Imaging should be considered for non-emergency cases in a person with a neurological exam showing nerve involvement and who has not responded to conservative treatment over a period of three to six weeks. LOBAK uses that algorithm and also looks for underlying systemic causes of back pain (e.g., metastatic cancer or spinal infection) and can suggest appropriate imaging to clarify the diagnosis.
Because of the false-positive and false-negative rates for HNP with imaging, caution is needed in its early use in order to avoid treatment pitfalls. As emphasized in the LOBAK app, the findings on history and physical exam are essential. Doctors and patients may be misled about the cause of a back problem by early indiscriminate imaging studies. A well respected spine specialist, Richard Deyo, M.D. has said, “the detection and treatment of small, unimportant abnormalities are creating an impression of unusually good outcomes.” ( A surgeon may not admit that his operation wasn’t really needed after finding only a bulging disc that would likely have improved without surgery.) In one study report, a large number of patients operated on and in whom no HNP was found nevertheless got good relief (See Section on Decision Analysis).
In addition to the risks of proposing unnecessary surgery after early imaging shows a disc abnormality, simply telling a patient that he or she has a herniated disk that may not be causing their pain could result in illness-related behavior and absence from work. Instead of providing reassurance, early testing may lead to further diagnostic testing and increase that person’s anxiety and requests for unneeded and sometimes risky care that can lead to a worse outcome.