What are the next steps for a patient with chronic lumbar back pain and a normal lumbar x-ray (radiograph)?

Management of Chronic Lumbar Back Pain with Normal X-ray

For a patient with chronic lumbar back pain and a normal lumbar x-ray, the next steps should focus on conservative management for at least 6 weeks before considering advanced imaging, unless red flags are present. 1, 2

Initial Assessment After Normal X-ray

• Evaluate for red flags that warrant immediate advanced imaging 1:

  • Severe or progressive neurologic deficits
  • Suspected serious underlying conditions (cancer, infection, cauda equina syndrome)
  • History of cancer
  • Unexplained weight loss
  • Fever or immunosuppression
  • Recent trauma relative to age
  • New urinary retention or overflow incontinence

• Assess for yellow flags (psychosocial factors) that may predict poorer outcomes 1:

  • Depression
  • Passive coping strategies
  • Job dissatisfaction
  • Higher disability levels
  • Disputed compensation claims
  • Somatization

Conservative Management (First-line Approach)

• Provide patient education about the generally favorable prognosis and self-management strategies 1

• Advise patients to remain active rather than rest in bed 1, 2

• Recommend evidence-based self-care education materials 1

• Consider pharmacologic therapy 3, 4:

  • NSAIDs as first-line medication
  • Acetaminophen as an alternative
  • Consider muscle relaxants for associated muscle spasms
  • Tramadol or short-term opioids may be considered for severe pain not responding to other measures

• Recommend non-pharmacologic therapies with evidence of effectiveness 4, 5:

  • Exercise therapy
  • Physical therapy
  • Spinal manipulation
  • Massage
  • Acupuncture
  • Heat/cold therapy
  • Yoga (strong evidence for effectiveness in chronic low back pain)

When to Consider Advanced Imaging

• MRI (preferred) or CT should be considered after 6 weeks of failed conservative therapy in patients who 1, 2:

  • Have persistent symptoms despite conservative management
  • Show signs or symptoms of radiculopathy or spinal stenosis
  • Are potential candidates for surgery or epidural steroid injection

• MRI is generally preferred over CT because it 1:

  • Does not use ionizing radiation
  • Provides better visualization of soft tissue, vertebral marrow, and the spinal canal
  • Is more sensitive for detecting disc pathology and nerve root compression

• CT may be appropriate when 6:

  • MRI is contraindicated or unavailable
  • Bony abnormalities are the primary concern
  • Evaluating for subtle erosions

Important Considerations and Pitfalls

• Routine advanced imaging in the absence of red flags or persistent symptoms does not improve outcomes and may lead to unnecessary interventions 1, 2
• Many imaging abnormalities (such as disc bulges) are common in asymptomatic individuals and may not correlate with symptoms 1, 2
• Referred pain from the hip or lumbar spine should be considered if knee radiographs are unremarkable 1
• For patients with suspected inflammatory back pain (sacroiliitis/spondyloarthropathy) with negative radiographs, MRI of the sacroiliac joints without contrast is appropriate 1
• Most patients with chronic low back pain will not benefit from surgery 3, 4

Re-evaluation

• Patients with persistent symptoms should be reevaluated after approximately 1 month of conservative therapy 1
• Earlier or more frequent reevaluation may be appropriate for patients with severe pain, functional deficits, or older age 1