The guidelines, and these are from across the world, are judicious with imaging early on for many reasons.
The biggest reason is that imaging often shows problems in people without back pain. The findings are just commonly there.
Coupled with real harms associated with imaging, not just increased radiation exposure which increases cancer risks, and yes cost for an extremely common condition.
There are harms associated with labeling: a “nocebo” effect. Divide matched patients into two groups, one with early imaging and one not. The early imaging group both gets better less often now aware of some structural “defect”, and is several fold more likely to have surgery (that fails to improve their symptoms any more than conservative management would).
That is the biggest point in the context of this thread’s discussions: the actual evidence that aggressive interventions help for these radiological findings (without red flags on history and exam) is weak to nonexistent, not clinically meaningfully better than controls of any sort, and no sham control studies done.
There is OTOH little evidence for significant harms risk from more conservative management options for those without the specific clinical red flags, and the evidence for their efficacy is at the same weak level or better. These include focused exercises, PT … and even acupuncture. The first two add in efficacy for prevention of recurrent problems, a major plus.
In any case, these preferred approaches are not based on my assessments of the evidence, but by the opinions of expert panels worldwide reviewing the evidence. Not by insurance companies.
But yes it is very easy to get early imaging done.
There’s a real problem with over-imaging in general turning up “incidentalomas” that don’t have any health significance; meanwhile patients go through unnecessary procedures with risk of harm.
Add to that outright fraud. Chiropractors have long been guilty of overdoing x-rays and wrongly identifying findings to justify repeat visits and even more radiation exposure.
The problem extends to overtesting, with people eagerly getting 100+ lab tests and providers (“functional medicine” docs especially) chasing after abnormalities that likely reflect false positives. I recently along with other MDs on Twitter responded to a poster outraged that docs were resisting his demands for oodles of unnecessary tests - he thought they were just “lazy”.
Without clinical justification for imaging and lab tests, costs spiral and patients do not benefit.
That to me is to biggest irony. Especially in my end of the clinical world. The lazy way out for a busy clinician to just order a bunch of tests or prescribe the antibiotic. It is quick. Doing “nothing” - not ordering the unnecessary tests which add costs, and sometimes provoke all from rabbit holes of chasing “normal abnormalities” to “series of unfortunate events”, is actually time consuming and not additionally compensated (unless it takes a LOT more time) hard work. It helps to have partners all on the same page and after a bit many patient families appreciate that “nothing” is often the best choice. Or maybe that’s a selection bias? The ones who do not end up finding someone who will give them antibiotics two days into a cold just in case, and who order X rays just because “it can’t hurt to be sure”?
17 years ago I developed severe lower-back pain with shooting pain down my left leg. Family and friends suggested I see a chiropractor. So, I went for a couple of “adjustments”. Horrible mistake. He made it so much worse.
Consulted with a Neureosurgen, was sent for an MRI, which showed I had a severely ruptured disc in my lower back. two weeks later had a partial discectomy and I’ve been pain free ever since.
Ever since I’ve had a hobby(?) of “researching” causes of and remedy for back pain. I have little tolerance for quackery and woo and needling and spinal manipulation are at the top of that list. Show me evidence and I may reconsider.
It still seems to me that DSeid’s arguments are based upon over-aggressive surgeons or unscrupulous quacks. Nothing there says that imaging caused harm. I would not go to PT without first having an X-ray so that I know they are not trying to treat muscles when there is a bulging disc. That makes no sense at all.
I’m sorry but then you are not reading what I wrote at all. Which is fine.
But others should be aware that your personal strongly held belief that you give as medical advice is very much different than the broadly held consensus of medical experts who have reviewed the evidence and created care guidelines across the world.
Which typically do include acupuncture as an acceptable early option based on weak but not zero evidence and the relative lack of harms.
What I give “as medical advice” is making sure there’s not a bigger problem to be exacerbated before looking on the internet for physical therapy tips. If you want to argue that’s bad advice, keep talking. SMDH
No interest in arguing. Merely sharing what the broadly held expert panel evidence based guidance is, across the world.
Individuals are free to find providers who ignore that evidence based guidance (not too hard) or argue with their providers that they want it even though expert assessments of the evidence strongly advise against such, concluding fairly strongly that early imaging in the absence of specific red flags in history and/or exam causes more harms than goods. There are few things in the low back guidelines that reach strong level of evidence; this does.
Remember, 99%+ of acupuncture studies out of China are positive, a truly remarkable vindication of the practice, especially when you add in systematic reviews based on such studies.
