Imaging strategies for low-back pain: systematic review and meta-analysis

Background: Some clinicians do lumbar imaging routinely or in the absence of historical or clinical features suggestive of serious low-back problems. We investigated the effects of routine, immediate lumbar imaging versus usual clinical care without immediate imaging on clinical outcomes in patients with low-back pain and no indication of serious underlying conditions. Methods: We analysed randomised controlled trials that compared immediate lumbar imaging (radiography, MRI, or CT) versus usual clinical care without immediate imaging for low-back pain. These trials reported pain or function (primary outcomes), quality of life, mental health, overall patient-reported improvement (based on various scales), and patient satisfaction in care received. Six trials (n=1804) met inclusion criteria. Study quality was assessed by two independent reviewers with criteria adapted from the Cochrane Back Review Group. Meta-analyses were done with a random effects model. Findings: We did not record significant differences between immediate lumbar imaging and usual care without immediate imaging for primary outcomes at either short-term (up to 3 months, standardised mean difference 0·19, 95% CI -0·01 to 0·39 for pain and 0·11, -0·29 to 0·50 for function, negative values favour routine imaging) or long-term (6-12 months, -0·04, -0·15 to 0·07 for pain and 0·01, -0·17 to 0·19 for function) follow-up. Other outcomes did not differ significantly. Trial quality, use of different imaging methods, and duration of low-back pain did not affect the results, but analyses were limited by small numbers of trials. Results are most applicable to acute or subacute low-back pain assessed in primary-care settings. Interpretation: Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, 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. Funding: American Pain Society.