-face with a patient that is suffering, searching for a solution that will help return them to a pain-free life, clinicians deal with a significant challenge. 

As clinicians, we are aware that too much treatment, or the wrong treatment, can cause more harm than no treatment at all. 

With the exception of certain specific spinal changes, surgical options have proven an unreliable fix for non-specific chronic lower back pain. Preferential treatments include multi-modal support: education, physiatry, psychology, psychiatry, and care coordination.5

The greatest impact we can have on patients with lower back pain may be to begin early on managing expectations with education and normalization of their pain as an unfortunate, but likely temporary, symptom that can be managed. 

Suppressing the curiosity to “have a look” by MRI or CT may short circuit the process by which a painful symptom becomes a disabling chronic disease.

This publication is informational and for educational purposes for practitioners only. The views and opinions expressed herein are those of the authors and do not necessarily represent the views of OptumCare. The views and opinions expressed may change without notice. 

 

Sources

  1. Balagué, F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2012). Non-specific low back pain. The Lancet, 379(9814), 482-491.
  2. Buchbinder, R., Blyth, F. M., March, L. M., Brooks, P., Woolf, A. D., & Hoy, D. G. (2013). Placing the global burden of low back pain in context. Best Practice & Research Clinical Rheumatology, 27(5), 575-589.
  3. Kalichman, L., Kim, D. H., Li, L., Guermazi, A., & Hunter, D. J. (2010). Computed tomography–evaluated features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain. The spine journal, 10(3), 200-208.
  4. Chou, R., Fu, R., Carrino, J. A., & Deyo, R. A. (2009). Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet, 373(9662), 463-472.
  5. Pillastrini, P., Gardenghi, I., Bonetti, F., Capra, F., Guccione, A., Mugnai, R., & Violante, F. S. (2012). An updated overview of clinical guidelines for chronic low back pain management in primary care. Joint Bone Spine, 79(2), 176-185.