American Chiropractic Association

View all recommendations from this society

August 15, 2017

Do not obtain spinal imaging for patients with acute low-back pain during the six (6) weeks after onset in the absence of red flags.

In the absence of red flags, evidence-based guidelines do not support the routine use of spinal imaging for patients with acute back pain of less than six weeks duration. Red flags include history of cancer, fracture or suspected fracture based on clinical history, progressive neurologic symptoms and infection, as well as conditions that potentially preclude a dynamic thrust to the spine, such as osteopenia, osteoporosis, axial spondyloarthritis and tumors. Unnecessary imaging incurs monetary cost, exposes the patient to ionizing radiation, and can result in labeling patients with conditions that are not clinically meaningful, creating a false sense of vulnerability and disability. Indeed, several studies have shown that the routine use of radiographs in the care of low-back pain may result in worse outcomes than without their use.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American Chiropractic Association (ACA) utilized its Committee on Quality Assurance and Accountability (CQAA) to serve as an expert task force of doctors of chiropractic (DCs) to identify areas/items common to the practice of chiropractic for which recommendations were supported by clinical research and would result in high-value, cost-effective services and improved patient outcomes. A literature search was conducted and the task force collaboratively identified a draft list of six recommendations based upon established Choosing Wisely® criteria. The list was submitted to the ACA Board of Governors for initial review. After further refinement, the final list of five strategies was selected, submitted to and approved by the ACA Board of Governors.

Choosing Wisely® recommendations 1 and 2 are performance measures approved by Centers for Medicare and Medicaid Services (CMS) for the 2017 Spine IQ Qualified Clinical Data Registry for Conservative Spine Care.

ACA’s disclosure and conflict of interest policy can be found at www.acatoday.org.

Sources

Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72.

Bussières AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults—an evidence-based approach—part 3: spinal disorders. J Manipulative Physiol Ther. 2008 Jan;31(1):33-88.

Kendrick D, Fielding K, Bentley E, Miller P, Kerslake R, Pringle M. The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial. Health Technol Assess. 2001;5(30):1-69.

Vining RD, Potocki E, McLean I, Seidman M, Morgenthal AP, Boysen J, Goertz C. Prevalence of radiographic findings in individuals with chronic low back pain screened for a randomized controlled trial: secondary analysis and clinical implications. J Manipulative Physiol Ther. 2014 Nov-Dec;37(9):678-87.

National Guideline Clearinghouse (NGC). Guideline summary: ACR Appropriateness Criteria® low back pain. In: National Guideline Clearinghouse (NGC) [Website]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [2016 Jan 22]. Available from: https://www.guideline.gov/summaries/summary/49915

Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6.