Imaging for the Lumbar back pain in my opinion ….

Often when a client comes to see me after a few weeks of persisting pain and symptoms in the lower back area I get asked the question, “Should I go get a scan done?”. I get it! As someone going to a health professional you have some clear expectations, you want to know what is going on and you want a clear diagnosis. We are lucky enough that we live in the future! In a world where technology allows us to see the inner workings of the human body, something that was only available to the super heroes you saw on TV not that long ago. The inner realm of the body is no longer a mystery. But is imaging such as MRI scans always a necessary tool when you have lower back pain?

The American College of Physicians reissued the guidelines for imaging patients with lumbar back pain, stating that there are not only inefficiencies of early imaging of the lumbar spine but early imaging can also be potentially harmful.

Why could it be inefficient?

It has been found that there is a high prevalence of what some might call ‘abnormal‘ findings on MRI in pain free populations. These are some common findings in pain free populations:

  • Disc degeneration 91%
  • Disc bulges 56%
  • Disc protrusion 32%
  • Annular tears 38%

So if the odds are high that you will find some changes in the spine that may not be associated with your symptoms it could very well be a waste of time, money and radiation (if you get an x-ray).

Also the words ‘abnormal findings’ should be taken lightly as disc bulges, protrusion and annular tears can all be considered normal degenerative changes that come with every humans ageing process. In fact a study that looked at MRI scans to 33 asymptomatic tennis players aged between 17-18 years old found that ‘abnormalities’ such as Pars injuries, facet joint arthroses and disc bulges were all relatively common.

But often we take what is written on radiography reports as gospel. If it says abnormal findings this can often be taken that there is a problem and can leave you feeling like there is something more sinister going on… which brings me to my next point.

Why is it potentially harmful?

O’Sullivan and Lin reported that imaging for non traumatic lumbar back pain can lead to; poorer health outcome, greater disability and work absenteeism due to the fact that often when we see abnormal findings on scans there can be a need to pathologize the issue without realising that these findings are very likely normal changes.

This could lead to unwarranted anxieties which can often make the whole situation worse. O’Sullivan and Lin reported that negative emotional factors play a significant role in sensitising spinal structures through the central nervous system.

Now it is important to note that there is a very small 1-2% of people with lower back pain who will have a serious or systemic disorder where scans will be a useful tool for guiding treatment options. As well as this Jarvik et al reported that severe central stenosis, root compressions and disc extrusions on scans are likely to be diagnostically and clinically relevant.

I think the moral of the story is that if it you fall into the small group who have a severe and serious pathology, scans are likely to be an important tool in helping health professionals direct individuals to the most appropriate treatment options but outside of this population it is not likely to be useful and possibly have some negative effects.

References

  1. Alyas, F., Turner, M., & Connell, D. (2007). MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. British Journal of Sports Medicine, 41(11), 836–841. doi:10.1136/bjsm.2007.037747
  2. Chou, R. (2011). Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Annals of Internal Medicine, 154(3), 181. doi:10.7326/0003-4819-154-3-201102010-00008
  3. Jarvik, J. J., Hollingworth, W., Heagerty, P., Haynor, D. R., & Deyo, R. A. (2001). The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study. Spine, 26(10), 1158–1166. doi:10.1097/00007632-200105150-00014
  4. McCullough, B. J., Johnson, G. R., Martin, B. I., & Jarvik, J. G. (2012). Lumbar MR Imaging and Reporting Epidemiology: Do Epidemiologic Data in Reports Affect Clinical Management? Radiology, 262(3), 941–946. doi:10.1148/radiol.11110618
  5. O’Sullivan, P & Lin, P. (2014). Acute Low back pain beyond drug therapies. Pain Management today, 1(1):813.



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