Lower Back Pain Imaging

Choosing Wisely Canada recommendation #8: Do not image for lower back pain unless red flags are present.

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Clinical scenario: A 45-year-old patient presents to their family physician for lower back pain that has lasted for the past two weeks. The family physician conducts a physical exam and recommends managing with ibuprofen use and activity modification. The patient mentions that her brother-in-law, who previously worked in a hospital setting, had received imaging for his back pain.

The patient reports no changes in their motor function or sensation, and has had no recent fevers, weight loss, or trauma. However, the patient is still worried about “missing something more serious.” Feeling pressure, the physician requests imaging “just to be safe.”

Ordering the X-ray takes time and coordination of various layers of work. The patient took time off work to attend the imaging appointment at a local imaging clinic. When the results return, the family physician discusses the findings with the patient, which shows a common benign abnormality. The patient is instructed to follow up as needed.

For a clinic of 10 clinicians, avoiding early imaging translates to 10 days per year that could be redirected toward higher-value care.  This time could be used for same-day access visits, chronic disease management, collaboration with allied health professionals, or outreach to patients in rural or underserved areas. In addition to re-allocating this time, this approach also spares patients unnecessary radiation, anxiety, and further unneeded testing.