Lower back pain is one of the most common reasons for physician visits in the United States. Up to 85% of adults experience low back pain at some point in their lifetime. Moreover, low back pain is responsible for significant health care expenditure — imaging is often used in diagnosis and management of patients. When advanced imaging is used unnecessarily, it contributes to unwarranted costs for the patient and carries the risk of incidental findings driving downstream testing to prove the findings are benign.

The Centers for Medicare and Medicaid Services (CMS) has delegated the Johns Hopkins University School of Medicine (JHUSOM) to write appropriate use criteria (AUC) for low back pain advanced imaging. In accordance with CMS requirements, a multispecialty team of Johns Hopkins physicians created AUCs based on the results of an evidentiary literature review detailed here. The evaluation focused on studies that defined red flags for serious spine pathology, with 15 high grade publications reviewed and incorporated in an evidence table. While results varied according to modalities tested, evidence supports avoidance of immediate advanced imaging at first presentation in the absence of neurologic deficit or serious underlying conditions including cancer, infection, fracture and cauda equina syndrome. This table details when advanced imaging is appropriate and the optimal protocol according to JHUSOM AUCs.

For Johns Hopkins providers, imaging AUCs for low back pain are integrated into a comprehensive diagnostic guideline in Epic, which indicates when patients should be referred to the emergency department, when advanced imaging is appropriate, the optimal CT or MRI protocol for the clinical condition suspected and the best service to consult based on imaging results. The resource can be accessed by searching “guideline” in the Epic search box, and orders can be placed directly via the guideline. For providers outside Johns Hopkins, we are working to integrate these ordering guidelines into other electronic medical records. Additional resources for Johns Hopkins providers include a low back pain myLearning module created by Johns Hopkins Community Physicians (JHCP) and Johns Hopkins Radiology (which provides CME and MOC credit), and value-based care resources on the Office of Johns Hopkins Physicians systematic learning webpage.

Lastly, lower back pain advanced imaging is one of the eight CMS priority clinical conditions for the PAMA AUC program, which requires ambulatory providers to consult AUC via a clinical decision support tool in the EMR when ordering CT, MRI and nuclear medicine. More information about the program is available on the CMS website.

This work is intended for use to assist hospital and healthcare audiences; however, Johns Hopkins makes no representations or warranties concerning the content or clinical efficacy of this work, its accuracy or completeness. Johns Hopkins is not responsible for any errors or omissions or for any bias, liability or damage resulting from the use of this work. This work is not intended to be a substitute for professional judgment, advice or individual root cause analysis.