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

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 unless serious disease is suspected.

A review of guidelines issued between 1994 and 2026 underscores the importance of assessing symptoms and identifying warning signs before deciding on investigation 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 Orthopedic and Robotic Joint Replacement Surgeon at SPARSH Hospitals, Bengaluru, said the approach has shifted from research-led care to one focused on clinical evaluation and restoration of 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.

According to him, treatment should focus on understanding symptoms, reassuring patients, maintaining normal activities, prescribing appropriate exercises and physiotherapy, and judicious use of medication.

Treat the patient, not the scan

Karuna Kabadi, a neurosurgeon at Apollo Specialty Hospital in Jayanagar, said the bulging or prolapsed disc described in the MRI report was an observation of the disc, not necessarily a diagnosis explaining the pain. “Many of us can have a bulging disc but have no symptoms and feel perfectly fit,” she said.

Back pain can originate from muscles, ligaments and joints and can also be associated with systemic diseases. A bulging disc can cause symptoms when it irritates or compresses a nerve, leading to 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 if necessary, she said.

Ravikumar T., head and consultant in the department of orthopedics at Ramaiah Memorial Hospital, said that incidental findings on scans can cause unnecessary anxiety if patients interpret them as evidence that their spine has been damaged.

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

Non-specific back pain can involve several factors, including muscle tension, weak core muscles, poor movement patterns, sedentary habits, stress and lack of sleep. A clinical exam helps assess pain, movement limitations and neurological symptoms before deciding on treatment, he said.

Movement after prolonged rest

The review found that most recommendations recommended taking a patient history, performing a physical examination and assessing psychological factors, including risk stratification tools where appropriate. Routine imaging was generally discouraged without evidence of serious pathology.

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

Dr. Ravikumar T. said treatment has shifted from prolonged bed rest and early reliance on strong pain relievers to reassurance, education, continued activity and structured physical therapy.

“Exercise is medicine,” he said, warning that avoiding activity for fear of scan findings can cause muscle deconditioning and prolonged disability.

Dr. Kabadi said long hours of sitting and limited 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.

When is a scan necessary?

The doctors emphasized that the discouragement of routine imaging did not mean that the scan was unnecessary. Imaging remains important when there are warning signs of serious disease, progressive neurologic deficits, or persistent symptoms where the findings could alter treatment.

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

Specialists said the focus should be on appropriate clinical assessment and treatment tailored to each patient to restore movement and function while avoiding unnecessary examinations and procedures without overlooking serious underlying conditions.

Published – 24 Oct 2026 20:47 IST