Diagnostic Imaging
Table 4. Summary of the American College of Physicians Best Practice Advice: Diagnostic Imaging for LBP (continued)
Disease or Condition
Evidence that expanding imaging to patients without these indications does not improve outcomes
Imaging for LBP
> Randomized trials of routine imaging versus usual care without routine imaging in patients without indications for diagnostic imaging suggest no clinically meaningful benefits on outcomes related to pain, function, quality of life, or mental health.
> Other supporting evidence includes the weak correlation between most imaging findings and symptoms, the favorable natural history of acute LBP with or without imaging, the low prevalence of serious or specific underlying conditions, and unclear effects of imaging on treatment decisions.
Harms of unnecessary imaging
> Radiation exposure (for lumbar radiography and CT). > Labeling > Hypersensitivity reactions and contrast nephropathy (for iodinated contrast with CT).
Approaches to overcome barriers to evidence-based practice
> Potential association with subsequent unnecessary, invasive, and expensive procedures.
> Patient expectations or preferences for routine imaging: Use talking points based on evidence-based guidelines to aid in patient education.
> Time constraints: Use evidence-based online or print education material to supplement face-to-face education.
> Clinician uncertainty: Recognize the low likelihood of serious conditions in the absence of clinical risk factors and the evidence that shows no benefit associated with routine imaging.
> Clinician incentives based on patient satisfaction: Advocate for incentives that are based on providing appropriate care.
Talking points for clinicians when discussing LBP imaging with patients
> Risk factor assessment can almost always identify patients who require imaging.
> The prevalence of serious underlying conditions is low in patients without risk factors.
> The natural history of acute LBP is quite favorable, but patients require re-evaluation if they are not better aſter about 1 month.
> Routine imaging does not improve clinical outcomes but increases costs and may lead to potentially unnecessary invasive treatments, such as surgery.
> Imaging abnormalities are extremely common, especially in older adults, but most are poorly correlated with symptoms.
> In most cases, treatment plans do not change aſter imaging studies. > Back imaging is associated with radiation exposure, which can
increase the risk for cancer in the case of lumbar radiography and CT.
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