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Question: I went to my doctor because I’ve had really bad back pain. I asked if I should get an MRI, CT scan or even an X-ray to find out what’s causing my discomfort. My doctor said I don’t need any tests. But what happens if there is something really wrong with me? Wouldn’t it be better to do something now, rather than let it get worse?
Answer: There are only a handful of situations when an X-ray or scanning test should be done to investigate back pain.
In such cases, the patients usually have additional symptoms, such as an inability to urinate or loss of bowel control, a history of cancer, unexplained weight loss or a fever.
When any of these “red flags” are present, it can be a sign of nerve damage or another serious problem requiring prompt medical attention – justifying an imaging test.
For most patients, however, backaches don’t involve nerve damage or other complex issues. They normally get better with gentle exercises, over-the-counter pain relievers, a heating pad – and time.
So, there really is no need for diagnostic scans in the vast majority of back pain cases, says Dr. Adina Weinerman, a staff physician at Sunnybrook Health Sciences Centre.
In fact, unnecessary testing contributes to longer wait times in the health care system.
“If we decrease the inappropriate testing, then when you need a test, it will be more accessible to you in a timely fashion,” Weinerman says.
But reducing wait times isn’t the only reason to eliminate unjustified tests – they can actually do patients more harm than good.
Weinerman explains that high-tech scans are so sensitive they sometimes pick up unrelated abnormalities. For instance, an image done for back pain might also reveal a cyst on the kidneys. “It could be inconsequential and would never cause you any problems, ” she says. But once it’s discovered, doctors feel obligated to probe further.
“It can just snowball,” Weinerman says, adding that doing more and more tests increases the chance of harm. Follow-up X-rays and CT scans expose patients to additional radiation. Furthermore, performing a biopsy to obtain a tissue sample could lead to an infection or other complications.
“The deeper you get into the spiral of investigations, the more invasive and risky the tests and procedures become,” says Dr. Danielle Martin, a family physician and vice-president at Women’s College Hospital in Toronto.
Even if the patient eventually gets a clean bill of health, and the procedures are problem free, the extra tests can provoke long-lasting stress and anxiety.
Martin is the author of “Better Now – Six Big Ideas to Improve Health Care For All Canadians.”
In this recently-published book, she provides a chilling story of what can happen when needless testing goes awry.
The case involves a healthy executive, identified as Sam, who had a physical exam at a posh private medical clinic. It was supposed to be a corporate “perk” provided by his employer.
“Some very slight irregularities were found when he did an exercise stress test,” Martin recalls. “In order to be sure that he didn’t have coronary artery disease, he was sent for an angiogram, which is an invasive test where dye is injected into the blood vessels around the heart to look for blockages.”
During the procedure, Sam had a stroke resulting in paralysis on one side of his body.
Martin notes that a stroke is a rare, but acknowledged complication of angiograms. Ironically, the same test that left Sam permanently disabled also confirmed that he didn’t have coronary artery disease after all.
Martin says this is an “extreme example,” but it illustrates the perils of doing needless medical procedures.
“It’s not that some tests are good and some tests are bad. Nearly all tests are good for some people, under some circumstances, some of the time,” says Martin. When there’s sufficient cause to do a test, it can provide invaluable information and may help save a patient’s life.
“But when misapplied, the risks may outweigh the benefits,” she adds.
Indeed, there is a growing recognition within the health professions of the need to reduce unnecessary tests and treatments.
To nudge the health care system in that direction, a broad range of medical groups are backing a campaign called Choosing Wisely.
As part of this effort, a website – choosingwiselycanada.org – has been created to provide guidance to physicians.
Patients should be involved in these decisions, too. So the website also has information for the public, explaining in plain language why they might not always need a test or treatment for common medical conditions, including your problem – back pain.
“If you just have regular back pain, with no other symptoms, you can rest assured there is nothing more sinister going on that requires imaging,” says Martin, echoing the evidence presented on the website. “Spending time, energy and resources getting imaging done may just hold up progress on the things that will actually make it better.”
Sunnybrook’s Patient Navigation Advisor provides advice and answers questions from patients and their families. His blog, Personal Health Navigator, is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Follow Paul on Twitter @epaultaylor.