What are the recommended orders for an X-ray of the cervical and lumbosacral spine three weeks post-fall?

X-ray Orders for Cervical and Lumbosacral Spine Three Weeks Post-Fall

Order plain radiographs (X-rays) of both the cervical spine (minimum 2 views: AP and lateral) and lumbosacral spine (AP and lateral views) as the initial imaging modality for suspected fracture evaluation at three weeks post-fall. 1

Rationale for Plain Radiography at This Time Point

At three weeks post-injury, you are evaluating for subacute fractures in a patient with suspected osteoporosis or persistent symptoms. The ACR Appropriateness Criteria explicitly rates X-ray of the spine area of interest as "usually appropriate" (rating 9/9) for suspected vertebral body fracture based on acute or subacute symptomatology. 1

• Plain radiographs should include at minimum 2 views of each region of interest (anteroposterior and lateral projections). 1
• This is the first-line examination because radiographs effectively demonstrate vertebral body fractures, compression deformities, and alignment abnormalities at this subacute time point. 1

Specific Order Format

For Cervical Spine:

• X-ray cervical spine, 2 views minimum (AP and lateral)
• Clinical indication: "Neck pain 3 weeks post-fall, evaluate for fracture"
• If the cervicothoracic junction is not adequately visualized on the lateral view, a swimmer's view may be added. 1

For Lumbosacral Spine:

• X-ray lumbosacral spine, 2 views (AP and lateral)
• Clinical indication: "Low back pain 3 weeks post-fall, evaluate for fracture"

When to Escalate Beyond Plain Films

If initial radiographs are negative but clinical suspicion remains high (persistent pain, neurological symptoms, or high-risk features like chronic steroid use or known osteoporosis):

• MRI without contrast is the next appropriate study (rated 9/9 for suspected fracture with negative initial radiographs). 1
• MRI is superior for detecting occult fractures, bone marrow edema, and soft tissue injuries not visible on plain films. 1

CT without contrast is an alternative if MRI is contraindicated or unavailable (rated 7/9), though it involves higher radiation exposure. 1

What NOT to Order

• Flexion-extension views are not indicated at this stage—they have poor sensitivity for detecting instability in the subacute setting and are often inadequate due to patient guarding. 1, 2
• CT as first-line imaging is not appropriate for subacute fracture evaluation in non-trauma settings; reserve CT for acute trauma or when plain films are inadequate. 1
• MRI with contrast adds no value for fracture detection compared to non-contrast MRI. 1

Critical Clinical Context Required

Document in your order the following clinical details to justify imaging:

• Mechanism of injury (fall from what height/circumstances)
• Duration and character of pain (persistent vs. improving)
• Presence of neurological symptoms (weakness, numbness, radiculopathy)
• Risk factors for fracture (age >50, osteoporosis, chronic steroid use >3 months, prior fragility fractures) 1

Common Pitfalls to Avoid

• Do not skip imaging in patients with persistent symptoms at 3 weeks, even if they initially declined imaging—subacute fractures can become symptomatic as the injury evolves. 1
• Do not order "complete spine series" without clinical justification—image only the symptomatic regions to minimize radiation exposure. 1
• Do not assume normal radiographs exclude fracture in high-risk patients (elderly, osteoporotic, on steroids)—30-40% bone destruction is needed before fractures become visible on X-ray, so proceed to MRI if suspicion persists. 1