How to order a full back X-ray

How to Order a Full Back X-ray

To order a full back X-ray, request anteroposterior (AP) and lateral radiographs of the complete spine, as these views remain the standard of care for initial imaging evaluation of back pain. 1

Appropriate Ordering Process

Standard Views to Request

• Anteroposterior (AP) view of the complete spine
• Lateral view of the complete spine
• Note: Oblique radiographs are generally not recommended as they contribute little additional diagnostic information 1

Clinical Documentation Requirements

When ordering a full back X-ray, include:

1. Specific clinical indication - Document the reason for imaging (pain location, duration, severity)

2. Red flag symptoms if present:

   • Morning stiffness
   • Gait abnormalities
   • Night pain
   • Neurologic deficit
   • Radiating pain
   • Fever
   • Unintentional weight loss
   • Pain lasting >4 weeks
   • Tachycardia
   • Lymphadenopathy
   • Abnormal spinal curvature 1

3. Relevant medical history - Include risk factors such as:

   • Diabetes mellitus
   • IV drug use
   • Cancer
   • HIV
   • Dialysis 1

Clinical Utility and Limitations

When Full Spine X-rays Are Appropriate

• Initial evaluation of back pain, especially with red flags
• Suspected spinal deformity
• Trauma assessment
• Follow-up of known spinal conditions

Diagnostic Yield

• Prospective studies show a 9% to 22% yield in accurate diagnosis when radiography is performed along with detailed history and physical examination 1
• In most instances, if initial radiographs identify a cause for back pain, specific treatment can be initiated without additional imaging 1

Important Limitations

• Radiographs alone may be inadequate for diagnosing severe pathologies
• Negative radiographs do not exclude pathology but can guide further investigation 1
• X-ray delivers a radiation dose equivalent to 65 times a chest X-ray and sends high doses to reproductive organs 2

When to Consider Alternative or Additional Imaging

If radiographs are negative or inconclusive but clinical suspicion remains high:

• MRI is the next appropriate step for:

  • Persistent symptoms after 6 weeks of optimal medical management
  • Suspected neural compression
  • Soft tissue pathology evaluation 1, 3

• CT scan may be appropriate for:

  • Better visualization of osseous details
  • Evaluation when MRI is contraindicated or equivocal 1

• Bone scan with SPECT or SPECT/CT may be suitable when:

  • Clinical suspicion suggests bony pathology such as spondylolysis or osseous neoplasms 1

Practical Ordering Tips

1. Specify "complete spine" rather than individual segments to ensure comprehensive evaluation
2. Position patient with arms bent touching clavicles or arms down with palms forward for optimal imaging 4
3. Ensure proper communication with radiology by providing detailed clinical information, as this has been shown to improve interpretation accuracy in 53% of cases 5
4. Consider the necessity of the study, as evidence suggests X-ray examinations have minimal diagnostic value for patients under 50 years without red flags 6

Remember that the decision to perform a targeted versus complete spine radiograph depends on the clinical question and will vary for each case 1.