Have you ever gone to your primary care physician complaining about back pain and were subsequently sent through a whole battery of diagnostic imaging tests? If you have, you may want to know that it is entirely possible the tests were excessive and unnecessary. Depending on the type of condition you have, even one test such as an x-ray or MRI may be too much.
Since I am not a doctor, I asked Neel Anand, MD, Director of Spine Trauma, and Minimally Invasive Spine Surgery at Cedars-Sinai Spine Center in Los Angeles to shed some light on the use of films, as diagnostic imaging tests are often called, for determining the cause of back pain as well as the treatment for it.
“For most cases of back pain that are not traumatic, diagnostic imaging tests are unnecessary”, he states. In other words, for back pain that was not precipitated by an accident, an on the job injury, or another type of injury, Dr. Anand tells me “there is no need to investigate."
Taking Films Compared to Not Taking Films
Dr. Anand says that acute and sub-acute back pain, i.e. pain you’ve had for 6 months or less is usually classified as simple. He lists muscle tears and slight disc bulges as among these simple types of back problems. With conservative treatment, such cases almost always get better in 2 or 6 weeks, he informs me.
Related: Back Strain
A 2009 review published in Lancet looked at 6 studies involving 1804 patients. The results confirm Anand’s position, as well as clinical practice guidelines published by the Agency for Health Care Policy and Research back in 1994. According to a 2011 commentary on the review by JC Andersen, entitled “Is Immediate Imaging Important in Managing Low Back Pain?” (published in the Journal of Athletic Training), the results of the Lancet review support the AHRQ’s guidelines which had “advocated against immediate imaging in patients with acute low back pain.”
The review, which was done by Chou and associates found that except in cases where there were signs of underlying diseases (such as tumor, infection and more), getting films for back pain immediately upon seeing a primary care doctor resulted in about the same degree of positive results from treatment as did usual care without diagnostic imaging.
“Ninety percent of people who see the doctor for their back pain get better after 2 weeks of taking anti-inflammatory medication,” Anand explains. “If the patient was fine before the incident that prompted the appointment, then no imaging test is needed whatsoever.”
What If you do have An Underlying Health Problem?
The Chou and associates review also revealed that for those patients seeking care who did have serious health conditions underlying their back pain - but didn't know it (i.e. they either didn't experience symptoms or they didn't notice them) - doctors were still able to find those underlying pathologies and get the patient into treatment in a timely way.
By the way, if a doctor suspects that an infection or a tumor is underlying your back pain, Dr. Anand says at CT (computed tomography) scan is likely in order.
When Do You Actually Need Imaging for Acute Back Pain?
What happens if you don’t feel better after 2 weeks? Anand says at that point, if conservative care, physical therapy and taking anti-inflammatory medication hasn’t helped, an x-ray may be in order. This is to see if there is anything going on in the spine.
And what happens if you don’t feel better after 6 weeks? In that case, Anand says, assuming you’ve continued with conservative care, physical therapy, anti-inflammatories such as ibuprophen and possibly muscle relaxers as well, an MRI may be of value. This is especially true if you have sciatica that accompanies your low back pain or radiating or shooting pain, or other nerve symptoms going down your arm if you have neck pain.
Related: Physical Therapy Modalities
Chronic Back Pain and Diagnostic Imaging
Chronic back pain is a different story Dr. Anand informs me. He defines it as as constant or on and off pain that lasts longer than 6 months. This type of spine pain does warrant imaging, he says. “If the patient with chronic back pain who comes to see the doctor for the first time since the pain started reports that it has not gotten better within that time frame, both an x-ray and an MRI should be taken.”
Unfortunately for the patient, though, imaging for chronic pain is regularly denied by insurance companies.
The reason for this may have begun in 2005 when Medicare stopped paying for diagnostic imaging for routine back pain complaints. After that, other insurance companies followed its lead.
“Radiology services, including x-ray, MRIs and CT scans used to be big money makers for facilities and doctors,” says Marcy Rogers, President and CEO of SpineMark, LLC. "But not any more." (SpineMark provides expertise and consultancy to physicians and hospitals building spine treatment centers.) “Due to the perception of over utilization, reimbursement for films was reduced at least 50 percent, and in many cases more.”
“The way insurance companies now reimburse (or rather don’t reimburse) for diagnostic imaging makes no sense whatsoever,” Dr. Anand comments. “In chronic cases these companies want you to go 6 months without knowing the cause of your pain. You have to have a drop foot or be paralyzed before they will grant a test.”
And he says that insurance companies are also increasingly denying image tests for acute pain. “Patients usually can get them at a trip to the emergency room, but not at an outpatient facility,” he notes.
Anand, Neel, MD. Director of Spine Trauma, Minimally Invasive Spine Surgery at Cedars-Sinai Spine Center,Los Angeles, CA. Phone Interview. August 2012.
Andersen, JC, Phd, PT, ATC, SCS. Is Immediate Imaging Important in Managing Low Back Pain? Journal of Athletic Training 2011. Accessed: August 2012.
Chou R, Fu R, Carrino JA, Deyo. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 373(9662) 463-472. http://www.ncbi.nlm.nih.gov/pubmed/19200918
Rogers, M. President and CEO Spinmark International, Inc. Email Interview. August 2012.