Should we encourage scans for low back pain?

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Lower back (lumbar) pain is by far one of the most common conditions we treat in our clinics. I can almost guarantee that at some point in your life you will experience a form of low back pain, whether it’s only an ache that lasts a day or two or a more severe pain that doesn’t seem to want to go away. The causes of back pain can vary dramatically; it could be as simple as sitting in one position for too long, lifting weights at the gym, twisting awkwardly, bending down to pick something up, the list goes on.

According to the Global Burden of Disease, in 2015 low back pain was ranked number 1 in Australia and New Zealand. Essentially what this is saying is that low back pain was the leading cause of financial cost, morbidity and disability compared to other health problems (i.e. diabetes and heart disease).

Anyway, enough with the numbers, let’s talk about medical imaging of the lower back. Before even considering whether medical imaging is necessary a comprehensive history of the pain should be taken. This is why your physiotherapist spends a good portion of your first visit chatting to you about your pain. If certain “red flags” arise during the chat such as: fever, unexplained loss of weight, loss of bladder/bowel control and/or trauma then medical imaging may be necessary to rule out any serious conditions.

In the case that there are no “red flags” then medical imaging may not be beneficial and instead may hinder the effects of treatment and delay improvements in pain levels. I will elaborate on this further, but first I want to start with an example; below are two patients who received lumbar X-ray’s.

Patient 1; is a 40 year old man. This man walks daily and plays soccer twice a week. He works as an accountant from 9-5 in an office. He does not suffer from back pain. His X-ray results display some degenerative changes to 2 of his lumbar discs. Again I repeat he has NO pain.

Patient 2; is a 42 year old man. He does no formal exercise, aside from walking the dog 3 times a week. He also works as an accountant. He does suffer from lower back pain. His X-ray results also display degenerative changes to 1 of his lumbar discs.

The reason these two patients are given as examples is to identify that not all changes on an X-ray correlate with pain. In the example above we can see that both patients have degeneration of their disc, but one has pain and the other does not. I’ve included some evidence below to explain why this is.

  • “Studies have shown that lumbar disc degeneration is present in 40% of people under the age of 30 and are present in 90% of those between the ages of 50-55”
  • “Another study showed that amongst healthy adults ages 20-22 years with no back pain, 48% had at least one degenerative disc and 25% had a bulging disc”

So to put it simply, it is normal to see changes in an X-rays from the age of 20 years onwards, which is why it isn’t always necessary to race into getting a scan performed.

There is also something called the “labelling phenomenon”, this is where a patient receives a medical imaging result with threatening words like; “degenerative”, “disc bulge” or “arthritic”, which can cause the patient to have a worse sense of well-being and can cause harmful effects from a psychological point of view.

Now if the information above hasn’t convinced medical image might not be the answer then there are a few other considerations to make; the out of pocket cost can be very expensive, there is risk of radiation associated with all types of medical images and there has been studies to prove that there has been a link to increased rate of medical imaging leads to increase rate of unnecessary surgery.

To summarise all this information; medical imaging should only be sought out if there is the possibility of something more serious going on, otherwise it should not be first line protocol for people suffering from back pain.

Jess

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