Chronic Back Pain: What's the Best Fix?

February 2, 2011

Imaging tests to diagnose back pain may not be the best answer according to new guidelines.

A discomforting statistic: four out of five people in the world will suffer from chronic back pain in their lives. The majority of these people will not know where to turn to make this pain vanish, and many will turn to modern technology to help find a source and cure. According to new guidelines released Monday from the American College of Physicians, however, going through a high-tech imaging test to diagnose the cause may not be the best answer, and can actually cause more damage.

The authors of the new guidelines state, "Routine imaging does not seem to improve clinical outcomes and exposes patients to unnecessary harms.” They cite statistics showing that despite the money patients suffering from lower back pain spend on these tests, they don't usually report feeling a relief from the pain and actually can come to handle the pain worse than in the past.

"When it comes to dealing with back pain, more isn't necessarily better; patients could benefit from having less," said Dr. Steven Atlas, internist, Massachusetts General Hospital, who is familiar with the new guidelines.

The guidelines recommend an X-ray, CT scan, or MRI only in the most severe cases, such as those with new back pain who are suspected of having a spinal tumor or infection, major traumatic injury from a fall or car accident, a spinal fracture from severe osteoporosis, or signs of a rare condition called cauda equina syndrome that causes nerve damage.

They further suggest that the vast majority of back pain sufferers should wait at least a month to see if their pain abates before considering an imaging test.

For those who ask what risk lies in getting a scan anyway, the guidelines have an answer. First, any patient who receives a CT scan or an X-ray (though not MRIs) will get a small dose of radiation, and recent research indicates that radiation from imaging tests accumulates over a lifetime, contributing to cancer risk. Second, imaging tests often show evidence of arthritis or spinal disk abnormalities that doctors may assume need to be treated with surgery, which proves to be unnecessary in many cases.

For those in pain, it can definitely be hard to hear the words “give it time,” but more often than not, the body will heal itself on its own without surgery. "It's hard for physicians to sit on these results and not do something to fix the problem," Atlas said.

"We think our backs are never supposed to hurt but that's not true," said Atlas. Many parents who are accustomed to lugging young children around know that their back still pangs from time to time, which Atlas says is probably a sign that arthritis is settling in.

He tries to explain all this to his patients when they come to him with back problems, saying that "it's very rare that I need a diagnostic imaging test to tell me what treatment to recommend.” Most of the time, he relies on taking a thorough patient history and a physical exam.Most often, Atlas recommends that his patients rely on over-the-counter pain relievers like ibuprofen or acetaminophen to help them "muddle through" while their body heals.

Physical therapy can also be of assistance to those suffering from back pain, since much of the therapy involves stretching the muscles that may be causing the pain. Atlas believes, however, that therapists may need to experiment with different regimens to see which one works best to alleviate pain.

"It's tough to find good evidence that any of these actually speed the healing process," he added, but a suffering patient may want to give these nearly risk-free options a try before exposing themselves to harmful radiation and needless surgery. Also on that list of easy ways to alleviate pain is simply walking, which may be the best thing one can do to help relieve the pain.Lying in bed, Atlas noted, may be the worst thing a person with back pain can do to themselves, due to the stationary position which does not allow for the natural stretching movement does, among other factors.

Should the pain persist for more than a few months, however, and the pain is “impacting your life, not allowing you to fully function," it may be time to have an imaging test, said Atlas.

In some cases, surgery really is the answer for speeding along the recovery process, such as for those suffering, for example, from a pinched nerve due to sciatica or severe spinal stenosis, which tends to afflict those older than age 65 years.

But surgery is not without drawbacks. It usually causes weeks of recovery pain. Atlas explained that most people bounce back from sciatica or disk surgery in about a month, but recovery from spinal stenosis often takes at least three months. Worse yet, about 5% of those who have surgery still wind up with chronic back pain.