MRI is the Most Appropriate Initial Imaging for Older Adults with Back Pain
For older adults presenting with back pain, MRI without IV contrast is the most appropriate initial imaging study when imaging is indicated, as it provides superior soft tissue resolution to identify compression fractures, marrow edema, cord compression, and malignancy—all critical concerns in this age group. 1
Clinical Context: When to Image Older Adults
Older adults (>65 years) represent a distinct population where early imaging is more justified than in younger patients due to:
- High risk for osteoporotic compression fractures even with minimal or no trauma 1
- Increased prevalence of malignancy requiring earlier detection 1, 2
- Greater likelihood of spinal stenosis and cord compromise 1
The American College of Radiology specifically identifies advanced age as a red flag warranting consideration of early imaging, unlike younger adults where conservative management without imaging is standard 1
Why MRI Over CT
MRI Advantages:
- Identifies compression fractures even when radiographs are negative, which is critical since thoracic vertebral fractures are difficult to date on plain films 1
- Detects marrow edema to determine fracture acuity and guide intervention planning 1
- Superior for soft tissue evaluation including cord signal abnormality, canal compromise, and nerve root compression 1
- No radiation exposure, an important consideration for older patients who may require serial imaging 1
CT Role:
- CT without IV contrast is complementary, not primary, as it better depicts osseous detail but misses marrow pathology and soft tissue abnormalities 1
- CT is appropriate when MRI is contraindicated (pacemakers, severe claustrophobia) or for presurgical planning to assess bony anatomy 1
Specific Imaging Protocol by Clinical Scenario
Standard Older Adult with Back Pain (No Red Flags Beyond Age):
- MRI thoracic/lumbar spine without IV contrast is usually appropriate 1
- Plain radiographs may be appropriate as initial screening if no neurologic deficits, though they have low sensitivity for early fractures 1
Red Flags Present (Cancer, Infection, Immunosuppression):
- MRI without AND with IV contrast is the initial modality of choice 1
- Contrast enhances sensitivity for infection, small marrow-replacing lesions, and intradural disease 1
Myelopathy or Radiculopathy:
- MRI without IV contrast is usually appropriate to evaluate compressive etiologies 1
- Urgent imaging is required if progressive neurologic deficits develop 2
Post-Radiograph Showing Fracture/Deformity:
- Both MRI (without ± with contrast) AND CT without contrast are usually appropriate as complementary studies 1
- MRI assesses soft tissue/neural structures; CT provides osseous detail 1
Critical Pitfalls to Avoid
Do not delay imaging if myelopathy signs emerge (spasticity, hyperreflexia, gait disturbance, bladder dysfunction)—this requires immediate MRI 2
Do not order CT with IV contrast alone—there is no literature supporting this for initial assessment of back pain 1
Do not assume radiographs rule out fracture—MRI or bone scan may be needed to age fracture acuity even with negative plain films 1
Recognize that early imaging in older adults does not necessarily improve outcomes at 12 months compared to delayed imaging, but this research included patients without red flags 3. The decision to image should be based on clinical red flags, not routine practice.
Evidence Quality Note
The 2024 ACR Appropriateness Criteria 1 represent the highest quality guideline evidence and specifically address thoracic back pain with age-stratified recommendations. These guidelines explicitly state that elderly individuals are at risk for compression fractures and warrant different imaging considerations than younger adults. The research evidence 3 showing no outcome benefit from early imaging studied patients without red flags, which does not apply when age-related risk factors are present.