Should I order a lumbar spine MRI with contrast or without contrast for a patient being evaluated for mechanical low‑back pain, disc herniation, spinal stenosis, facet arthropathy, or uncomplicated radiculopathy?

MRI Lumbar Spine Without Contrast for Mechanical Low Back Pain

For patients with mechanical low back pain, disc herniation, spinal stenosis, facet arthropathy, or uncomplicated radiculopathy, you should order an MRI lumbar spine WITHOUT contrast. Contrast is not necessary for evaluating these common degenerative conditions and adds no diagnostic value. 1

When to Order MRI (Timing Matters)

Do NOT order imaging initially for uncomplicated low back pain without red flags:

• Routine imaging provides no clinical benefit in acute or subacute uncomplicated low back pain and leads to increased healthcare utilization 1
• Most patients respond to conservative management (medical therapy and physical therapy) within 6 weeks 1

Order MRI lumbar spine without contrast when:

• Patient has failed 6 weeks of optimal conservative therapy AND is a surgical or intervention candidate 1
• Patient presents with radiculopathy or clinical signs of spinal stenosis suggesting nerve root compression 1
• Diagnostic uncertainty remains after conservative management 1

Why MRI Without Contrast is Sufficient

MRI without IV contrast accurately depicts all the pathology you need to see:

• Disc degeneration and herniation 1
• Thecal sac and neural structures 1
• Nerve root compression 1
• Spinal stenosis 1
• Facet arthropathy 1

Contrast is typically not necessary in surgical or intervention candidates with persistent symptoms after conservative management 1. The ACR Appropriateness Criteria explicitly state that MRI with IV contrast is not typically performed independently as an initial study 1.

When Contrast IS Indicated (Special Circumstances)

Consider MRI with AND without contrast only in these specific scenarios:

• Postoperative patients with new or progressive symptoms—contrast helps distinguish recurrent/residual disc from fibrosis/scar 1
• Nondiagnostic or indeterminate noncontrast MRI 1
• Suspected underlying malignancy, infection, or inflammation (red flag symptoms) 1

Common Pitfalls to Avoid

Overimaging asymptomatic findings:

• Many MRI abnormalities appear in asymptomatic individuals 1
• Disc abnormalities are common in asymptomatic patients (20-28% prevalence) 1
• Size and type of disc herniation do not correlate with patient outcomes 1

Ordering imaging too early:

• Early imaging in uncomplicated low back pain increases likelihood of unnecessary injections, surgery, and disability compensation 1
• One study showed 27.2% of patients received imaging within 4 weeks despite lack of indication 1

Unnecessary contrast administration:

• MRI with contrast alone should never be ordered—it requires correlation with noncontrast sequences 1
• Contrast adds cost, time, and potential adverse reactions without benefit for degenerative conditions 1

Alternative Imaging Considerations

CT without contrast may be useful as an alternative when:

• MRI is contraindicated (pacemakers, certain implants) 1
• Preoperative planning for hardware trajectory 1
• CT is equal to MRI for predicting significant spinal stenosis 1
• However, CT has lower sensitivity for disc herniation (55%) and disc signal changes compared to MRI 2

Plain radiographs are complementary but insufficient alone:

• Useful for assessing alignment, spondylolisthesis with flexion/extension views 1
• Not indicated as initial imaging for uncomplicated low back pain 1