What is the initial X-ray (X-radiation imaging) to order for a patient presenting with back pain?

Initial X-ray for Back Pain

For adults with nonspecific low back pain, do not order routine lumbar spine radiography unless red flags are present or symptoms persist beyond 4-6 weeks of conservative management. 1, 2

When X-rays Are NOT Indicated

Routine imaging provides no clinical benefit in uncomplicated acute low back pain and does not improve patient outcomes compared to selective imaging. 1, 2

• Avoid lumbar spine radiography in the first 4-6 weeks for patients without red flags, even when radiculopathy is present 2
• Most acute low back pain is self-limiting, with substantial improvement occurring within the first month 1
• Early imaging increases unnecessary healthcare utilization, including injections, surgeries, and disability compensation 2
• A single 2-view lumbar spine radiograph delivers gonadal radiation equivalent to daily chest x-rays for over one year, particularly concerning in young women 1, 2

When X-rays ARE Indicated: Red Flags

Obtain imaging promptly when red flags suggest serious underlying pathology. 1, 2

Immediate imaging required for:

• Severe or progressive neurologic deficits (motor weakness, sensory loss, reflex changes) 1, 3
• Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction, bilateral leg weakness) 1, 3
• Suspected spinal infection or osteomyelitis 1, 3
• Cancer history with suspected spinal cord compression 1, 3
• History of significant trauma, especially with osteoporosis risk factors 3, 2

However, MRI is strongly preferred over plain radiography for all red flag scenarios above, as it provides superior soft tissue visualization without ionizing radiation. 1, 3, 2

Persistent Symptoms Without Red Flags

For patients with persistent low back pain after 4-6 weeks of conservative management without red flags, plain radiography (anteroposterior and lateral views) may be a reasonable initial option. 1, 2

• Reevaluate patients with unimproved symptoms after 1 month of conservative treatment 1
• Consider earlier reevaluation in patients with severe pain, functional deficits, older age, or signs of radiculopathy/spinal stenosis 1

Specific X-ray Views to Order

When radiography is indicated, order anteroposterior (AP) and lateral views of the lumbar spine. 1

• Oblique views contribute little diagnostic information and are not useful 1
• Target the specific spinal region (cervical, thoracic, or lumbar) based on physical examination findings and symptom location 1

Critical Pitfalls to Avoid

• Do not order imaging before 4-6 weeks in the absence of red flags - this leads to unnecessary procedures and increased costs 2
• Avoid thermography or electrophysiologic testing for nonspecific low back pain evaluation 1
• Recognize that many radiographic findings (osteophytes, disc degeneration) are poorly correlated with symptoms and are common in asymptomatic individuals 1, 4
• Do not continue physical therapy when red flags emerge - undiagnosed malignancy, infection, or inflammatory conditions can worsen with delayed diagnosis 3

Pediatric Considerations

For children with back pain, anteroposterior and lateral radiographs remain the standard initial imaging. 1

• Radiography has 9-22% diagnostic yield when combined with detailed history and physical examination 1
• Oblique views are not useful in pediatric patients 1
• If red flags are present or radiographs are negative with high clinical suspicion, proceed directly to MRI rather than additional plain films 1