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New Guidelines: Back Off On Low Back Imaging

February 4, 2011
Written by: , Filed in: Diagnostic Imaging, Musculoskeletal Radiology
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The head of musculoskeletal imaging at a New York hospital agrees with new American College of Physicians recommendations against immediate imaging for most patients with low back pain.

The guidelines, which appear in the February 1 issue of the Annals of Internal Medicine, recommend X-rays, CT scans, or MRI only when low back pain may be caused by cancer, infection, or nerve damage, or when pain worsens despite initial treatment. Signs of those conditions include weight loss, fever, abnormal reflexes, and loss of muscle strength or sensation in the legs.

“Every patient feels their workup isn’t complete without an MRI,” says Daniel M. Walz, MD, chief of the division of musculoskeletal imaging at North Shore University Hospital in Manhasset, New York. He was quoted by WebMD.

“These imaging places are so present in the community that patients truly feel they should get it,” he said, “but it doesn’t change anything.”

Dr. Walz said he reads 30 or more spinal MRIs a day. After a certain age, he said, almost everyone has abnormalities that show up. “Sometimes,” he said, “we see too much, and the imaging doesn’t correlate with the back pain, so this leads us down a road where we are pursuing things that we shouldn’t be pursuing.”

Things such as bulging discs. A previous study showed that 90 percent of people 60 or older had a degenerating or bulging disc. “A patient hears that they have bulging discs and says, ‘You have to fix it,'” Dr. Walz said.

Dr. Walz and Andrew Haig, MD, a professor of physical medicine and rehabilitiation at the University of Michigan in Ann Arbor, agreed that anyone suffering back pain should consult a doctor who specializes in that kind of pain. That alone, said Dr. Haig, could reduce unnecessary imaging test and unnecessary surgeries by as much as a third.

Back pain that persists or worsens despite therapy should trigger imaging, according to the new guidelines. “If pain persists, you would then do appropriate imaging studies to decide the appropriate therapies,” said Richard J. Herzog, MD, an attending radiologist at the Hospital for Special Surgery in New York City. “Yes, imaging is overutilized, but the more patients are educated, the more these tests will be ordered appropriately.”

Related seminar: Musculoskeletal MRI

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