Practice Rational imaging

Low back pain in primary care

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4266 (Published 16 July 2014) Cite this as: BMJ 2014;349:g4266
  1. Richard A Deyo, professor12345,
  2. Jeffrey G Jarvik, professor567,
  3. Roger Chou, professor28
  1. 1Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
  2. 2Department of Internal Medicine, Oregon Health and Science University, Portland, OR, USA
  3. 3Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, OR, USA
  4. 4Oregon Institute for Occupational Health Sciences, Oregon Health and Science University, Portland, OR, USA
  5. 5Department of Health Services, University of Washington, Seattle, WA, USA
  6. 6Department of Radiology, University of Washington, Seattle, WA, USA
  7. 7Department of Neurological Surgery, University of Washington, Seattle, WA, USA
  8. 8Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA
  1. Correspondence to: R A Deyo, Department of Family Medicine, Mail code FM, Oregon Health and Science University, Portland, OR, USA 97239 deyor{at}ohsu.edu
  • Accepted 11 June 2014

Key points

  • Imaging of the lumbar spine for low risk patients can be overused given its low yield of useful findings, high yield of misleading findings, and lack of proved benefit for outcome

  • Radiography (with or without erythrocyte sedimentation rate) is often an appropriate initial test for suspected cancer, fracture, or inflammatory spondylopathy

  • MRI is appropriate for patients with major neurologic deficits. It is also appropriate for those with a clinical picture of sciatica or stenosis who fail to improve with a therapeutic trial and are potential candidates for surgery or epidural steroids

  • Patient histories of cancer, injection drug use, major trauma, or prolonged corticosteroid use are important “red flags” to prompt imaging; other individual red flags have weak likelihood ratios, and the full clinical picture should guide the ordering of lumbar images

A woman aged 71 with smoking related lung disease and frequent use of corticosteroids presented to clinic with acute severe low back pain. The pain began yesterday after she moved furniture in her apartment, is centrally located in the upper lumbar region without radiation to the legs, and is worse with movement. On examination, she has tenderness to palpation over the upper lumbar spine.

What is the next investigation?

Many observers argue that lumbar spine imaging is overused in developed countries because of a low yield of clinically useful findings, a high yield of misleading findings, radiation exposure (especially to the gonads), and costs. This is a particular concern in the United States, where imaging capacity is high, and spine specialists commonly have their own imaging facilities. These concerns are valid, despite the broad differential diagnosis of back pain, which includes not only degenerative changes but deformity, fracture, and underlying systemic diseases such as malignancy, infection, or ankylosing spondylitis. Though metastatic cancer might be the most common of these systemic conditions, its prevalence in …

View Full Text

Sign in

Log in through your institution

Subscribe