Back pain: Lancet review calls for clinical assessment over routine scans

Non-specific back pain can involve several factors, including muscle strain, weak core muscles, poor movement patterns, sedentary habits, stress and inadequate sleep.

A recent review of international clinical practice guidelines published in The Lancet Rheumatology highlights a shift in the management of non-specific low back pain towards clinical assessment, patient education, physical activity, and exercise, while discouraging routine imaging when there is no suspicion of serious disease.

Examining guidelines issued between 1994 and 2026, the review underscores the importance of assessing symptoms and identifying warning signs before deciding on investigations or treatment. Bengaluru-based specialists said the approach reflected a growing emphasis on restoring function and avoiding unnecessary investigations and interventions.

Ravikumar Mukartihal, senior consultant orthopaedic and robotic joint replacement surgeon at SPARSH Hospitals, Bengaluru, said the approach had moved from investigation-driven care to one focused on clinical assessment and restoring function.

“Most cases of non-specific low back pain do not indicate a serious structural problem and can be managed without extensive investigations or invasive procedures,” he said.

Treatment should focus on understanding symptoms, reassuring patients, maintaining normal activities, prescribing appropriate exercises and physiotherapy, and using medication judiciously, he said.

Karuna Kabadi, neurosurgeon at Apollo Speciality Hospital, Jayanagar, said a disc bulge or prolapse described in an MRI report was an observation about the disc, not necessarily a diagnosis explaining the pain. “Many of us may be having disc bulges but do not have symptoms and feel perfectly fit,” she said.

Back pain can arise from muscles, ligaments, and joints, and may also be associated with systemic diseases. A disc bulge may cause symptoms when it irritates or compresses a nerve, resulting in shooting pain in the buttock or leg, commonly known as sciatica. A detailed history and clinical examination help doctors assess the likely cause, with imaging supporting the diagnosis where necessary, she said.

Ravikumar T., Head and Consultant of the Department of Orthopaedics at Ramaiah Memorial Hospital, said incidental findings on scans could cause unnecessary anxiety if patients interpreted them as proof that their spine was damaged.

“Treat the patient and not the scan,” he said, noting that disc bulges and mild degenerative changes were also seen in people without back pain.

Non-specific back pain can involve several factors, including muscle strain, weak core muscles, poor movement patterns, sedentary habits, stress and inadequate sleep. Clinical examination helps assess pain, movement limitations and neurological signs before treatment is decided, he said.

The review found that most guidelines recommended taking a patient’s history, conducting a physical examination and assessing psychological factors, including risk-stratification tools where appropriate. Routine imaging was generally discouraged without indications of serious pathology.

For acute low back pain, recommendations commonly included self-management, heat therapy, spinal manipulation and non-steroidal anti-inflammatory drugs (NSAIDs). For chronic pain, they included exercise therapy, psychological interventions and multidisciplinary care, with acupuncture and spinal manipulation recommended in some guidelines as part of broader treatment programmes.

Dr. Ravikumar T. said treatment had moved away from prolonged bed rest and early reliance on strong painkillers towards reassurance, education, continued activity and structured physical therapy.

“Movement is medicine,” he said, warning that avoiding activity out of fear of scan findings could cause muscle deconditioning and prolonged disability.

Dr. Kabadi said sitting for long hours and reduced daily movement contributed to mechanical back pain. Staying active, avoiding prolonged sitting and following guided physiotherapy and muscle-strengthening exercises could help, although consistency was essential.

Doctors stressed that discouraging routine imaging did not mean scans were unnecessary. Imaging remains important when there are warning signs of serious disease, progressive neurological deficits or persistent symptoms for which the findings could change treatment.

Surgery also has a role in selected patients, but decisions should be based on clear clinical indications rather than an MRI finding alone, Dr. Mukartihal said.

The specialists said the focus should be on appropriate clinical assessment and treatment tailored to each patient, with the aim of restoring movement and function while avoiding unnecessary investigations and procedures without overlooking serious underlying conditions.