Australasian Faculty of Occupational and Environmental Medicine
Recommendations from the Australasian Faculty of Occupational and Environmental Medicine on low back imaging, opioids, time off work and asbestos exposure. The Australasian Faculty of Occupational & Environmental Medicine (AFOEM) is a Faculty of the Royal Australasian College of Physicians (RACP) that connects and represents Occupational and Environmental Medicine Fellows and trainees in Australia and New Zealand.
Do not order X-rays or other imaging for acute non-specific low back pain, unless there are red flags or other clinical reasons to suspect serious spinal pathology.
As little as two per cent of low back pain cases represent potentially serious conditions requiring surgical or medical intervention. The majority of acute low back pain episodes are benign, self-limiting cases that do not warrant any X-ray or imaging studies. Indeed, unnecessary X-rays and imaging can be harmful due to the potential adverse health effects associated with radiation exposure, incidental findings that trigger more imaging to be performed, and description of asymptomatic, age-related changes in the spine that can result in inappropriate patient anxiety. Moreover, the attribution of symptoms to unrelated incidental findings can then lead to unnecessary surgery.
It is therefore recommended that X-rays and other imaging of the lower back should be performed only if there are red flags such as: a history of significant trauma, cauda equina syndrome, symptoms suggestive of a tumour or infection (fever, weight loss, and a history of cancer), and steroid use. Also, plain radiography is insufficiently sensitive and specific pain associated with these risk factors with the exception of suspected ‘low energy’ fractures e.g. low-height falls in the elderly or osteoporotic. In these cases, plain radiography can be useful to determine whether a fracture is present and inform investigation and treatment of patients at risk of osteoporosis to prevent further fragility fractures.
- Graves JM, Fulton-Kehoe D, Martin DP, et al. Factors associated with early magnetic resonance imaging utilization for acute occupational low back pain: a population-based study from Washington State workers' compensation. Spine 2012; 37(19):1708-18.
- Suri P, Boyko EJ, Goldberg J, et al. Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskeletal Disorders 2014; 15:152.
- Webster BS, Bauer AZ, Choi Y, et al. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine 2013; 38(22):1939-46.
The College worked with the President and EVOLVE Lead Fellow of AFOEM to compile and refine a list of nine recommendations regarding low-value clinical practices in occupational and environmental medicine. This initial list served as the basis for an online survey. Based on survey responses, each of the nine recommendations was assigned a score and ranked accordingly. Based on the ranking of the initial nine, and the review of newly suggested items, these five low-value practices and interventions were chosen.
- 1 Do not request low back X-rays or other forms of low back imaging as part of a routine preplacement medical examination.
- 2 Do not order X-rays or other imaging for acute non-specific low back pain, unless there are red flags or other clinical reasons to suspect serious spinal pathology.
Do not prescribe opioids for the treatment of acute or chronic pain without assessing the patient’s clinical condition, potential side effects, alternative analgesic options, work status, and capacity to perform safety-critical activities such as driving a motor vehicle.
- 4 Do not certify a patient as totally unfit for work unless the work absence is clinically necessary and the patient is unfit for suitable alternative or restricted duties.
- 5 Do not repeat chest X-rays when screening asbestos-exposed workers unless clinically indicated.