People with a new episode of non-specific LBP, without suggestion of a serious and/or specific underlying cause do not receive the following potentially harmful investigations:
Bardin, L.D., King, P. and Maher, C.G., 2017. Diagnostic triage for low back pain: a practical approach for primary care. The Medical Journal of Australia, 206(6), pp.268-273.
NHMRC Australian Acute Musculoskeletal Pain Guidelines Group 2003. Evidence-based Management of Acute Musculoskeletal Pain. Available at: https://www.nhmrc.gov.au/
Appropriate investigations are indicated in cases of acute low back pain when alerting features (‘red flags’) of serious conditions are present.
NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE Guideline [NG59] November 2016. Available at: https://www.nice.org.uk/guidance/NG59
Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica.
Explain to people with low back pain with or without sciatica that if they are being referred for specialist opinion, they may not need imaging.
Consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain with or without sciatica only if the result is likely to change management.
Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012.
Clinicians should not recommend imaging (including computed tomography [CT], magnetic resonance imaging [MRI] and x-ray) for patients with non-specific low back pain.
Imaging should be done to rule out underlying pathology or for those who are considering surgery, including epidural steroid injections
Plain x-rays of the lumbar spine are not routinely recommended in acute non-specific low back pain as they are of limited diagnostic value and no benefits in physical function, pain or disability are observed.
TOP 2015. Toward Optimised Practice - Evidence-Informed Primary Care Management of Low Back Pain: Clinical Practice Guidelines. 3rd Edition. December 2015. Institute of Health Economics, Alberta, Canada.
Order AP and lateral plain film imaging for low back pain when compression or other fracture is suspected. Oblique x-rays should not be done in this circumstance.
Order a CRP and/or an ESR blood test if inflammatory disease is suspected based on patient presentation. Patients with inflammatory disease should be referred to a rheumatologist.
Order the appropriate blood tests if cancer or infection is suspected. In the absence of red flags, no laboratory tests are recommended.
DO NOT order diagnostic imaging test, including x-ray, CT, and MRI for acute low back pain (no red flags). In the absence of red flags, routine use of x-rays is not justified due to the risk of high doses of radiation and lack of specificity.
DO NOT order imaging where the results are not going to affect treatment.
Lumbar spine x-rays may be required for correlation prior to more sophisticated diagnostic imaging, for example prior to an MRI scan. In this case, the views should be limited to standing AP and lateral in order to achieve better assessment of stability and stenosis. CT scans are best limited to suspected fractures or contraindication to MRI. X-rays of the lumbar spine are very poor indicators of serious pathology. Hence, in the absence of clinical red flags spinal x-rays are not encouraged. More specific and appropriate diagnostic imaging should be performed on the basis of the pathology being sought (e.g., DEXA scan for bone density and bone scan for tumours and inflammatory diseases). In the absence of red flags, radiculopathy, or neurogenic claudication, MRI scanning is generally of limited value. Oblique view x-rays are not recommended; they add only minimal information in a small percentage of cases and more than double the patient’s exposure to radiation.
DO NOT recommend electrodiagnostic studies in primary care. They should only be used as an adjunct to clinical examination and imaging to rule out conditions that may mimic radiculopathy. When the diagnosis of lumbar disc herniation with radiculopathy is suspected, cross-sectional imaging is the diagnostic test of choice.
Low Back Pain: Medical Treatment Guidelines. July 2007. Department of Labor and Employment, State of Colorado, USA.
Radiographic imaging of the lumbosacral spine is a generally accepted, well-established, and widely used diagnostic procedure when specific indications based on history and/or physical examination are present. There is some evidence that early radiographic imaging without clear indications is associated with prolonged care, although it does not change functional outcomes.
Laboratory tests are generally accepted, well-established, and widely used procedures. They are, however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia, underlying rheumatologic disorder, or connective tissue disorder based on history and/or physical examination.
Myelography should be considered only in the following instances:
• when CT and MRI are unavailable;
• when CT or MRI is contraindicated such as for morbidly obese patients or those who have undergone multiple surgical procedures; and when other tests prove non-diagnostic in the surgical candidate.
CT Myelogram: This test provides more detailed information about relationships between neural elements and surrounding anatomy and is appropriate in patients with multiple prior operations, tumorous conditions, or those that cannot have MRIs due to implants.
Dynamic [Digital] Fluoroscopy: Dynamic [Digital] Fluoroscopy of the lumbar spine measures the motion of intervertebral segments using a videofluoroscopy unit to capture images as the subject performs lumbar flexion and extension, storing the anatomic motion of the spine in a computer. Currently, it is not recommended for use in the diagnosis of lumbar instability because there is limited information on normal segmental motion for the age groups commonly presenting with low back pain, and diagnostic criteria for specific spinal conditions are not yet defined. No studies have yet demonstrated predictive value in terms of standard operative and non-operative therapeutic outcomes.
OTHER TESTS: The following diagnostic procedures in this subsection are listed in alphabetical order, not by importance
Electrodiagnostic Testing – not recommended.
Injections Diagnostic -
Specific Diagnostic Injections: In general, relief should last for at least the duration of the local anesthetic used and should significantly result in functional improvement and relief of pain.
Discography may be indicated when a patient has a history of functionally limiting, unremitting low back pain of greater than four months duration, with or without leg pain, which has been unresponsive to all conservative interventions and meets all of the criteria for spinal fusion.
Thermography: An accepted and established procedure, but it has no use as a diagnostic test for low back pain
Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M etal. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2017 Apr 20. doi: 10.1007/s00586-017-5099-2. [Epub ahead of print]
Do not routinely offer imaging (MRI or X-ray) to patients with recent onset LBP, as the evidence does not support a positive effect
Stochkendahl, M.J., Kjaer, P., Hartvigsen, J., Kongsted, A., Aaboe, J., Andersen, M., Andersen, M.Ø., Fournier, G., Højgaard, B., Jensen, M.B. and Jensen, L.D., 2017. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. European Spine Journal, pp.1-16.
PICO 4 The working group agreed that imaging without indications of serious underlying conditions does not improve clinical outcomes. Further, the potential harm (i.e., radiation exposure and risk of labelling patients with diagnoses that might not be the actual cause of their pain) outweigh the potential positive effects, which led to a recommendation against routine imaging