Back pain is usually benign and self-limited, but occasionally it is a symptom of systemic disease such as cancer or spinal infection. Thus, the major diagnostic task is to distinguish the 95 percent of patients with simple back pain from the 5 percent with serious underlying diseases or neurologic impairments. A new study supported by the Agency for Healthcare Research and Quality (HS08194 and HS09499) recommends a diagnostic strategy similar to that recommended in the AHRQ clinical guidelines on acute low back problems.
University of Washington researchers Jeffrey G. Jarvik, M.D., M.P.H., and Richard A. Deyo, M.D., M.P.H., reviewed abstracts and selected articles from 1996 to September 2001 on accuracy of the clinical and radiographic examination of patients with low back pain. They extracted diagnostic results from clinical examinations and imaging tests and evaluated these methods informally, since there were few studies, and there were methodologic problems. Based on this review, Drs. Jarvik and Deyo recommend that for adults younger than age 50 with no signs or symptoms of systemic disease, symptomatic therapy without any x-rays or other imaging is appropriate. For patients 50 years of age and older and those whose findings suggest systemic disease, plain x-rays and simple laboratory tests can almost completely rule out underlying systemic diseases.
Advanced imaging such as magnetic resonance imaging (MRI) and computerized tomography (CT) should be reserved for patients who are considering surgery or those in whom systemic disease is strongly suspected. Imaging may not be needed for patients with acute back pain of less than 6 weeks' duration unless findings suggest systemic disease or progressive neurologic deficit. Choice of imaging tests after acute pain has persisted for 6 weeks depends on clinical findings. For patients with systemic diseases, MRI probably offers the greatest sensitivity and specificity; for patients with degenerative conditions that produce neurologic compromise, MRI offers results comparable to those obtained with CT.
See "Diagnostic evaluation of low back pain with emphasis on imaging," by Drs. Jarvik and Deyo, in the October 2002 Annals of Internal Medicine 137, pp. 586-597.
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