Diagnostic Challenges of Back Pain

Back pain is a leading cause of disability worldwide and one of the most frequent complaints encountered in the clinical practice.[1] Despite its prevalence, diagnosing and managing back pain remains a significant challenge for healthcare professionals. This complexity arises from the multifactorial nature of pain, improper use of diagnostic tools, and the need for a patient-centered approach. Identifying the source of pain in degenerative spinal disorders presents significant challenges, as incidental radiologic pathologies and associated back or leg pain are frequently observed. Despite the prevalence of these issues, the topic has not been adequately addressed in the existing literature. Moreover, the relationship between incidental radiological findings and surgical interventions in degenerative spinal conditions remains an unexplored research area. Radiological abnormalities are widespread, often incidental, and unrelated to clinical symptoms. Forty percent of individuals under 30 years have lumbar disc degeneration, increasing to over 90% by the age of 50–55 years.[2] Approximately 25% of asymptomatic adults show disc herniations on lumbar magnetic resonance (MR) images.[3] Furthermore, the prevalence rate of incidental thoracic disc herniation is 6.5%, and the rate of thoracic hypertrophied ligament flavum causing stenosis is about 19.0%.[4] Misinterpreting these findings can lead to unnecessary interventions. As a result, unnecessary surgical interventions can be done, which then result in no relief of the patient’s pain and even cause new complications [Figure 1].Figure 1: The current physician policy for diagnosing back pain is like this. This is not correct and causes new problems with unnecessary treatments, even surgeriesDespite technological advances, the mismatch between imaging results and pain symptoms remains a significant challenge. There is no good correlation between radiology and symptoms. The source of pain may be multiple and hidden. Multiple pain generators are present in degenerative spinal conditions, complicating pinpointing a single source. We must choose diagnostic strategy tools following a good anamnesis and examination. The evaluation of pain through examination and history-taking is more critical than radiology. A “less is more” approach to low back pain recommends avoiding imaging within the first 6 weeks unless red flags are present, focusing on efficient and evidence-based care.[5] The so-called National Physicians Alliance’s project has made some recommendations called “Promoting Good Stewardship in Clinical Practice.” They made a list of the top five activities in primary care for which changes in practice could lead to higher-quality care and better use of finite clinical resources. One of the top five recommendations was “Don’t do imaging for low back pain within the first 6 weeks unless red flags are present.”[5] Red flag rules indicate when imaging tests will be requested for back and neck pain. Some of these red flags include (1) a history of malignancy, (2) loss of weight and appetite, (3) fever, (4) being older than 60 years of age, (5) the presence of neurological findings, (6) pain that does not subside even 4 weeks after its onset, and (7) pain that does not relieve with rest and continues especially at night.[6] Studies have shown that unnecessary imaging does not improve the outcomes and may increase healthcare costs.[7] Wnuk et al. have studied the extent of overuse and the potential harmful effects of imaging in back pain patients.[8] They have looked at the proportion of examinations with a detectable impact on patient care (actionable outcomes). From 5365 outpatient lumbar spine MR examinations, actionable outcomes were 13%. Of 36 suspected cases of cancer or infection, 81% were false positives. American College of Physicians have also prepared the Clinical Guidelines for diagnostic imaging for low back pain.[9] Similarly, a randomized trial of routine advanced imaging versus no imaging found no differences in diagnoses or treatment plans.[10] Surgery should be reserved for cases with a clear and direct correlation between imaging findings and clinical symptoms, supported by comprehensive evaluation. Furthermore, many degenerative spinal conditions, such as mild disc herniations, may resolve spontaneously without surgical intervention. Another topic must be chronic back pain. Suppose you are dealing with a patient with long-term back pain (mostly more than 3 months), nonrestorative sleep, and low energy. In that case, you must take a multidisciplinary approach, including psychotherapy, occupational therapy, and exercise therapy. To address the challenges in diagnosing and managing back pain, it is essential to prioritize improved medical training emphasizing clinical evaluation and patient examination over-reliance on imaging. In addition, promoting evidence-based research to understand better the correlation between the clinical findings and pain outcomes can refine the diagnostic and treatment strategies. Finally, developing and implementing patient-centered guidelines focusing on conservative management and patient education is crucial for achieving the better outcomes and more efficient care [Figure 2].Figure 2: An example for a diagnostic failure if you look at the films. This is a 62-year-old female. She had low-back pain for 30 years and right leg pain for 6 months. On examination, she had sacroiliac joint pain. She responded a test injection. Her pain completely relieved by radiofrequency lesion of right sacroiliac jointCONCLUSIONS We must always remember the phrase “operate the patient, not the films.” To prevent operating films, we must not order films in unnecessary conditions. We need more training to teach residents better patient evaluation and examination than surgical techniques.