The 6 Week Wait: Imaging In Low Back Pain Michelle Gittler M.D. Medical Director Schwab Rehabilitation Hospital

Low Back Pain Low back pain (LBP) is the fifth most common reason for all physician visits. Up to one-quarter of the population will have low back pain in any given year. Greater than 90% of the population will experience at least one episode of back pain during their lifetime.1 Lumbar strain is the cause of low back pain in 70% of cases, and is most common between age 20 and 50.

Low Back Pain Do not obtain spinal imaging for patients with acute low-back pain during the six (6) weeks after onset in the absence of red flags. Possible fracture Possible tumor/infection Possible significant neurologic deficit

Possible Fracture Major trauma Minor trauma in the elderly or, an osteoporotic patient

Possible Tumor/Infection History of cancer Constitutional symptoms (fever, chills, weight loss) Recent bacterial infection IV drug use Immunosuppression Pain worse at night or when supine

Possible Significant Neurological Deficit Severe or progressive motor or sensory changes Bladder or bowel dysfunction (fecal incontinence, urinary retention)

In the Absence of Red Flags Evidence-based guidelines do not support the routine use of spinal imaging for patients with acute back pain of less than six weeks duration Unnecessary imaging incurs monetary cost, exposes the patient to ionizing radiation, and can result in labeling patients with conditions that are not clinically meaningful, (creating a false sense of vulnerability and disability). Several studies have shown that the routine use of radiographs in the care of low-back pain may result in worse outcomes than without their use

Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Douglas K. Owens, MD, MS; Paul Shekelle, MD, PhD; for the Clinical Guidelines Committee of the American College of Physicians Clinical Guidelines 1 February 2011

Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians A meta-analysis of 6 randomized trials (6), which comprised 1804 patients with primarily acute or sub acute low back pain and no clinical or historical features that suggested a specific underlying condition, found no differences between routine lumbar imaging (radiography, MRI, or CT) and usual care without routine imaging in terms of pain, function, quality of life, or overall patient-rated improvement For short-term outcomes (<3 months), trends slightly favored usual care without routine imaging. Routine imaging was also not associated with psychological benefits, despite the perception that it can help alleviate patient anxiety about back pain On the basis of the systematic review, routine imaging can be considered a low-value health care intervention; because it is more costly than usual care (without routine imaging) and offers no clear clinical advantages, it cannot be cost-effective.

Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians Many abnormalities detected with advanced imaging are so common in asymptomatic persons that they could be viewed as normal signs of aging. In a cross-sectional study, 36% of asymptomatic persons aged 60 years or older had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc. It is important to understand that the presence of imaging abnormalities need not mean that the abnormalities are responsible for symptoms. The National Committee for Quality Assurance (NCQA) recommends that imaging for low back pain should be avoided for at least 28 days in the outpatient setting, unless there are clear indications requiring more aggressive interventions

Waddell’s Nonorganic Signs for Low Back Pain Waddell, et al. (1980) described five categories or signs, 3/5 of which should make you think about a supratentorial etiology for pain Tenderness tests: superficial and diffuse tenderness and/or nonanatomic tenderness Simulation tests: these are based on movements which produce pain for the patient, with no anatomic likelihood of that movement actually causing pain, such as axial loading causing back pain Distraction tests: positive tests are rechecked when the patient's attention is distracted, such as a straight leg raise test Regional disturbances: regional weakness or sensory changes which deviate from accepted neuroanatomical Overreaction: subjective signs regarding the patient's demeanor and reaction to testing