Are there indications for imaging in a patient with acute on chronic low back pain and new onset dizziness?

Indications for Imaging in Acute on Chronic Low Back Pain with New Onset Dizziness

Imaging is not indicated for uncomplicated acute on chronic low back pain, but the new onset dizziness may warrant brain imaging if it suggests a serious neurological condition or vertebrobasilar insufficiency. 1

Assessment of Red Flags

Imaging is only warranted when specific "red flags" are present:

Back Pain Red Flags Requiring Imaging:

• Progressive neurologic deficits (major weakness, numbness)
• Cauda equina syndrome (urinary retention, saddle anesthesia)
• History of cancer or suspected malignancy
• Suspected infection (fever, IV drug use, immunosuppression)
• Significant trauma relative to age
• Osteoporosis or chronic steroid use
• Age >50 with unexplained weight loss or fever
• Persistent symptoms despite 6 weeks of conservative management 1, 2, 3

Dizziness Assessment:

The new onset dizziness requires careful evaluation as it may represent:

• Vertebrobasilar insufficiency
• Central nervous system pathology
• Vestibular disorders
• Medication side effects

Imaging Algorithm

1. For isolated low back pain without red flags:

   • No imaging indicated initially
   • Conservative management for 4-6 weeks 1, 2

2. For low back pain with neurological deficits:

   • MRI lumbar spine without IV contrast is the preferred initial study 1

3. For dizziness with concerning features:

   • Brain MRI (with or without contrast depending on suspected pathology)
   • Consider MRI or CT angiography if vertebrobasilar insufficiency is suspected

4. For suspected connection between back pain and dizziness:

   • MRI of cervical and upper thoracic spine may be warranted to evaluate for pathology affecting vertebral arteries

Important Clinical Considerations

• Routine imaging for uncomplicated low back pain provides no clinical benefit and can lead to unnecessary procedures, radiation exposure, and increased healthcare costs 1, 2
• Most disc herniations show regression after 8 weeks of symptom onset 1, 2
• Incidental findings on imaging are common in asymptomatic individuals and may lead to unnecessary interventions 1
• A systematic review found increasing prevalence of degenerative spine findings in asymptomatic patients with increasing age 1

Common Pitfalls to Avoid

1. Premature imaging: Ordering imaging before completing conservative management for uncomplicated back pain
2. Overlooking serious causes of dizziness: Failing to consider central causes of dizziness that may require brain imaging
3. Attributing dizziness to back pain: Without proper evaluation of both symptoms independently
4. Ignoring progression: Failing to reassess and image if symptoms worsen or new neurological deficits develop

When both back pain and dizziness are present, each symptom should be evaluated based on its own characteristics and red flags, with imaging decisions made accordingly.