Diagnostic Radiology in Low Back Pain

Dr. Ted Findlay, D.O., CCFP,1 Amar Suchak, MD, FRCP(C),2

1Clinical Assistant Professor, Department of Medicine, University of Calgary, Private Family Medicine practice, Medical Staff, Alberta Health Services, Calgary Zone, Calgary, Alberta.
2Clinical Assistant Professor Department of Radiology, Department of Nuclear Medicine, University of Calgary, Calgary, Alberta.


Abstract: Many clinicians believe that imaging is necessary to accurately diagnose and manage low back pain. However, there is good evidence that in the absence of "Red Flags", there is an overuse of both routine X-rays and advanced diagnostic imaging such as MRI. When imaging is used without appropriate clinical indications, it is rare for the results to lead to a change in a treatment plan. Management is based on adequate history and confirmatory physical examination. This article uses three actual cases as the basis for exploring the place of diagnostic imaging in treating low back pain.
Key Words: low back pain, diagnosis, radiology, indications, appropriate.

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1. While imaging may be required in the management of specific cases of low back pain particularly when "Red Flags" are present, it is rare that unexpected findings will result in a change of the treatment plan.
2. Be very cautious about the terminology used to describe the results of imaging studies and whenever possible normalize the results for the patient. Many abnormal findings may be "normal" for patients in older age groups. Many may be present in patients who are pain free.
3. Ensure that the patient understands that the results of the images are not necessarily a barrier to recovery.
4. Except to establish the boney contours of the spine, when advanced imaging is required an MRI examination is often the preferred option.
5. Be very cautious about attributing the cause of a patient's pain to the results found on imaging. Careful correlation with the clinical presentation is required before deciding on any change in treatment.
In the absence of clinical "Red Flags", there is no indication to image the spine before initiating treatment.
It is never appropriate to delay treatment for mechanical low back pain to wait for an imaging procedure.
Prepare the patient, before advanced imaging is performed, that there is a very high likelihood that the investigation will find "abnormalities" but that these changes are usually the result of natural aging and no cause for concern.
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