From the Guidelines
Imaging is not immediately warranted in this case, and a 6-week trial of conservative management with physical therapy is recommended before considering imaging to rule out compression fracture or disc herniation. According to the American College of Radiology Appropriateness Criteria, imaging is typically not necessary for acute low back pain with or without radiculopathy, without red flags, and no prior management 1. The majority of patients with acute low back pain will experience improvement within the first 4 weeks with noninvasive management 1.
If the patient presents with acute back pain and has risk factors for compression fracture (such as older age, osteoporosis, steroid use, or trauma) or shows red flag symptoms (including severe pain, neurological deficits, bowel/bladder dysfunction, or fever), imaging becomes necessary 1. In such cases, plain radiographs (X-rays) of the spine are recommended as the initial imaging study, as they can identify vertebral fractures, alignment issues, and degenerative changes, while being readily available and cost-effective.
If X-rays are inconclusive or if neurological symptoms suggest nerve compression, an MRI would be the appropriate next step, as it provides superior visualization of soft tissues, including intervertebral discs, nerve roots, and the spinal cord 1. CT scans may be considered if MRI is contraindicated or unavailable. The imaging results will guide treatment decisions, which may include conservative management with pain control and physical therapy or, in severe cases, surgical intervention.
It is essential to note that routine advanced imaging, such as MRI or CT, is not associated with improved patient outcomes and may lead to additional, possibly unnecessary interventions 1. Therefore, imaging should be reserved for patients who are potential candidates for surgery or epidural steroid injection, or those with persistent symptoms despite conservative management 1.
In summary, a 6-week trial of conservative management is recommended before considering imaging, and imaging should be reserved for patients with red flags, risk factors for compression fracture, or those who have not responded to conservative management.
From the Research
Initial Assessment
To determine if imaging is warranted in this case, it's essential to consider the patient's symptoms and medical history. According to 2, a thorough history and clinical assessment can help screen for serious pathology, such as vertebral fracture, as a cause of low back pain.
Red Flags for Vertebral Fracture
Certain red flags can indicate a higher likelihood of vertebral fracture, including:
- Trauma
- Older age
- Corticosteroid use
- Presence of contusion/abrasion
These red flags can guide clinical decisions to further investigate suspected vertebral fractures 2.
Imaging for Vertebral Fracture
If a vertebral fracture is suspected, plain radiographs can be used to confirm the diagnosis, while computed tomography (CT) and magnetic resonance imaging (MRI) may be required to evaluate for a malignant cause or neurological deficits 3.
Imaging for Disc Herniation
For suspected disc herniation, advanced imaging such as MRI can be used to confirm the diagnosis and guide treatment plans 4, 5.
Initial Management
For patients with low back pain, initial management is often nonoperative, with pain management and bracing. A focused history and exam can identify patients likely to benefit from further intervention 6.
Treatment Approach
Most patients with lumbar disc herniation can experience relief with nonsurgical measures, such as physical therapy and medication 4, 5. However, if symptoms persist or worsen, surgery may be appropriate.
Waiting Period
According to 6, two-thirds of patients with vertebral compression fractures will have spontaneous resolution of pain in 4 to 6 weeks. Therefore, a waiting period of 6 weeks with initial management and therapy may be considered before proceeding with further imaging or intervention.