Conservative Management Without Imaging
For this 70-year-old woman with intermittent mild low back pain, mild scoliosis, and no red flags, the next step is to initiate conservative management with NSAIDs or acetaminophen, advise her to remain active, provide reassurance about the favorable prognosis, and avoid any imaging—no further X-rays, MRI, or CT are indicated. 1, 2
Why No Additional Imaging Is Needed
Routine imaging provides no clinical benefit in uncomplicated low back pain without red-flag symptoms and actually increases unnecessary healthcare utilization, leading to incidental findings that trigger unwarranted interventions and worse outcomes. 1, 2, 3
The X-ray has already excluded fracture, and the mild scoliosis finding is not clinically significant in this context—degenerative changes and mild spinal curvature are extremely common in asymptomatic older adults and do not correlate with symptoms. 2, 4
In patients over 70 years old, disc protrusions are present in up to 43% of asymptomatic individuals, so any additional imaging would likely reveal age-related degenerative changes that are unrelated to her intermittent mild pain. 4
First-Line Conservative Management Protocol
Pharmacologic Approach
Start with oral NSAIDs (ibuprofen 400-800 mg three times daily, naproxen 500 mg twice daily, or diclofenac 50 mg twice daily) or acetaminophen if NSAIDs are contraindicated—these are the guideline-recommended first-line analgesics. 1, 3, 5
Add a short course of muscle relaxants if muscle spasm is prominent, as they provide modest benefit for acute exacerbations. 3, 5
Monitor for gastrointestinal, cardiovascular, and renal adverse effects with NSAID use, especially in older patients. 3
Non-Pharmacologic Approach
Advise the patient to remain active within her pain tolerance rather than bed rest—activity-preserving approaches lead to better outcomes than rest. 1, 3, 6
Provide reassurance that most mechanical low back pain is self-limited, with 90% of acute episodes resolving within one month with conservative care. 1, 7
Consider spinal manipulation if symptoms persist beyond initial presentation, as it provides small-to-moderate short-term benefit for acute low back pain (< 4 weeks duration). 3, 8
When to Reassess and Escalate
Reevaluate within 2-4 weeks to assess response to conservative therapy. 3, 4
If pain persists beyond 6 weeks of optimal conservative management and significantly limits function, only then consider MRI lumbar spine without contrast—and only if she would be a candidate for interventional procedures or surgery. 1, 2, 4
Do not order imaging before 6 weeks unless new red-flag symptoms develop. 1, 2, 3
Red Flags That Would Change Management
Watch for any new development of:
Cauda equina syndrome signs: urinary retention/incontinence, saddle anesthesia, bilateral leg weakness, loss of anal sphincter tone—these require emergency MRI and surgical referral. 1, 3, 4
Progressive motor deficits such as new foot drop—this mandates prompt imaging. 2, 4
Cancer red flags: unexplained weight loss, history of malignancy, or night pain unrelieved by rest in a patient over 50. 1, 4
Infection red flags: fever, immunosuppression, IV drug use, or recent spinal procedure. 4, 5
Critical Pitfalls to Avoid
Do not order MRI "just to be safe" in the absence of red flags or failed conservative therapy—this is the single most common error leading to unnecessary procedures and poorer outcomes. 2, 3
Do not assume imaging abnormalities correlate with symptoms in older patients, as degenerative changes increase with age and are often incidental. 4
Do not prescribe complete bed rest—patients should stay active as tolerated. 1, 3, 6
Do not delay specialist referral beyond 3 months if symptoms persist despite adequate conservative management, as this can lead to prolonged disability. 4