Guidelines for Diagnosing Low Back Pain

Posted by: admin on: September 15, 2011

Clinical Guidelines Committee of the American College of Physicians (ACP) released recommendations for diagnostic imaging for low back pain. These guidelines are the first in a series to help physicians and patients identify potentially misused medical treatments and to practice high-value healthcare


  • Low back pain is one of the most common reasons for patients to see physicians.
  • Many who suffer from low back pain receive routine imaging followed by unnecessary additional tests, interventions, follow-ups and referrals.
  • In some cases, imaging tests may even be harmful.
  • Nonetheless, use of imaging tests, particularly MRI, for low back pain continues to increase.

Important New Recommendations for Low Back Pain

  • A key theme of the ACP guideline is that routine imaging for low back pain does not appear to improve patient health.
  • This is based on evidence that the use of diagnostic imaging in patients without indications offers little or no benefit.
  • The vast majority of imaging findings does not correlate well with the presence or severity of symptoms, and do not affect initial management.
  • Randomized trials comparing routine imaging with usual care without imaging suggest there is no clinically meaningful benefit on outcomes of pain, function, quality of life, or mental health.

The guideline recommends immediate imaging for patients with acute low back pain who have the following:

  • Major risk factors for cancer (personal history of cancer or strong clinical suspicion).
  • Risk factors or signs of spinal infection.
  • Signs of cauda equina syndrome.
  • Severe or progressive neurological deficits.
  • Imaging after a trial of treatment is recommended for patients who have the following:
    1. Minor risk factors for cancer.
    2. Risk factors or signs of inflammatory back disease.
    3. Risk factors or signs of vertebral compression fracture.
    4. Persistent signs or symptoms of radiculopathy.
    5. Persistent symptoms of spinal stenosis.
  • Repeated imaging is recommended only in patients with new or changed low back symptoms.

Reducing Routine Imaging for Low Back Pain

  • Efforts to reduce the routine use of imaging in individuals with low back pain will be most effective if they address clinician behaviors, patient expectations, and financial incentives.
  • Education is needed to inform patients of current and effective standards of care; patients must be educated on the potential benefits and harms of diagnostic imaging modalities so that expectations can be appropriately managed.

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