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Back pain is the leading cause of disability in the western world and a major reason for activity avoidance and athlete retirement. In spite of enormous and increasing costs, current approaches to management are fuelling rather than reducing the burden of the problem.1 This was highlighted by the huge media interest generated recently over the demise of Tiger Woods and his golf game relating to his back pain disorder. Tiger's story has demonstrated common underlying beliefs about back pain often reinforced by well-meaning health professionals, which in turn leads to the quest for ‘magic bullet’ treatments to ‘fix’ the disorder. Tiger's situation highlights the diagnostic and management dilemma faced by many health professionals regarding the mechanisms for, and the management of, recurrent and disabling back pain disorders.
Tiger's public quotes raise five key themes for discussion
“Tiger has a pinched nerve in his back causing his pain” What is the role of imaging for the diagnosis of back pain?
Commonly in clinical practice back pain is considered from a purely biomedical perspective, where radiological imaging is the basis for diagnosis. The dilemma of imaging is that while it has an important role in the triage of people with back pain in order to identify fractures, malignancies and nerve root compression in 1–2% of people, it also identifies many pathoanatomical findings which are poorly related to back pain.2 Imaging findings such as disc degeneration, disc bulges, annular tears and prolapses are highly prevalent in pain-free populations, are not strongly predictive of future low back pain (LBP) and correlate poorly with levels of pain and disability.3 ,4
The documented adverse effects of early MRI for LBP include increased disability levels, increased medical costs and surgery, highlighting the risk of iatrogenic disability if spinal imaging is not communicated carefully and matched to the presenting disorder.5 ,6 …
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
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