From the Guidelines
Imaging for back pain should generally be ordered only when specific red flags are present, as most acute low back pain resolves within 4-6 weeks without intervention. The American College of Radiology recommends that imaging is usually not appropriate for the initial imaging of patients with acute low back pain with or without radiculopathy, no red flags, and no prior management 1. This approach is supported by the fact that numerous studies have shown that routine imaging provides no clinical benefit in patients with acute uncomplicated low back pain 1.
Key Considerations for Imaging
- Immediate imaging is warranted for patients with signs of cauda equina syndrome, suspected spinal infection, or trauma with neurological deficits.
- Imaging should also be considered for patients with risk factors for malignancy, age over 50 with new-onset pain, progressive neurological deficits, or when symptoms fail to improve after 4-6 weeks of conservative treatment.
- For most patients without these red flags, initial management should focus on conservative measures like activity modification, physical therapy, and appropriate analgesics.
Recommendations for Imaging Modalities
- When imaging is needed, MRI is typically preferred as it provides better visualization of soft tissues, neural structures, and potential pathology 1.
- Plain radiographs may be appropriate as an initial step in certain cases, such as patients with low-velocity trauma, osteoporosis, elderly individuals, or chronic steroid use 1.
Benefits of a Selective Approach to Imaging
- Avoids unnecessary tests and reduces healthcare costs.
- Prevents incidental findings that may lead to unnecessary interventions.
- Supports the American College of Radiology's recommendations for appropriate imaging in patients with low back pain 1.
From the Research
Imaging for Back Pain
When to order imaging for a patient presenting with back pain is a crucial decision in clinical practice. The following points highlight the key considerations:
- Imaging is not always necessary for patients with back pain, and its use should be guided by the presence of "red flags" that indicate a higher likelihood of serious underlying pathology 2, 3, 4.
- Red flags for back pain include a history of trauma, fever, incontinence, unexplained weight loss, a cancer history, long-term steroid use, parenteral drug abuse, and intense localized pain and an inability to get into a comfortable position 2, 4.
- The presence of red flags does not always mean that imaging will be positive for serious pathology, and the absence of red flags does not rule out the possibility of serious pathology 3.
- Guidelines for the management of low back pain recommend imaging only when there are red flags or when conservative treatment has failed 5, 4.
- A systematic review and meta-analysis found that inappropriate imaging is common in the management of low back pain, including both overuse in those where imaging is not indicated and underuse of imaging when it is indicated 5.
Red Flags for Back Pain
The following red flags are commonly associated with serious pathology in patients with back pain:
- Recent trauma 3, 4
- Fever, chills, or sweating 3, 4
- Unexplained weight loss 2, 4
- History of cancer 2, 4
- Long-term steroid use 2, 4
- Parenteral drug abuse 2
- Intense localized pain and an inability to get into a comfortable position 2
- Night pain 3, 4
Clinical Use of Imaging
The clinical use of imaging for back pain is not always consistent with guidelines, and both overuse and underuse of imaging are common 5. Clinicians should use caution when utilizing red flag questions as screening tools and consider the individual patient's presentation and medical history when deciding whether to order imaging 3.