Diagnose First, Scan Second

A recent study found that the routine use of radiography (X-ray), MRI, or CT scans in patients with low-back pain but no indication of a serious underlying condition does not improve clinical outcomes. Meaning scans taken without first having an idea that it might be more than just a muscle strain. The study suggests that clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.

Authors of The Lancet article, “Imaging strategies for low-back pain: systematic review and meta-analysis“, reviewed trials of six separate studies covering over 1800 patients. The analysis found no significant differences between immediate imaging and usual clinical care.

Sylvia Ho says, “Given that imaging such as MRI and CT scans are relatively costly and have no significant impact in such cases, it would be wise not take them unnecessarily. Even in cases of X-rays which are now relatively cheap, unnecessary exposure to the radiation should be considered.” Sylvia Ho is a Principal Physiotherapist with Core Concepts, a musculoskeletal healthcare group.

Authors of the study added, “Rates of utilisation of lumbar MRI are increasing, and implementation of diagnostic-imaging guidelines for low-back pain remains a challenge. However, clinicians are more likely to adhere to guideline recommendations about lumbar imaging now that these are supported by consistent evidence from higher-quality randomised controlled trials. Patient expectations and preferences about imaging should also be addressed, because 80% of patients with low-back pain in one trial would undergo radiography if given the choice, despite no benefits with routine imaging. Educational interventions could be effective for reducing the proportion of patients with low-back pain who believe that routine imaging should be done. We need to identify back-pain assessment and educational strategies that meet patient expectations and increase satisfaction, while avoiding unnecessary imaging.”

“You first need to know what you are looking for when ordering a scan. If the scan is not properly directed, it can sometimes miss crucial pieces of information.” says Sylvia Ho.

To further compound the issue on the utility of the use of routine imaging, detailed scans such as MRIs can reveal too much and mislead the clinician on the diagnosis. A report on the New York Times website (8 December 2008), The Pain May Be Real, but the Scan Is Deceiving, as part of their Evidence Gap series provides an excellent read on this issue.


1. Imaging strategies for low-back pain: systematic review and meta-analysis, The Lancet, Volume 373, Issue 9662, Pages 463 – 472, 7 February 2009 doi:10.1016/S0140-6736(09)60172-0

2. The Pain May Be Real, but the Scan Is Deceiving 

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