No, an X-ray is NOT appropriate for this patient—proceed directly to MRI
Given the presence of weakness and paresthesia in the lower limbs, this patient has neurological deficits that mandate advanced imaging with MRI, not plain radiography. 1
Why X-ray is Inadequate
Plain radiography cannot visualize nerve root compression, disc herniation, or spinal canal compromise—the likely causes of this patient's radicular symptoms. 1
X-rays are specifically not recommended for patients with signs or symptoms of radiculopathy or spinal stenosis, as they provide no useful diagnostic information for these conditions. 1
The American College of Physicians and American Pain Society explicitly state that MRI (preferred) or CT should be used to evaluate patients with persistent low back pain and signs or symptoms of radiculopathy. 1
The Correct Imaging Approach
MRI lumbar spine without IV contrast is the appropriate initial imaging study for this patient. 1
MRI provides superior visualization of soft tissue pathology, nerve root compression, vertebral marrow, and spinal canal patency compared to all other modalities. 1
The presence of weakness (a motor deficit) and paresthesia (sensory changes) constitutes a "red flag" that overrides the standard recommendation to wait 6 weeks of conservative therapy before imaging. 1
Delayed diagnosis and treatment of progressive neurologic deficits are associated with poorer outcomes, making prompt imaging essential. 1
Critical Red Flags Present in This Case
This patient demonstrates multiple concerning features requiring immediate advanced imaging:
Lower limb weakness—indicates potential motor nerve root compromise 1
Paresthesia in lower limbs—suggests sensory nerve involvement 1
History of chronic heavy lifting—increases risk for significant disc herniation or spinal stenosis 1
When X-rays Have Limited Utility
Plain radiography is only recommended in specific scenarios that do NOT apply to this patient:
Suspected vertebral compression fracture in high-risk patients (history of osteoporosis or steroid use) 1
Evaluation of segmental motion in known spondylolisthesis 2
Assessment of axial loading and functional alignment for preoperative planning 2
Common Pitfall to Avoid
Do not order an X-ray first "just to see" before getting an MRI—this delays definitive diagnosis, exposes the patient to unnecessary radiation, and provides no clinically useful information for radiculopathy evaluation. 1 The presence of neurological deficits mandates proceeding directly to MRI. 1