Use of Imaging Studies for Low Back Pain (LBP)

The percentage of persons 18–75 years of age with a principal diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. 

Why It Matters?

Approximately 4.3 million ED visits in the U.S. each year are due to a low back pain-related disorder1. An estimated 75%–85% of all Americans will experience back pain at some point in their lives, and approximately 39% of American adults will experience at least one day of back pain during any three-month period2 3. 

Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation in collaboration with more than 70 specialty society partners, promotes a “national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures” by publishing recommendations from the specialty societies to, “facilitate wise decisions about the most appropriate care based on a patient’s individual situation.” Nine specialty societies have published recommendations regarding the use of imaging for patients with low back pain4, indicating the topic’s importance to health care providers. 

Clinical guidelines for treating patients with acute low back pain strongly recommend against the use of imaging in the absence of “red flags” (i.e., indications of a serious underlying pathology such as a fracture or tumor)4. Routine imaging is problematic because it is not associated with improved outcomes and exposes patients to harms such as radiation exposure and unnecessary treatment5. Red flag conditions include history of cancer, osteoporosis and IV drug use. 

There is no compelling evidence to justify substantial deviation from the diagnostic strategy published in clinical guidelines, which indicate that for most patients with low back pain, diagnostic imaging is usually unnecessary. Although patients may have a perceived need for imaging studies, efforts to educate patients on appropriate indications for imaging are within a provider’s capacity. Organizations can provide information, best-care practice models and other support to providers, imaging centers and members to increase knowledge and ensure that imaging studies are used appropriately for evaluation of lower back pain patients, based on the duration of symptoms and the presence of red flags. 

Historical Results – National Averages

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References

  1. Magel, J., K. Suslavich, K. Roper, J. Fritz, & T. Madsen. 2022. “Emergency Department Evaluation, Treatment, and Functional Outcomes Among Patients Presenting with Low Back Pain.” The American Journal of Emergency Medicine 59, 37–41.
  2. Deyo, R.A., S.K. Mirza, B.I. Martin. 2006. “Back Pain Prevalence and Visit Rates: Estimates from U.S. National Surveys, 2002.” Spine 31(23):2724–7.
  3. Lucas, J. W., E.M. Connor, & J. Bose. 2021. “Back, Lower Limb, and Upper Limb Pain Among US Adults, 2019.”
  4. Downie, A., et al. 2013. “Red Flags to Screen for Malignancy and Fracture in Patients with Low Back Pain: Systematic Review.” BMJ 347:f7095. doi: 10.1136/bmj.f7095
  5. Chou, R., R. Fu, J.A. Carrino, R.A. Deyo. 2009. “Imaging Strategies for Low-Back Pain: Systematic Review and Meta-Analysis.” Lancet 373:463-72. doi: 10.1016/S0140-6736(09)60172-0

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