What X-ray (radiograph) can be ordered for a patient experiencing severe lower back pain, radiating to the upper buttock, with pain alleviation upon ambulation (walking)?

From the Guidelines

For a patient experiencing 8/10 lower back pain radiating to the upper buttock with pain alleviation during walking, I would not recommend ordering an X-ray as the initial imaging study, as the latest evidence suggests that imaging is usually not appropriate for the initial evaluation of patients with acute or subacute low back pain without red flags or prior management 1. Instead, the patient's symptoms should be thoroughly evaluated, and a comprehensive physical examination should be performed to identify any potential red flags or underlying conditions that may require immediate attention. The symptoms suggest possible sciatica or radiculopathy, which may be caused by disc herniation, spinal stenosis, or facet joint arthropathy. The pain relief with walking is characteristic of neurogenic claudication, often seen in spinal stenosis. However, according to the ACR Appropriateness Criteria, imaging is usually not appropriate for the initial imaging of patients with acute LBP with or without radiculopathy, no red flags, and no prior management 1. If the patient's symptoms persist or worsen, or if neurological deficits develop, advanced imaging such as MRI may be more appropriate to evaluate disc pathology and nerve compression, as recommended by the American College of Physicians and the American Pain Society 1. Key points to consider in the evaluation and management of this patient include:

• Thorough evaluation of symptoms and physical examination to identify potential red flags or underlying conditions
• Consideration of non-imaging approaches for initial evaluation and management, such as physical therapy or pain management
• Reservation of advanced imaging, such as MRI, for patients with persistent or worsening symptoms, or those with suspected underlying conditions that require further evaluation.

From the Research

Imaging Options for Lower Back Pain

The patient's symptoms of 8/10 lower back pain radiating to the upper buttock, with pain alleviated by walking, suggest a possible degenerative lumbar spine condition 2.

• The clinical presentation indicates a need for imaging to determine the most likely anatomical nociceptive source, thereby enhancing the therapeutic approach by targeting a specific lesion.
• A study comparing the prevalence of MR imaging features of lumbar spine degeneration in adults with and without low back pain found that symptomatic individuals had a higher prevalence of disc bulge, disc degeneration, disc extrusion, disc protrusion, Modic 1 changes, and spondylolysis 3.

Recommended Imaging Tests

Based on the patient's symptoms and the studies, the following imaging tests can be considered:

• MRI of the lumbar spine to evaluate for disc degeneration, disc bulge, disc extrusion, disc protrusion, Modic 1 changes, and spondylolysis 3.
• X-ray of the lumbar spine to evaluate for spondylolisthesis, spondylolysis, and other bony abnormalities, although the study found that these findings were not significantly associated with low back pain 3.

Considerations

• The patient's pain alleviation with walking suggests a possible mechanical component to their pain, which may be related to degenerative changes in the lumbar spine 2.
• The choice of imaging test should be based on the patient's specific symptoms and clinical presentation, as well as the potential risks and benefits of each test 2, 3.