Red flags or red herrings? Redefining the role of red flags in low back pain to reduce overimaging

Low back pain is the leading cause of years lived with disability and the second most common reason for a physician visit.1 Although its prevalence has not changed, imaging for low back pain and the cost of its management have continued to increase. For example, in a US study 9.6% of all patients with low back pain had a CT or MRI in 2006 compared with 3.2% in 2002.1 Lumbar imaging is of low yield in the general population presenting with low back pain, as the majority of cases are self-limited and benign. In a previous editorial,2 we discussed the negative effects of inappropriate imaging such as subsequent additional downstream testing, additional imaging, invasive diagnostic procedures and unwarranted patient fear and anxiety leading to poorer outcomes, with concomitant cost and radiation exposure. Lumbar imaging is indicated when serious pathology is suspected and red flags are an accepted method for identifying when such pathology …