“Tell me about your troubles,” I say.  “It’s my L4 disc,” says the patient.

One of the most prestigious journals in the world, The Lancet, published a review of investigations for back pain. The study summarized the findings of research that looked at the outcome for patients with back pain if they had versus did not have immediate lumbar imaging such as x-rays, CT, or MRI scans for the new onset of back pain.

There were six studies that included 1800 patients in total.  The review looked at the patient’s

• Pain and function,
• Quality of life,
• Mental health,
• Overall patient-reported improvement, and
• Patient satisfaction with the care received.

The researchers wanted to find out whether people who had investigations for the back pain were better or worse off than those who didn’t.

They found there was no significant difference between the outcome of the patients who had immediate x-rays or scans and those who did not.  This included person’s pain and function, quality of life, mental health, reported improvement, and patient satisfaction in the care they received.

Why then, are x-rays or scans repeatedly done?

More important than the scan being done is how the results are conveyed to the patient. 

For the patient learning they have a disc bulge has meaning, and that meaning has consequences.  They might consider that their health is significantly affected by a “named” condition.  Many do, and they worry about their future.

Even worse, the employer might want the result, and the claims officer may make decisions about the claim based on the scan.

“Well, the MRI is normal, so they can’t be that bad, can they?”

Occasionally I see patients who have had discograms.  This is a test which has little scientific validity, and a small but important proportion of people can have serious side effects from the injection.  Why is it done?  The rationale appears to be scientific, it allows the advising doctor to be formal about the label, yet it has no more meaning than describing the pathology of a wrinkle. 

The cycle continues.  Patients want an updated scan to see how their back is going.  Then the claims officer or dispute resolution person wants to see the scan, if the case goes to trial even the judges seem to take the results into account in awarding lump sums payments.  The scan conveys an aura of objectivity and science; this is one of the best examples of science that is misunderstood and misused.

The research shows that there is no significant difference between the outcome of the patients who had immediate x-rays or scans and those who did not.  We need to get the research into practice.