You hurt your back deadlifting… Do you need an x-ray or MRI?

A picture is worth a thousand words, unless it is an x-ray or MRI in an episode of acute Low back pain (LBP), but this picture...

This one is worth a thousand words.

In 2005 total healthcare cost in the US for low back pain was estimated at $85.9 billion. MRI and CT scan, is being used more in evaluation for patients with LBP and the findings often trigger both medical and surgical intervention.

However, recent research suggest findings on imaging may not be the source of your pain and a still picture of the spine does not identify how your movement system behaves. A review done by Brinjikji et al. in 2015 included 33 studies with 3110 individuals and showed that imaging findings of degenerative spine disease have high rates among people who have no pain.

The authors of the study concluded that imaging findings of a “diseased” spine is generally part of the normal aging process rather than a condition requiring intervention.
In 2007, the American College of Physicians and the American Pain Society published a joint clinical practice guideline for the management of low back pain stating: "Imaging should not be routinely performed for nonspecific low back pain, Imaging should be done if the history and physical exam reveal serious underlying conditions such as bowel/bladder and reflex changes, and Imaging should be done for patients who may need surgery or epidural steroid injection."

What it boils down to is that if you have a sports or performance related injury conservative management (physical therapy, chiropractors, etc) should be the first line of treatment.
Newer research is showing better outcomes and decreased out of pocket costs for patients when seeing PT first when experiencing low back pain. A study by Frogner et al 2018 reported individuals who saw a PT first had lower probability of being prescribed opioids (89.4%) and any imaging (27.9%). Another source reports patients saw significantly lower out of pocket costs (on average $500) when seeking PT treatment first.

References:

1.         Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012;379(9814):482-91.
2.         Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41(11):838-46.
3.         Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6.
4. Frogner BK, Harwood K, Andrilla CHA, Schwartz M, Pines JM. Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Health Serv Res. 2018.
5. From: https://www.mprnews.org/story/2018/05/23/npr-physical-therapy-curbs-use-of-opioids-for-lower-back-pain