Are you feeling a lower back ache after spending countless hours on your laptop? Did you wake up feeling great in the morning, but are now stuck after trying to pick up something? All of these cases have one thing in common: low back pain (LBP).
Is all back pain the same? Do you need to get imaging done such as MRI (Magnetic resonance imaging) or X-ray (radiographs) to relieve your concerns? Will the results of imaging studies help in managing LBP? Is there a downside to getting imaging studies too soon? Let’s find out.
Low back pain is very prevalent. It is one of the most common reasons for physician visits in the United States. Most Americans have experienced low back pain, and approximately one quarter of U.S. adults reported having low back pain lasting at least 1 day in the past 3 months [1]. There were an estimated 31 million patient visits annually attributed to LBP in the United States [2]. It is estimated that up to 84 percent of adults have low back pain at some time in their lives [3]. According to a study done by Machado et al, 2017 one year incidence of recurrence of low back pain was 33 percent, and the one year incidence of recurrence of low back pain with care seeking was 18 percent [4]. Low back pain is also very costly to the economy. The total costs attributable to low back pain in the United States were estimated at $100 billion in 2006, two thirds of which were indirect costs of lost wages and productivity [1].
Based on duration, low back pain can be categorized into acute, subacute and chronic. Acute low back pain is a back pain lasting for four weeks or less. Subacute back pain will last between 4 and 12 weeks, and chronic back pain persists for more than 12 weeks. All three types of LBP can further be categorized by impairments of body function associated with clinical findings into A) mobility impairments, B) referred or radiating pain into a lower extremity, and C) generalized pain [5]. There are also cases of LBP that are evident of serious pathology (i.e. metastatic cancer, abdominal aortic aneurysm, vertebral fracture, infection), but those are very rare. In fact, less than 1% of people with LBP are diagnosed by their primary care doctor with a condition that may require spine surgery—such as cauda equina syndrome, spinal infection or metastatic spinal cancer [3]. Generally, many low back pain cases such as LBP are due to poor postural alignment, muscle spasms, strained muscles, or sprained ligaments. Even though some of these are extremely painful and debilitating, some LBP will improve in days or a few weeks. However, do you still need to get imaging done to find out the reason why your back is hurting? If so, what kind of imaging should you get?
Let’s take a look at two of the most popular imaging studies used in diagnosing low back pain: the X-ray and the MRI. Medical X-rays are a form of electromagnetic radiation that is used to generate images of tissues and structures inside the body. In orthopedics, X-ray radiography is the most cost effective and important initial test that is predominantly used to detect bone and joint pathologies rather than soft tissue injury [6]. There is no evidence to prove that obtaining X-rays is associated with better patient outcomes. [7]
MRI (Magnetic resonance imaging) is a non-invasive imaging technology that produces three dimensional detailed anatomical images. It is predominantly used to detect soft tissue injuries such as lumbar disc herniations, lesions of the brain, spinal cord and nerves, as well as muscles, ligaments, and tendons. The MRI works by rotating a magnet around a person, which changes the excitation level of hydrogen atoms in the body (humans are composed primarily of water, which is two parts hydrogen). After the atoms return to their normal level of excitation, they emit energy that is picked up on an MRI scanner [8]. MRI studies are very detailed and sometimes can pick up a spinal abnormality that may appear to be serious but is not and it may not be the cause of back pain. Numerous clinical studies have shown that MRI findings do not always correlate to patient symptoms. According to a systematic review by Brinjikji et al., imaging findings of spine degeneration such as disk degeneration, facet hypertrophy, and disk protrusions are present in high proportions of people that do NOT have any back pain. [9] Therefore, an MRI scan cannot be interpreted on its own. Everything seen on an MRI needs to be well-correlated to the individual patient’s clinical condition including symptoms (such as the duration, location, and severity of pain) and any neurological deficits on their physical examination. Landon et al, 2013 also found out that when people with routine back pain are referred for MRI imaging too early, they are eight times more likely to have unnecessary spine surgery [10].
Another downside of the overutilization of MRI studies is its cost. Papanicolas et al. 2018 compared general spending, population health, structural capacity, utilization, pharmaceuticals, access to quality and equity in the U.S. and 10 other high-income countries, including Canada, the U.K., Germany, Japan and Sweden. Data were collected from 2013 to 2016 from international organizations such as the Organization for Economic Co-Operating and Development. Utilization in the U.S. was similar to those of other nations—except in medical imaging. The U.S. performed the second highest number of imaging exams (the second highest MRI and CT technology utilization rate) following Japan. According to the study, the U.S. performed 118 MRIs per 1,000 people compared with a mean in all 11 countries of 82 per 1,000 people. The average cost of an MRI in the U.S. was $1,145 compared with $350 in Australia and $461 in the Netherlands [11].
Who should and when should they get an MRI study? An MRI is recommended urgently for patients with severe or progressive neurologic deficits such as bowel or bladder incontinence or progressive weakness in both legs. MRI is rarely indicated except in patients presenting with acute back pain with signs or symptoms of herniated disk or a systemic disease, unless there is a strong suspicion of cancer, infection or cauda equina syndrome based on their history and physical examination. A small number of patients who still have significant pain or neurologic deficit even after 6 weeks of conservative treatment will require an MRI in consideration of surgery [7].
So, what should you do when your back hurts? In the most recent review of physical therapy approaches to the treatment of low back pain, professor Edward A. Shipton looked at multiple guidelines for LBP treatment. He states that low back pain guidelines regularly recommend the use of physical exercise, education and self-management, and resuming normal activities, with the addition of psychological programs in those whose symptoms persist. The aim of physical treatments is to improve function and prevent disability from getting worse. He also notes that active strategies such as exercise are related to decreased disability, whereas passive methods (rest, medications) are associated with worsening disability, and are not recommended [12].
Next time you feel your lower back hurting, do not panic! Remember that most cases of low back pain will get better in a few days or weeks. Take comfort in knowing that undergoing an X-ray or MRI will not make your back pain go away faster. So, keep calm, call your physical therapist, and keep moving!
In good health,
Alena Goldfine, PT, DPT
References:
1. Timothy J. Wilt , Robert M. McLean , Mary Ann Forciea et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine 2017;166:514-530. [Epub ahead of print 14 February 2017]. doi:https://doi.org/10.7326/M16-2367
2. Licciardone JC. The epidemiology and medical management of low back pain during ambulatory medical care visits in the United States. Osteopath Med Prim Care. 2008; 2: 11. doi: 10.1186/1750-4732-2-11
3. Wheeler SG, Wipf JE, Staiger TO, Deyo RA, et al. Evaluation of low back pain in adults. October 26, 2019
4. Machado, Gustavo & Maher, Chris & Ferreira, Paulo & Latimer, Jane & Koes, Bart & Steffens, Daniel & Ferreira, Manuela. (2017). Can Recurrence After an Acute Episode of Low Back Pain Be Predicted?. Physical Therapy. 97. 889-895. 10.1093/ptj/pzx067.
5. Delitto et al. Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2012; 42(4), A1-A57.
6. https://www.nibib.nih.gov/science-education/science-topics/x-rays
7. Lateef H, Patel D. What is the role of imaging in acute low back pain? Curr Rev Musculoskelet Med. 2009 Jun; 2(2): 69–73.
8. https://www.nibib.nih.gov/science-education/science-topics/magnetic-resonance-imaging-mri
9. Brinjikji et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Am J Neuroradiol. 2015 Apr; 36(4): 811–816.
10 . Landon et al. Worsening Trends in the Management and Treatment of Back Pain. JAMA Intern Med. 2013;173(17):1573–1581. doi:10.1001/jamainternmed.2013.8992
11 . Papanicolas et al. Health Care Spending in the United States and Other High-Income Countries. JAMA. 2018;319(10):1024–1039. doi:10.1001/jama.2018.11509.
12. Shipton E. Physical Therapy Approaches in the Treatment of Low Back Pain Pain Ther. 2018 Dec; 7(2): 127–137.
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