Protocol for Ordering X-ray for Lower Back Pain
For patients with lower back pain, upright anteroposterior (AP) and lateral views are the minimum standard requirement for lumbar spine radiographs, as they provide crucial functional information about axial loading of the spine. 1
When to Order X-rays for Lower Back Pain
- X-rays are generally not recommended for nonspecific low back pain within the first 6 weeks unless red flags are present, as routine imaging does not improve patient outcomes 2
- X-rays should be ordered when the following red flags are present:
- Suspected vertebral compression fracture (history of osteoporosis or steroid use) 2
- Severe or progressive neurologic deficits 2, 3
- Suspected serious underlying conditions (vertebral infection, cauda equina syndrome, cancer) 2
- Post-surgical evaluation to assess hardware integrity and alignment 4
- Persistent symptoms after 6 weeks of conservative management 3
Standard Views to Order
- Upright anteroposterior (AP) and lateral views are the minimum standard requirement 1
- The lateral view should visualize the entire lumbar spine, including the lumbosacral junction 1
- For suspected segmental instability, spondylolisthesis, or post-surgical evaluation, include flexion and extension views 1, 4
Proper Technique for Ordering
- Specify "upright" or "weight-bearing" positioning on the order to ensure functional information about axial loading is captured 1, 4
- For post-surgical patients, specify the need for flexion and extension views to identify segmental motion and potential instability 4
- If the patient has specific symptoms with certain positions (e.g., pain worsens with standing/walking), note this on the order 3
When to Consider Advanced Imaging Instead
- For persistent low back pain with radiculopathy after 6 weeks of conservative management, MRI without contrast is preferred over X-ray 3
- For suspected disc herniation, spinal stenosis, or nerve root compression, MRI is more appropriate as it provides superior soft tissue visualization 2, 3
- For patients who are potential candidates for surgery or epidural steroid injection, MRI is recommended 2
Common Pitfalls to Avoid
- Ordering X-rays too early (before 6 weeks) for nonspecific low back pain without red flags exposes patients to unnecessary radiation 2, 5
- Failing to order flexion/extension views when evaluating for instability can miss important dynamic changes 1, 4
- Ordering only AP view is insufficient, as the lateral view detects significantly more abnormal findings 6
- Relying solely on old imaging studies may miss new pathology, especially in post-surgical patients 4
Special Considerations
- In young women, be particularly cautious about unnecessary X-rays as the gonadal radiation from a single lumbar spine X-ray (2 views) is equivalent to daily chest X-rays for more than a year 2
- For patients with suspected lumbar instability, consider ordering seated lateral X-rays as they may show greater changes in lumbar kyphosis compared to standing flexion views 7