What Tests Do I Need? Spring Chore Back Pain Edition

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By Kathryn Galbraith, MD

In this era of high tech and high cost healthcare, it can be quite difficult to know what tests and treatments are most likely to be beneficial, are least likely to harm, and are most cost-effective.  For example, do you need an X-ray or MRI when you wrench your back digging compost into your vegetable garden?

A program called  “Choosing Wisely” was part of a multi-year effort of the ABIM (American Board of Internal Medicine) Foundation, along with its partners including Consumer Reports, to help physicians be better stewards of our finite health care resources and helps answer questions like this one. Choosing Wisely aimed to promote conversations between doctors and patients and to help patients choose care that is supported by evidence, does not duplicate other tests or procedures already received, is free from harm, and is truly necessary.  National organizations representing medical specialists asked their providers to “choose wisely” by identifying tests or procedures commonly used in their field whose necessity should be questioned and discussed. The resulting lists of “Things Providers and Patients Should Question” is meant to encourage discussion about whether many frequently ordered tests or treatments are truly needed. This article is the second in a series of articles highlighting some of the commonly requested tests in medicine and the recommendations for their safe and effective use.  With the start of spring chores and the resultant increase in complaints of back pain, this one will focus on imaging for acute low back pain.

Back pain can be severe and can significantly limit a person’s ability to attend to his or her responsibilities at work and at home and can prevent a person from being able to participate in recreational activities for enjoyment. Many patients think that an imaging test will help identify the problem to speed recovery and “prevent further damage.”  The truth of the matter is that most people with lower back pain feel better within a month, regardless of whether they had an imaging test or not.

Not only may imaging not help, imaging can be harmful.  There is good data that imaging tests can lead to surgery and other treatments that are not needed.  In a study cited by the Choosing Wisely campaign, people who had an MRI were much more likely to have surgery than those who did not have an MRI, but the surgery did not help them get better any faster.  In addition, other imaging techniques like X-ray and CT scan expose patients to radiation that can add up over time causing harmful effects including cancer.

Furthermore, imaging is expensive.  According to CompareMaine.com, X-rays of the lower back can range in cost from $50-$500 depending on the facility (state average $111), and an MRI can set you back $650 to $2300 (state average $980).  If these tests then lead to surgery, the cost grows greatly.  While some patients may reason that insurance will cover that cost, it is important to recognize that the cost of such unnecessary tests comes back to the patient in the form of premium increases down the road.

According to the American Academy of Family Physicians (AAFP), Xrays, CT scans and MRIs should not be done in patients with acute low back pain within the first 6 weeks of the start of their symptoms unless concerning findings called “red flags” are present.  These “red flags” include a fever over 102oF, the loss of feeling or strength in the legs, the loss of bowel or bladder control, problems with your reflexes, or certain historical items that could suggest cancer including unexplained weight loss or a known history of cancer.  A large number of other medical societies have variations on this same recommendation to avoid or limit imaging including the American Association of Neurological Surgeons and Congress of Neurological Surgeons, the American College of Occupational and Environmental Medicine, the American College of Physicians, the American College of Emergency Physicians, and the American Academy of Physical Medicine and Rehabilitation.

So what should you do in the initial days or weeks of low back pain?

First, stay active.  Staying in bed increases back stiffness making pain worse and can lead to muscle weakness from lack of use.  Take short walks instead.

Heat is very beneficial to treating back pain because it loosens tight muscles.  Apply heat with a heating pad, hot water bottle, or by taking a warm bath or shower.  Generally using heat at 20 minute intervals followed by some gentle stretches or a short walk can limit back spasms.

Over-the-counter medications can help to relieve back pain.  Tylenol is an excellent pain reliever.  Non-steroidal Anti-inflammatory Drugs (NSAIDs) like ibuprofen and naproxen help pain, too, and can also decrease the swelling and inflammation of injured muscles.  If you are unsure which type of medication is best for you, call your doctor.

If these at-home therapies are not working or you develop any of the “red flag” symptoms noted above, talk to your doctor.  Also call if there is inadequate improvement after a month of symptoms; other therapies could be considered at that point including physical therapy, chiropracty, massage therapy, acupuncture, yoga, or Osteopathic Manipulation Therapy (OMT).  Surgery is generally considered in appropriate cases only as a last resort.

For more information, talk to your doctor or visit https://medlineplus.gov/ency/article/007493.htm.

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