Kirkham Wood MD1, and Craig McMains MD2 1 Stanford Health Care, Stanford University, Stanford, CA, USA 2 Community Health Network, Indianapolis, IN, USA In the US, LBP is one of the most common issues leading to medical evaluation. Roughly 85% of the population will experience an episode of mechanical LBP at some point in their lives.1,2 More than 85% of patients who present to primary care with this symptom will have LBP that cannot reliably be attributed to a specific disease or spinal abnormality.3 This translates to a significant healthcare expense, with only cancer and heart disease having a larger financial impact.4–8 A variety of advanced imaging studies can be used to evaluate LBP, but many have high associated costs. However, more expensive tests may be justified if there is a possibility to positively affect outcomes.9 Physicians are burdened with appropriately and effectively treating a patient while also preventing financially wasteful testing. Expensive imaging is difficult to justify if the clinical outcomes are unaffected. In addition to the stress the physician feels to be fiscally responsible, the patient is taxed with potentially having to make another appointment to obtain the advanced imaging. This can lead to decreased patient satisfaction if the additional time within the healthcare system is not justified. Furthermore, unindicated imaging could lead to findings that trigger further intervention without benefit. The overwhelming consensus in the treatment of LBP is that advanced imaging is not indicated for acute and subacute symptoms. Multiple clinical guidelines and meta‐analyses support this opinion in both the United States and the United Kingdom.10 A 2009 meta‐analysis of randomized controlled trials (RCTs) showed that in the primary care setting there was no significant difference in outcomes between early imaging versus no immediate imaging for acute or subacute LBP.11 This was true for both short‐term (up to three months, standardized mean difference 0.19; 95% confidence interval [CI]: –0.01 to 0.39 for pain and 0.11, –0.29 to 0.50 for function; with negative values favor 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. Imaging in this study was defined as radiography, MRI, or CT. The American College of Physicians and the American Pain Society released a series of clinical guidelines in 2007 regarding the diagnosis and management of LBP.12 In their second recommendation, the guidelines state that “Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific LBP.” This was labeled a strong recommendation with moderate quality evidence. They further clarified indications for imaging by delineating neurologic deficits or underlying conditions that could support the administration of injections or surgery as a reason to obtain an MRI or CT. Several studies have also documented both the overuse and underuse of advanced imaging in the treatment of LBP.13 When being referred for lumbar spine imaging, 34.8% of referrals (95% CI: 27.1–43.3) were deemed inappropriate by the absence of red flags for serious pathology and 31.6% (95% CI: 28.3–35.1) were determined to be inappropriate by the criteria of no clinical suspicion of pathology. Subsequent research demonstrated how little the actual management of LBP is informed by lumbar MRI, with one study stating only 13% of said MRIs were actionable.14 With most population centers supporting both medical and chiropractic practices, many patients often ask about skeletal manipulations as a form of treatment for LBP. Many physicians do not have any direct experience with or in‐depth knowledge of these treatments in order to inform their patients regarding use. Once diagnosed with acute or subacute LBP, most patients are typically encouraged to undergo a variety of both pharmacological and nonpharmacological conservative treatments. Commonly used medications include nonsteroidal anti‐inflammatories (NSAIDs), acetaminophen, and muscle relaxants. Opioids are typically avoided in these scenarios. Nonpharmacological therapies include a variety of modalities: exercise and physical therapy, spinal manipulation, acupuncture, yoga, and psychological therapies. Chiropractic care is often a popular option among patients with acute or subacute LBP. However, is this extra method of treatment more beneficial than standard medical care?
113 Mechanical Low Back Pain: Nonoperative Management
Clinical scenario
Top three questions
Question 1: In patients presenting with acute or subacute LBP, does early advanced imaging, e.g. computed tomography (CT) and magnetic resonance imaging (MRI), lead to improved outcomes when compared to delayed imaging?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
Resolution of clinical scenario
Question 2: For patients undergoing initial treatment of mechanical LBP, does skeletal manipulation prevent the progression of symptoms more effectively than medical care?
Rationale
Clinical comment
Available literature and quality of the evidence
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