How do I order a magnetic resonance imaging (MRI) of the thoracic spine and left scapular region for a patient with persistent left scapular‑spinal pain lasting more than six weeks and no clear etiology?

How to Order an MRI for Left Scapular-Spinal Pain

For persistent pain between the left scapula and spine lasting more than 6 weeks without clear etiology, order an MRI thoracic spine without contrast as the initial imaging study, but only after systematically excluding red flags and documenting failed conservative management. 1, 2

Step 1: Determine If Imaging Is Actually Indicated

Do not order imaging for acute thoracic back pain (<4 weeks) without red flags, myelopathy, or radiculopathy. 1, 3 The American College of Radiology explicitly states imaging is not indicated in this timeframe unless concerning features are present. 1, 3

Red Flags Requiring Immediate Imaging:

• Age >65 years, chronic steroid use, or known osteoporosis (fracture risk) 1, 2, 3
• History of cancer with new back pain (metastatic disease) 1, 2, 4
• Fever, recent infection, immunosuppression, or IV drug use (spinal infection/epidural abscess) 2, 3
• Unexplained weight loss (malignancy) 2, 3, 4
• Midline tenderness on examination (fracture) 2, 3
• Any neurological deficits including weakness, numbness, or bowel/bladder dysfunction (myelopathy/radiculopathy) 1, 2, 4
• Trauma history (fracture) 2, 3

If Red Flags Are Present:

Proceed directly to imaging regardless of symptom duration. 1, 2

If No Red Flags Are Present:

Wait 4-6 weeks with conservative management before considering imaging. 3, 4 Routine imaging for nonspecific back pain does not improve outcomes and may identify incidental findings that correlate poorly with symptoms. 4

Step 2: Choose the Correct MRI Protocol

For Most Cases (No Red Flags, Persistent Pain >6 Weeks):

Order: MRI thoracic spine without contrast 1, 2

This protocol is appropriate for:

• Persistent pain after conservative management failure 1, 2
• Suspected disc herniation (most common below T7) 2, 3
• Myofascial pain evaluation 2
• Spinal stenosis assessment 2

For Suspected Infection or Malignancy:

Order: MRI thoracic spine without AND with IV contrast 1, 2

Use this protocol when:

• History of cancer is present 1, 2, 4
• Fever, immunosuppression, or systemic symptoms suggest infection 1, 2
• Unexplained weight loss is present 2, 4
• Constant pain unrelieved by position changes 2

Contrast enhances detection of osseous destruction, epidural abscess, and metastatic lesions. 1

For Myelopathy or Radiculopathy:

Order: MRI thoracic spine without contrast 1, 2

This is the imaging of choice for neurological compromise. 1, 2

Step 3: Consider Initial Radiography First

In patients with fracture risk factors (age >65, steroid use, osteoporosis, midline tenderness), obtain thoracic spine X-ray before MRI. 1, 2, 3

Radiographs are useful for:

• Confirming or excluding obvious fractures 1, 3
• Assessing alignment and spinal deformity 1
• Identifying bone destruction 1

If radiographs show fracture, bone destruction, or spinal deformity, then proceed to MRI for further characterization. 1

Step 4: Document for Insurance Approval

Critical elements to include in your order:

• Duration of symptoms (typically ≥6 weeks) 4
• Failed conservative treatments (NSAIDs, physical therapy) 4
• Specific symptoms (location, radiation pattern, aggravating/relieving factors) 4
• Neurological examination findings (motor strength, sensory deficits, reflexes) 4
• Presence or absence of red flags 2, 3
• Rationale for imaging (rule out serious pathology, surgical planning) 4

Step 5: Specify the Correct Anatomical Region

Order "MRI thoracic spine" specifically, not "MRI spine" or "MRI back." 1

The thoracic spine extends from T1-T12 and includes the region between the scapula and spine. 1, 2 If scapular pathology (bursitis, dyskinesis) is suspected rather than spinal pathology, consider adding "include scapulothoracic region" to the order. 5, 6

Critical Pitfalls to Avoid

• Do not order MRI for acute pain (<4 weeks) without red flags – this leads to overdiagnosis and unnecessary interventions. 1, 3, 4
• Do not delay imaging in cancer patients with new neurological symptoms – spinal cord compression requires urgent diagnosis. 4
• Do not attribute symptoms to "arthritis" in high-risk patients without ruling out serious pathology first. 4
• Do not rely solely on imaging findings without clinical correlation – up to 73% of asymptomatic individuals have abnormal thoracic spine MRI findings including disc herniations and cord deformation. 7
• Do not forget to consider referred pain from cardiac ischemia, pulmonary embolism, peptic ulcer disease, pancreatitis, or renal pathology, which can all present as thoracic back pain. 2

Special Populations

Elderly Patients (>65 years):

Lower threshold for imaging due to increased fracture and malignancy risk. 2, 3 Consider X-ray even with minor trauma or lifting history. 3

Patients with Prior Spinal Surgery:

Early imaging is warranted regardless of symptom duration. 2, 3 Consider MRI with and without contrast to assess for postoperative infection, hematoma, or hardware complications. 1

Patients Unable to Undergo MRI:

CT thoracic spine without contrast is a reasonable alternative, with >80% sensitivity for most pathologies, though it provides inferior soft tissue visualization and involves ionizing radiation. 4, 8