Health Care Utilization and Pain Outcomes Following Early Imaging for Low Back Pain in Older Adults

Adam C. Powell, PhD; Teresa L. Rogstad, MPH; Sarah W. Elliott, PhD; Stephen E. Price, DPT, MBA; James W. Long, BSBA; Uday U. Deshmukh, MD, MPH; M. Hassan Murad, MD, MPH; Mark W. Steffen, MD, MPH


J Am Board Fam Med. 2019;32(6):773-780. 

In This Article

Abstract and Introduction


Background: Professional societies have provided inconsistent guidance regarding whether older patients should receive early imaging for low back pain, in the absence of clinical indications. The study assesses the implications of early imaging by evaluating its association with downstream utilization in an elderly population.

Methods: Patients were included if they had a Medicare Advantage plan, had claims-based evidence of low back pain in 2014, and lacked conditions justifying early imaging. The outcomes examined were short-term, nonchronic, and chronic opioid use, steroid injections, and spinal surgery in the following 730 days, and persistent low back pain at 180 to 365 days. Morphine dose equivalents of opioid use was used as a measure of intensity. Logistic and γ regressions were used to assess the association between imaging in the first 6 weeks and the outcomes.

Results: Among the 57,293 patients meeting inclusion criteria, the mean age was 71.2, and 26,606 (46.4%) received early imaging. Early imaging was associated with increased adjusted odds of short-term (odds ratio [OR], 1.21; 95% CI, 1.15 to 1.28), nonchronic (OR, 1.78; 95% CI, 1.69 to 1.88), and chronic (OR, 1.13; 95% CI, 1.07 to 1.18) opioid use, as well as steroid injections (OR, 2.55; 95% CI, 2.28 to 2.85) and spinal surgery (OR, 3.40; 95% CI, 2.97 to 3.90). Patients that received early imaging were more likely to experience persistent pain (OR, 1.09; 95% CI, 1.05 to 1.14) and used significantly more morphine dose equivalents if they had nonchronic opioid use.

Conclusions: Early imaging for low back pain in older individuals was common, and was associated with greater utilization of downstream services and persistent pain.


At least 5 specialty societies have stated that physicians should not order imaging for new-onset low back pain in the absence of certain "red flags" in the patient's clinical history that would warrant immediate imaging.[1–5] There is some controversy regarding whether this guidance is applicable to patients over the age of 50 years. The North American Spine Society's Choosing Wisely Guideline states, "In the absence of red flags, advanced imaging within the first 6 weeks has not been found to improve outcomes," and then proceeds to list age greater than 50 years as a red flag.[2] In contrast, the American College of Physicians and American Pain Society clinical practice guideline for the diagnosis and treatment of low back pain states, "For patients older than 50 years of age without other risk factors for cancer, delaying imaging while offering standard treatments and reevaluating within 1 month may also be a reasonable option."[6]

Coming to a consensus regarding the imaging of older people is important because both low back pain and abnormal imaging findings have greater prevalence in older people. A study of the prevalence of low back pain found that the most afflicted population was aged 55 to 64 years (15.4%), and the least afflicted was aged 21 to 34 years (4.3%).[7] Furthermore, the majority of older people have spinal issues; 1 cross-sectional study found that 93% of asymptomatic people aged 60 to 80 years had a degenerated disk, and 79% had a bulging disk.[8]

Given the high prevalence of spinal issues even in asymptomatic older people, low back imaging has the potential to serve as a justification for more aggressive intervention, even in situations where such intervention may not be beneficial. In a general population, advanced imaging as a first management strategy for low back pain has been found to be associated with significantly increased odds of spinal surgery, epidural injections, spine surgeon visits, any spine specialist visits, and emergency department visits.[9] Geographic variation in practice patterns has been shown to influence physician decision making regarding whether to pursue surgery, and higher rates of lumbar discectomy and laminectomy were found to be associated with inferior outcomes.[10] A meta-analysis of 7 trials comparing imaging to no imaging for low back found a significant effect in favor of no routine imaging, in terms of severity of pain at short-term and long-term follow-up, as well as overall improvement.[11]

To bring additional attention to the lack of clarity that surrounds whether older individuals should receive early imaging for new-onset low back pain, this study explored the association between early imaging and downstream utilization in a Medicare population. While this observational study is unable to show causal relationships between imaging and downstream outcomes as patients were not randomly assigned to receive imaging, its findings may inspire future researchers to conduct experiments on this topic. As America ages, the management of low back pain in older individuals will be a growing concern.