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INTRODUCTION

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James Anderson, a 45-year-old accountant, regularly plays basketball and has always been healthy and active. For the past 2 weeks though he has not been able to shoot hoops due to low back pain. Two Saturdays ago, he cleaned out his garage and was moving around heavy boxes. He awoke the next morning feeling an aching pain in his low back, with an occasional intermittent sharp pain when he moved in certain positions. The discomfort seemed to be worse with bending and standing, and after lying down for long periods. After 2 weeks of using ice and heat packs, and Tylenol, with only temporary improvements, he decided to go see his doctor.

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His doctor asked him a number of questions about the pain, ensuring that he did not have any bowel or bladder incontinence, fevers, weakness or numbness in his legs, or other concerning neurologic symptoms. He performed a full examination including a neurologic exam, which was completely normal except for some limited back mobility due to discomfort and some tenderness surrounding the lumbar spine region.

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The physician explained to Mr Anderson that his back pain was almost assuredly “benign” and would get better slowly over about 4 to 6 weeks, but then suggested that he would order a magnetic resonance imaging (MRI) study of his back, “just to be sure.”

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Approximately one-quarter of American adults have had low back pain that lasted at least 1 day in the last 3 months,1 leading low back pain to be the fifth most common outpatient complaint.2 In the United States, we spend a lot of money on back pain. The direct expenditures annually are similar to that for diabetes and for cancer.2,3 And yet for low back pain we are not actually making people much better. Between 1997 and 2005 the United States had rapidly increasing medical expenditures for low back pain, but there were no measurable improvements in outcomes for patients, including self-assessed health status, functional disability, work limitations, or social functioning.2.

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Expensive imaging tests are a major contributor to these excessive healthcare costs.4 The problem is that abnormalities on imaging are as common in individuals with and without back pain. More than 57% of asymptomatic people over 60 years have abnormalities on lumbar MRIs.5 Clinical guidelines published by the American College of Physicians (ACP) recommend against obtaining imaging in any patient with low back pain without “red flag” symptoms—specific symptoms that are considered concerning for certain possible underlying diseases—within 4 to 6 weeks of onset, since imaging of the lumbar spine before 6 weeks does not improve outcomes but does increase costs.4,6 The American College of Radiology (ACR) agrees that imaging is frequently overused in the evaluation of low back pain and notes that most patients return to normal activity within one month regardless of imaging.7

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