How to Order X-Ray of the Back After a Fall
For a patient with back pain after a fall, start with anteroposterior (AP) and lateral plain radiographs of the thoracolumbar spine if the patient has any of the following: back pain/tenderness, abnormal neurologic signs, altered mental status (GCS <15), intoxication, or distracting injuries 1, 2.
Clinical Decision Framework
Step 1: Determine if Imaging is Needed
You need imaging if the patient has any of these criteria:
- Positive physical examination: Back or midline tenderness, pain, or visible deformity 1
- Neurologic deficit: Any abnormal findings on neurologic exam 1
- Altered consciousness: GCS <15 1
- Intoxication: Cannot perform reliable clinical exam 1
- Distracting injury: Other painful injuries that may mask spinal pain 1
- High-risk mechanism: Fall from ≥3 feet/5 stairs, motor vehicle crash, crush injury 1, 2
- Age >60-65 years: Higher fracture risk 2
- Osteoporosis or chronic steroid use: Increased compression fracture risk 3
Step 2: Choose Initial Imaging Modality
Plain radiographs (X-rays) are the appropriate first-line study 3, 1, 4:
- Order: AP and lateral views of the symptomatic region (thoracic or lumbar spine)
- Radiation exposure: Moderate (☢☢☢ = 1-10 mSv for adults) 3
- Advantages: Cost-effective, widely available, adequate for detecting most fractures and alignment issues
Step 3: Specify the X-Ray Order Correctly
Write your order as:
- "AP and lateral radiographs of the [thoracic/lumbar/thoracolumbar] spine"
- Include clinical indication: "Fall with back pain, rule out fracture"
- For lumbar spine specifically, order PA (posterior-to-anterior) rather than AP position when possible to reduce radiation dose to sensitive organs 5
When to Escalate Beyond Plain Films
Immediate CT Scanning Instead of X-Rays
Skip plain films and go directly to CT if 6, 1, 2:
- Severe trauma or polytrauma patient
- Neurologic deficit present
- Patient is obtunded/unconscious and cannot be clinically evaluated
- High clinical suspicion for unstable injury
- Known ankylosing spondylitis or spinal fusion (even minor trauma can cause unstable fractures) 7
CT provides near 100% sensitivity for bony injuries and is superior to plain films, particularly at the cervicothoracic junction 6.
Add MRI When
Order MRI without contrast if 1, 7:
- Neurologic deficit is present (to evaluate spinal cord, nerve roots, ligaments)
- Plain films or CT show fracture but neurologic exam doesn't correlate
- Suspected ligamentous injury without fracture
- Patient has known spinal ankylosis with normal CT but persistent symptoms
Common Pitfalls to Avoid
Don't skip imaging in elderly patients with "minor" falls: Patients >65 years have high rates of osteoporotic compression fractures, even from standing-height falls 3, 2
Don't rely on plain films alone in obtunded patients: If the patient cannot participate in clinical exam, CT is mandatory as plain films miss significant injuries 6
Don't forget the cervicothoracic junction: This area is poorly visualized on standard chest X-rays and requires dedicated spine imaging 6, 8
Don't delay imaging in patients with ankylosing spondylitis: These patients can have unstable three-column fractures from trivial trauma; multiplanar CT is required 7
Don't order "routine" spine films for uncomplicated acute back pain without red flags: If the patient is alert, neurologically intact, not intoxicated, has no tenderness, and sustained low-energy mechanism, imaging may not be needed initially 3, 1
The Evidence Hierarchy
The 2024 ACR Appropriateness Criteria for Thoracic Back Pain 3 and 2025 ACR Criteria for Acute Spinal Trauma 2 represent the highest quality, most recent guidelines. These establish that plain radiographs remain the mainstay for initial evaluation when imaging is indicated, with CT reserved for higher-risk scenarios or when plain films are inadequate. The 2012 intensive care review 6 reinforces that CT has essentially 100% sensitivity for bony injuries and should be used liberally in obtunded or high-risk patients, while the 2004 polytrauma guidelines 8 established the framework for three-view spine series that remains valid today.