What is the role of imaging studies in the workup for mechanical back pain?

Updated: Aug 27, 2020
  • Author: Debra G Perina, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Answer

The American College of Radiology (ACR) has come up with appropriateness criteria for low back pain, including the following [5] :

  • Uncomplicated acute low back pain and/or radiculopathy are benign, self-limited conditions that do not warrant any imaging studies.
  • MRI of the lumbar spine should be considered for those patients presenting with red flags raising suspicion for a serious underlying condition, such as cauda equine syndrome, malignancy, or infection.
  • In patients with a history of low-velocity trauma, osteoporosis, or chronic steroid use, initial evaluation with radiographs is recommended.
  • In the absence of red flags, first-line treatment for chronic low back pain remains conservative therapy with both pharmacologic and nonpharmacologic (eg, exercise, remaining active) therapy.
  • If there are persistent or progressive symptoms during or following 6 weeks of conservative management and the patient is a surgery or intervention candidate or diagnostic uncertainty remains, MRI of the lumbar spine has become the initial imaging modality of choice in evaluating complicated low back pain.
  • MRI is the imaging procedure of choice in patients suspected of cord compression or spinal cord injury.
  • Patients with recurrent low back pain and history of prior surgical intervention should be evaluated with contrast-enhanced MRI.

Lumbosacral spine series are expensive and expose the reproductive organs to significant radiation. Annually, 7-8 million such tests are obtained, but most have little value in directing therapy, particularly among adults younger than 50 years. Osteophytes are the most frequently seen abnormality of plain films followed by intervertebral disc space narrowing. Both increase with age. Disc space narrowing appears to be more frequent in women. Disc space narrowing at 2 or more levels is strongly associated with back pain pathology. [23]

Unless a history of traumatic injury or systemic illness is present, such films should be obtained only for suspicion of malignancy or infection. Malignant involvement of vertebral bodies can be evident on plain film when as little as 30% of the vertebral body has been replaced. Other indications that suggest the need for radiographic imaging include chronic steroid use and acute onset of pain in patients older than 50 years or in the pediatric age group. The physician may also consider obtaining radiographs in patients whose cases involve (or potentially involve) litigation or for patients seeking compensation.


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