Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work

Eur Spine J. 2019 May;28(5):937-950. doi: 10.1007/s00586-019-05918-1. Epub 2019 Feb 22.


Purpose: Imaging (X-ray, CT and MRI) provides no health benefits for low back pain (LBP) patients and is not recommended in clinical practice guidelines. Whether imaging leads to increased costs, healthcare utilization or absence from work is unclear. Therefore, this study systematically reviews if imaging in patients with LBP leads to an increase in these outcomes.

Methods: We searched PubMed, CINAHL, EMBASE, Cochrane Library and Web of Science until October 2017 for randomized controlled trials (RCTs) and observational studies (OSs), comparing imaging versus no imaging on targeted outcomes. Data extraction and risk of bias assessment was performed independently by two reviewers. The quality of the body of evidence was determined using GRADE methodology.

Results: Moderate-quality evidence (1 RCT; n = 421) supports that direct costs increase for patients undergoing X-ray. Low-quality evidence (3 OSs; n = 9535) supports that early MRI may lead to an increase in costs. There is moderate-quality evidence (1 RCT, 2 OSs; n = 3897) that performing MRI or imaging (MRI or CT) is associated with an increase in healthcare utilization (e.g., future injections, surgery, medication, etc.). There is low-quality evidence (5 OSs; n = 15,493) that performing X-ray or MRI is associated with an increase in healthcare utilization. Moderate-quality evidence (2 RCTs; n = 667) showed no significant differences between X-ray or MRI groups compared with non-imaging groups on absence from work. However, low-quality evidence (2 Oss; n = 7765) did show significantly greater mean absence from work in the MRI groups in comparison with the non-imaging groups.

Conclusions: Imaging in LBP may be associated with higher medical costs, increased healthcare utilization and more absence from work. These slides can be retrieved under Electronic Supplementary Material.

Keywords: Absence from work; Costs; Healthcare utilization; Imaging; Low back pain.

Publication types

  • Systematic Review

MeSH terms

  • Diagnostic Imaging / economics*
  • Humans
  • Low Back Pain*
  • Lumbar Vertebrae / diagnostic imaging*
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Sick Leave*