For a patient with thoracic back pain and midline tenderness, should I order a computed tomography (CT) scan without contrast or an X-ray?

Imaging for Thoracic Back Pain with Midline Tenderness

For a patient with thoracic back pain and midline tenderness, thoracic spine radiography (X-ray) should be ordered as the initial imaging study rather than CT without contrast. 1

Initial Imaging Selection Algorithm

Step 1: Assess for Red Flags

• Determine if any of these red flags are present:
  • Myelopathy or radiculopathy symptoms 1
  • Suspicion of cancer, infection, or immunosuppression 1
  • History of trauma, especially with risk factors (osteoporosis, advanced age, chronic steroid use) 1
  • Bone destruction, fracture, or spinal deformity on previous imaging 1
  • History of instrumented spinal fixation 1

Step 2: Select Imaging Based on Clinical Presentation

For Patients WITHOUT Red Flags:

• Acute thoracic back pain (<4 weeks) without red flags:

  • Imaging is typically not indicated 1
  • Conservative management should be first-line treatment 1

• Subacute (4-12 weeks) or chronic (>12 weeks) thoracic back pain without red flags:

  • Imaging is typically not indicated 1
  • Conservative therapy should be first-line 1

For Patients WITH Midline Tenderness (Your Patient):

• Initial imaging recommendation: Thoracic spine radiography (X-ray) 1
  • Midline tenderness may indicate possible vertebral fracture, especially in at-risk populations 1
  • X-ray can assess for alignment issues, fractures, and bone destruction 1
  • X-ray is useful as an initial screening study, particularly in patients without neurologic deficits 1

Why X-ray Instead of CT Without Contrast

• X-ray is appropriate as the initial study because:

  • It provides adequate screening for most structural abnormalities 1
  • It involves less radiation exposure than CT 1
  • It is more cost-effective for initial evaluation 1

• CT without contrast should be reserved for:

  • Follow-up after abnormal X-ray findings 1
  • Presurgical planning when intervention is being considered 1
  • Cases where more detailed osseous evaluation is needed after initial imaging 1
  • Patients with instrumented spinal fixation history 1

Important Clinical Considerations

• Midline tenderness may indicate vertebral fracture, especially in patients with risk factors like osteoporosis, advanced age, or chronic steroid use 1

• If X-ray is negative but clinical suspicion remains high, further imaging with MRI (preferred) or CT may be warranted 1

• Be aware that thoracic disc abnormalities (herniations, bulges) are common in asymptomatic patients and may not correlate with pain 1

• If the patient has point tenderness at a specific level, this should be noted, though site of tenderness may not always correspond to the exact fracture location 2

Special Populations Requiring Different Approaches

• For patients with myelopathy or radiculopathy: MRI without contrast is the preferred initial imaging 1

• For patients with suspected cancer or infection: MRI with and without contrast is preferred 1

• For patients with diffuse idiopathic skeletal hyperostosis (DISH): Consider whole spine CT as targeted imaging may miss fractures 2

• For elderly patients or those with osteoporosis: X-ray is still appropriate initially, but have lower threshold for advanced imaging 1