Do young athletes with low back pain need advanced imaging?

Young athletes with low back pain may not need to undergo imaging beyond initial x-ray, according to survey results published February 2 in the International Journal of Sports Physical Therapy.

"Given that most cases improve with conservative management and that delayed imaging does not appear to worsen outcomes, these findings may support efforts to reduce unnecessary imaging and establish clearer, evidence-based guidelines for this athletic population," wrote a team led by physical therapist John Winslow of Ithaca College and Andrew Getzin, MD, of Sports Medicine Cayuga Medical Center, both in Ithaca, NY.

Young athletes and children (ages 6 to 18) who participate in organized sports often present with extension-based low back pain, a condition that can be associated with spondylolysis, spondylolisthesis, stress reaction, or other mechanical causes, the authors explained. Although these patients are typically evaluated with x-ray imaging, "there is no consensus regarding the appropriate use and timing of imaging in this population, particularly given concerns about radiation exposure and health care costs," they wrote, and "there is mounting evidence that the pain associated with extension-based low back pain may not correlate closely with structural imaging findings."

Winslow and Getzin assessed imaging practices of clinicians managing young athletes with extension-based low back pain, tracking physician and contextual factors associated with possible imaging overuse. The two conducted a survey that included 13 questions focused on imaging and treatment preferences for individuals with the condition and categorized responses by practice, practice setting, and years in sports medicine practice; they received 397 responses.

The pair reported the following:

• 68% of respondents reported that they always or most of the time order x-ray imaging on patients' first visit.
• 13.1% ordered advanced imaging on the first visit, and 27.2% ordered advanced imaging within four weeks.
• MRI was the most commonly ordered advanced imaging modality (69.3%), followed by SPECT (19.2%) and CT (5%).
• Initial x-ray imaging was most common in orthopedic offices, private sports medicine settings, and among less-experienced physicians.
• MRI was the predominant modality across groups (practice setting, years in practice, and sports-medicine caseload).

The survey findings suggest that young athletes with lower back pain tend to undergo advanced imaging (MRI, SPECT, or CT) within the first four weeks of evaluation, the authors noted, writing that "these imaging modalities contribute to increased healthcare costs and, in the case of SPECT and CT, expose the athlete to ionizing radiation, which carries a significantly higher risk of cancer for children compared to adults, estimated to be nearly tenfold greater."

These results underscore a need for "evidence-informed imaging guidelines specifically tailored to young athletes with lower back pain, similar to existing adult guidelines, to support more consistent and appropriate use of [x-ray] and advanced imaging in this population," they concluded.

Access the full study here.