Table 1.
Suggestions for Imaging in Patients with Low Back Pain (alone or with leg pain)*
|
Indicators for Initial Imaging |
Imaging Action |
|---|---|
| Immediate imaging | |
| · Risk factors for cancer (multiple risk factors for cancer, or strong clinical suspicion for cancer) |
Radiography plus ESR† |
| · Risk factors for cancer (history of cancer with new onset of LBP) |
MRI (or CT if MRI not available) |
| · Risk factors for spinal infection (new onset of LBP with fever and history of intravenous drug use or recent infection) | |
| · Risk factors for or signs of the cauda equina syndrome (urine retention, motor deficits at multiple neurologic levels, fecal incontinence, or saddle anesthesia) | |
| · Severe neurologic deficits (progressive motor weakness) | |
| |
Defer imaging after a trial of therapy(about 1 month) |
| · Weaker risk factors for cancer (unexplained weight loss or age >50 years) |
Radiography with or without ESR |
| · Risk factors for or signs of ankylosing spondylitis (morning stiffness that improves with exercise, alternating buttock pain, awakening because of back pain during the second part of the night, or younger age [20 to 40 years]) | |
| · Risk factors for vertebral compression fracture (history of osteoporosis, corticosteroid use, significant trauma, or older age [>65 for men or >75 for women]) | |
| · Signs and symptoms of radiculopathy (back pain with leg pain in an L4, L5 or S1 nerve root distribution or positive result on straight leg raise or crossed straight leg raise test) in patients who are candidates for surgery or epidural steroid injection |
MRI (or CT if MRI not available) |
| · Risk factors for or symptoms of spinal stenosis (radiating leg pain, older age, or pseudoclaudication) in patients who are candidates for surgery | |
| |
No imaging |
| · No criteria for immediate imaging and back pain improved or resolved within 1-month trial of therapy |
|
| · Previous spinal imaging with no change in clinical status |
* Adapted from Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007, 147:478–91. [PMID: 17909209]
† Consider MRI if the initial imaging result is negative but a high degree of clinical suspicion for cancer remains.