Does All Back Pain Warrant Imaging?
By Debra Johnston, M.D.
Experts estimate that well over 80 percent of people will experience back pain at some point in their lives. Perhaps ten percent of adults experience it at any given moment. Back pain is extremely common, and people with back pain can be extremely miserable. It may hurt to move, sit, stand, lay, even breathe. No wonder back pain accounts for so many visits to the doctor!
When people with acute back pain come to see me, they often have a preconceived notion of what will happen. They anticipate I will talk with them, examine them, and many expect x-rays or an MRI. They are often surprised, and sometimes worried, when I stop short of ordering imaging.
My first goal when I see someone with acute back pain is to rule out rare conditions that threaten life and limb. Could this be a fracture? Cancer? Infection in the bone or spinal cord? Severe and rapidly progressing compression of the nerves? These conditions could require imaging for diagnosis and urgent treatment. However, they are uncommon, and unless specific “red flags” are revealed during the patient history and exam, it is extremely unlikely a rare condition is responsible for the pain.
Most acute back pain gets better in four to six weeks. Unwarranted imaging only increases medical costs and the likelihood of invasive treatment like surgery or injections but doesn’t get people better any faster. For most people, the best approach for relieving back pain is to stay as active as you can, take an anti-inflammatory pain medicine if you don’t have a reason to avoid them, use a heating pad, and perhaps have manipulation by a chiropractor, osteopathic doctor, or physical therapist.
When imaging is used, it is important to realize that something seen on an x-ray or MRI might not actually be responsible for the back pain. Indeed, it has been found that as we age, it becomes more likely that, even with no back symptoms, we will have abnormalities on imaging. This is true in about ten percent of people in their 30s; among the very old, the likelihood approaches 100 percent.
There is no one-size-fits-all solution to chronic back pain. It takes a knowledgeable clinician to tease out what might be causing the problem and which treatment might help. I urge caution if anyone tries to sell you a treatment without careful analysis of your individual situation. Your money might be better spent on a heating pad, and a gym membership.
Debra Johnston, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.