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Diagnostic Imaging Guidelines from ACP for Low Back Pain


Routine diagnostic imaging for all patients with low back pain does not lead to improved care. The American College of Physicians (ACP) and American Pain Society has issued guideline to implement a selective approach.

The new guidelines published in the February 1 issue of Annals of Internal Medicine are based on a systematic review and meta-analysis conducted for the diagnosis and treatment of low back pain and represent joint clinical practice guidelines from ACP and the American Pain Society.

Available imaging modalities for the low back include radiography, CT, and MRI and should be reserved for patients with low back pain who have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition.

ACP notes the evidence indicates in other patients routine imaging is not associated with clinically meaningful benefits. Most patients with acute back pain, with or without radiculopathy, have substantial improvements in pain and function in the first 4 weeks and routine imaging is unlikely
to improve on this.

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About 0.7% of patients with low back pain in primary care settings have metastatic cancer, 0.01% have spinal infection, and 0.04% have the cauda equina syndrome. Immediate imaging is recommended for patients who present with risk factors or signs of these conditions or have severe &/or progressive neurologic deficits.

For patients who have minor risk factors for cancer, risk factors for vertebral compression fracture, signs or symptoms of radiculopathy, or risk factors for or symptoms of symptomatic spinal stenosis, it is recommended these patients receive a trial of conservative treatment before imaging is offered.

Decisions for subsequent imaging should be guided by development of new symptoms or changes in current symptoms, with repeated imaging recommended only in patients with new or changed low back symptoms.

Patient education is needed to inform patients of current and effective standards of care and to educate them regarding the benefits and potential harms of diagnostic imaging. Remind patients that substantial improvements in pain and function occur within the first 4 weeks with conservative treatment. This should be done first if no risk factors for cancer, etc are present.

Potential harms of unnecessary imaging include the radiation exposure involved in lumbar radiography and CT; hypersensitivity reactions and contrast nephropathy for use of iodinated contrast with CT; and the possibility that subsequent unnecessary, invasive, and expensive procedures could be performed. In addition, knowledge of clinically irrelevant imaging findings might hinder recovery by causing patients to worry more, focus excessively on minor back symptoms, or avoid exercise or other recommended activities for fear of causing more structural damage.

Clinical Guidelines: Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians; Roger Chou, Amir Qaseem, Douglas K. Owens, Paul Shekelle, and for the Clinical Guidelines Committee of the American College of Physicians; Ann Intern Med February 1, 2011 154:181-189;