What type of X-ray can be ordered for a patient with severe right lower back pain radiating from the renal area to the gluteal region, alleviated by ambulation?

From the Guidelines

For a patient experiencing 8/10 pain in the right lower back radiating from the kidney area to above the right buttock, with pain alleviation during walking, I would recommend against ordering an X-ray as the initial imaging study, as imaging is usually not appropriate for the initial imaging of patients with acute low back pain with or without radiculopathy, no red flags, and no prior management, according to the American College of Radiology Appropriateness Criteria 1.

Given the patient's symptoms, it's essential to consider the potential causes of the pain, including musculoskeletal issues, kidney stones, or other abdominal pathologies. However, the fact that walking helps alleviate the pain suggests that the condition may not be related to a severe or life-threatening cause.

• The patient's pain pattern, which radiates from the kidney area to above the right buttock, could be indicative of renal colic or musculoskeletal issues.
• The alleviation of pain during walking could suggest a positional component relevant to the diagnosis.
• According to the American College of Radiology Appropriateness Criteria, imaging is usually not appropriate for the initial imaging of patients with acute low back pain with or without radiculopathy, no red flags, and no prior management 1.
• If the patient's symptoms persist or worsen, or if red flags are identified, further imaging such as an MRI or CT scan may be necessary to evaluate the patient's condition fully.

In this scenario, a more appropriate initial approach might involve a thorough clinical evaluation, including a physical examination and medical history, to identify potential causes of the pain and to determine the need for further imaging or other diagnostic tests, as recommended by the American College of Radiology Appropriateness Criteria 1.

From the Research

Imaging Options for Lower Back Pain

The patient is experiencing 8/10 pain on their right lower back, which may be related to various causes such as degenerative changes, infection, or insufficiency and pathologic fractures 2. Given the patient's symptoms, imaging tests can help determine the cause of the pain.

Magnetic Resonance Imaging (MRI)

MRI is the imaging modality of choice to assess the cause and complicating features of spine pain, especially when conservative treatment fails or worrisome clinical findings are present 2. It allows for the differentiation of various sources of spine pain and potential complicating features, permitting the appropriate direction of therapy.

Computed Tomography (CT)

CT scans can also be used to evaluate chronic low back pain, and studies have shown that CT is as sensitive as lumbar MRI in the evaluation of most items analyzed, excluding Modic changes, degenerative changes, signal of the disc, and disc herniation 3. However, the use of CT scans should be considered carefully, as repeat CT scans may not provide added diagnostic value in patients with chronic or recurrent low back pain or radiculopathy 4.

Low-Dose CT

Low-dose CT of the lumbar spine has been compared with radiography, and studies have shown that low-dose CT has superior image quality and provides more anatomical and diagnostic information 5. The effective dose for low-dose CT is approximately 1 mSv, which is slightly higher than the effective dose for radiography.

Considerations for Imaging Tests

When ordering an imaging test for the patient, it is essential to consider the clinical presentation and the potential causes of the pain. A combined lumbar spine MRI and CT appropriateness checklist can help facilitate appropriate imaging and reduce the number of inappropriate imaging requests 6. The patient's symptoms, such as pain alleviation with walking, should also be taken into account when selecting the most suitable imaging test.

• Key points to consider:
  • MRI is the imaging modality of choice for assessing spine pain
  • CT scans can be used to evaluate chronic low back pain, but should be considered carefully
  • Low-dose CT has superior image quality compared to radiography
  • A combined lumbar spine MRI and CT appropriateness checklist can help facilitate appropriate imaging
  • The patient's clinical presentation and symptoms should guide the selection of the most suitable imaging test 2, 3, 4, 6, 5