X-ray for Lower Back Pain
X-rays should NOT be routinely obtained for patients with nonspecific lower back pain without red flags, as they expose patients to unnecessary radiation without improving clinical outcomes. 1
When to Consider Imaging for Lower Back Pain
Imaging should be reserved for specific clinical scenarios:
Red Flags Requiring Immediate Imaging
- Severe or progressive neurologic deficits
- Suspected serious underlying conditions based on history and physical exam 1
- Suspected cancer, infection, or cauda equina syndrome 1
- History of significant trauma 2
Other Situations Where Imaging May Be Appropriate
- Persistent pain (>4-6 weeks) despite conservative therapy 2
- History of osteoporosis or steroid use (plain radiography recommended) 1
- Older patients with severe pain when standing (to evaluate for vertebral compression fracture) 2
- Persistent radiculopathy in patients who are potential candidates for surgery or epidural steroid injection 1
Imaging Modality Selection
When imaging is indicated, the appropriate modality should be selected:
Plain Radiography (X-ray):
MRI (preferred over CT when available):
- For patients with severe/progressive neurologic deficits 1
- When serious underlying conditions are suspected 1
- Provides better visualization of soft tissue, vertebral marrow, and spinal canal 1
- Without contrast for persistent neurological symptoms 2
- With and without contrast when infection or malignancy is suspected 2
Risks of Unnecessary Imaging
- Exposure to ionizing radiation (particularly concerning in young women) 1
- A single lumbar spine X-ray (2 views) equals radiation exposure of daily chest X-rays for >1 year 1
- Identification of incidental findings poorly correlated with symptoms 1
- Potential for unnecessary additional interventions 1
- Increased healthcare costs without clinical benefit 3
- Increased likelihood of patient returning for additional GP consultations 4
Evidence Against Routine Imaging
Multiple studies demonstrate that routine imaging for nonspecific low back pain:
- Does not improve patient outcomes including pain and function 5
- Does not reduce patient worry about serious disease 4
- May actually lead to worse outcomes at 3 months 4
- Is not cost-effective 4
Common Pitfalls to Avoid
- Ordering imaging to reassure patients (evidence shows this doesn't reduce worry) 4
- Yielding to patient pressure for imaging (approximately 80% of patients would choose X-ray if given the option) 4
- Failing to explain why imaging is not indicated (patient education is crucial)
- Ordering imaging for acute low back pain without red flags (occurs in approximately one-third of emergency visits) 6
Instead of unnecessary imaging, focus on conservative management, patient education, and reassurance that most low back pain improves with time and appropriate non-imaging interventions 7.