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Diagnostic Imaging Pathways Low back pain

Population Covered By The Guidance

This pathway provides guidance for imaging adult patients with acute lower back pain. It highlights the red
flag signs and symptoms that prevent indiscriminate use of plain radiography for this complaint.

Date of review: August 2013

Date of next review: August 2015

Quick User Guide

Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient
points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE

None 0

Minimal < 1 millisieverts

Low 1-5mSv

Medium 5-10 mSv

High >10 mSv

Pathway Diagram

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{tip Red flags for

the investigation of acute low back pain

Patients with any of the following Red Flags may benefit from plain radiographs:

Age of onset < 20 years or > 55 years

Recent history of violent trauma
Constant progressive, non mechanical pain (no relief with bed rest)
Thoracic pain
Past medical history of malignant tumour
Prolonged use of corticosteroids
Drug abuse, immunosuppression, HIV
Systemically unwell
Unexplained weight loss
Widespread neurological symptoms (including cauda equina syndrome)
Structural deformity
Fever

} {tip Plain radiograph

Generally of limited value except when a patient has a red flag indication or has not improved with
conservative therapy.

} {tip Magnetic resonance imaging (MRI)

Considered the investigation of choice for imaging the spinal cord and soft tissue structures.

} {tip Magnetic resonance imaging (MRI)

Considered the investigation of choice for imaging the spinal cord and soft tissue structures.

} {tip Magnetic resonance imaging (MRI)

Considered the investigation of choice for imaging the spinal cord and soft tissue structures.

} {tip Bone scan

Mainly used for the detection of occult fractures, infections or metastases and to distinguish them from
degenerative disease.

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Image Gallery

Note: These images open in a new page

1a XL4/L5 Disc Herniation

Image 1a and 1b (Computed Tomography): Axial and sagittal images

demonstrating a large left sided eccentric disc bulge at L4/L5 that does not
compress traversing or exiting nerve roots (arrows).

1b

1c Image 1c and 1d (Magnetic Resonance Imaging): Axial and sagittal images

of the same patient.

1d

Teaching Points
The prevalence of previously undiagnosed serious pathology in patients presenting with acute low
back pain in the primary care setting is very rare. 1
Most patients with acute low back pain have substantial improvements in pain and function within
one month. 2
Teaching Point line 3.
Routine or immediate lumbar spine imaging for low back pain without indications of serious

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underlying conditions does not affect management or improve clinical outcomes and is associated
with radiation exposure and increased expenses. 3,4
'Red flags' that prompt imaging include recent significant trauma (mild trauma if age = 50),
unexplained weight loss, fever, age 55 years, history of malignancy or immune compromise,
intravenous drug use, osteoporosis or glucocorticoid use, suspicion of ankylosing spondylitis and
compensation or work injury issues.
If there are no 'red flags', imaging is indicated only after a period of conservative therapy is trialled
first. 3
Initial investigation is with plain films.

Red Flags
These features on history and examination may help to increase the yield of lumbar radiography
and have been adapted from criteria proposed by various guidelines 5-8
Constitutional symptoms e.g. fever, night sweats
Immunosuppression
Intravenous drug use
History of malignancy or unexplained weight loss of insidious onset
Prolonged use of corticosteroids, osteoporosis
Age <20 or >55 years
Recent history of violent trauma (or mild trauma if age = 50)
Presence of associated contusion or abrasion
Constant progressive, non mechanical pain (no relief with bed rest)
Thoracic pain
Structural deformity
Widespread neurological signs and symptoms (including cauda equina syndrome)
Failure to improve after 4-6 weeks of conservative low back pain therapy
There is no convincing evidence that the absence of these red flags is sufficient to exclude serious
underlying disease and some red flags have high false positive rates,1,9,10 but they may help to
reduce unnecessary use of plain radiography.

Plain Radiography
Frequently but often inappropriately used for the investigation of low back pain.
The majority of patients with low back pain have either normal lumbar radiographs or age related
degenerative changes that do not necessarily correlate with the presence or severity of pain. 8,
11,12
Disc space narrowing is more strongly associated with back pain than other radiographic features.
13
Routine, immediate plain radiographs are of limited diagnostic value and have no benefit to patient
function, pain or disability, other than patient satisfaction, which must be weighed against the
significant gonadal radiation dose. 3,8,14,15
Plain radiographs are not indicated in patients with low back pain unless there are significant risk
factors or red flags for serious underlying disease or symptoms have persisted for greater than 6
weeks. 3,16,17

Magnetic Resonance Imaging

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Advanced imaging modality of choice in evaluation of low back pain.

There is a paucity of evidence for the appropriate timing of MRI, but emergent MRI has been
suggested for suspected cord compression, cauda equina syndrome, abscess or infection. It may
be appropriate to trial a period of conservative care prior to MRI for patients with radiculopathy. 18
Advantages compared to CT include:
No ionising radiation
Better soft tissue contrast modality of choice for detection of spinal infections,
metastases, nerve root disorders and disc abnormalities
Disadvantages compared to CT include: 17
Lower spatial resolution cortical bone lesions are not as well visualised. Where bony
anatomy is critical, CT may be preferred.
Claustrophobia
Longer scanning time needed
Contraindicated in the presence of a ferromagnetic substance, e.g. Pacemaker, aneurysm
clip, cochlear implant, ocular foreign body, spinal cord stimulator and some stent materials.
Most findings on MRI in patients presenting with low back pain represent progressive age-related
changes and are not associated with acute events, although primary radiculopathies may have
new root compression findings. 19
MRI is recommended for vertebral inflammatory and infectious processes. It can detect
osteomyelitis as early as 3-5 days after onset of infection and is reported to have a sensitivity of
96% and specificity of 92% for the detection of spinal infections, more accurate than plain
radiography or bone scan. 20,21
MRI is the most accurate modality for detecting suspected malignancy and vertebral metastasis
and determining disease extension around the spinal cord. Where there is a high clinical suspicion
MRI should be considered even if bone scintigraphy is negative or equivocal. 20-25
A recent metaanalysis concluded MRI can help distinguish benign from malignant vertebral
compression fractures.26
MRI has a high sensitivity (87-96%) and moderate specificity (68-75%) in the detection of spinal
stenosis. 27
MRI has a pooled 75% sensitivity (64-92%) and 77% sensitivity (55-100%) for detection of lumbar
disc herniation on metaanalysis, and high sensitivity (81%) but lower specificity (52%) in detection
of resultant nerve root compression compared to surgical reference standard, not significantly
different compared to CT and CT myelography. 27,28
Abnormalities such as disc degeneration, spondylosis, disc herniation, bulging disc and foraminal
stenosis can be seen on MRI in asymptomatic individuals and any causal attribution should be
made after strict correlation with clinical signs and symptoms. 29-31
The ability to distinguish between extrusions and protrusions, both subtypes of disc herniations, is
important. Disc extrusions have a 'neck' and are rare in asymptomatic patients where as
protrusions are broad based and commonly occur in asymptomatic people

Computed Tomography
Advantages of CT over MRI include:
Superior bony detailing of the spine, particularly the facet joints 32 and the posterior
elements
Faster acquisition time and less sensitive to patient movements
CT is useful for identifying bone structural problems and for post-surgical evaluation of bone graft
integrity, surgical fusion and instrumentation 5,33
CT has a similar accuracy to MRI and CT myelography in identification of lumbar disc herniation.
28 A recent metaanalysis on the detection of lumbar disc herniation reported a pooled 77.4%

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sensitivity and 73.7% specificity for CT compared to surgical findings. 34

As with other imaging tests, many abnormalities found with CT, including herniated discs are found
in asymptomatic people and this reduces the specificity of the test.
There is a paucity of evidence on the accuracy of CT for detection of vertebral metastases,
osteomyelitis, compression fractures or ankylosing spondylitis. 34

CT Myelography
CT myelography is an invasive procedure that involves injecting the thecal sac with iodinated
contrast material. This allows the nerve root sleeves to be visualised and a lack of filling,
displacement, or swelling of a nerve root may indicate adjacent pathology. 28,35
MRI is the preferred first line investigation of suspected radiculopathy or spinal stenosis due to its
excellent soft tissue definition and non-invasiveness. Currently, the main diagnostic role of CT
myelography is as an alternative method of investigation if MRI is unavailable or contraindicated.
28,36
For detecting a herniated disc, CT myelography has a sensitivity of 73-95% and a specificity of
57-88%. This is similar to that of non-invasive helical CT 28,36
Limitations:
Invasive procedure.
Associated small risk of exacerbating the neurological deficit.

Lumbar Discography
Lumbar provocation discography, which includes disc stimulation and morphological evaluation,
may distinguish a chronically painful lumbar disc from other potential sources of pain where less
invasive studies have been indeterminate. 38
However, careful consideration should be given to the risks of the procedure. A recent study
suggested that discography may cause accelerated degenerative changes, disc herniation, loss of
disc height and development of reactive end-plate changes in tested discs. 39

Bone Scan
Sensitive but not very specific for detecting infection, malignancy or occult fractures. Generally MRI
is preferred for localised lower back pain.
Bone scintigraphy is useful in the evaluation of suspected widespread or multifocal osseous
infections or metastases, or where MRI is contraindicated or unavailable. 17

References
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of and screening for serious spinal pathology in patients presenting to primary care
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2001;220(2):393-9. (Level II evidence)

5. Expert Panel on Neurologic Imaging:, Davis PC, Franz JW, Cornelius RS, Angtuaco EJ, Broderick
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20. Pineda C, Vargas A, Rodrguez AV. Imaging of Osteomyelitis: Current Concepts. Infectious
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clinically suspected lumbar disc herniation . Spine (Phila Pa 1976). 1995 Feb 15;20(4):443-8.
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