Diagnostic Imaging
Table 2. Suggestions for Imaging in Patients with Acute LBP Suggestions for Initial Imaging
Imaging Action and Clinical Situation
Immediate Imaging
Radiography plus erythrocyte sedimentation ratea
MRI
> Major risk factors for cancer (new onset of LBP with history of cancer, multiple risk factors for cancer, or strong clinical suspicion for cancer)
> Risk factors for spinal infection (new onset of LBP with fever and history of intravenous drug use or recent infection)
> Severe neurologic deficits (progressive motor weakness or motor deficits at multiple neurologic levels)
Defer Imaging Aſter a Trial Therapy
Radiography with or without erythrocyte sedimentation ratea
> Weaker risk factors for cancer (unexplained weight loss or age > 50 y)
> 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 y])
> Risk factors for vertebral compression fracture (history of osteoporosis, use of corticosteroids, significant trauma, or older age [> 65 y for men or > 75 y for women]
MRI
> 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
No Imaging a
> No criteria for immediate imaging and back pain improved or resolved after a 1-mo trial of therapy
> Risk factors for or signs of the cauda equina syndrome (new urine retention, fecal incontinence, or saddle anesthesia)
> Risk factors for or symptoms of spinal stenosis (radiating leg pain, older age, or pseudoclaudication) in patients who are candidates for surgery
> Previous spinal imaging with no change in clinical status
Consider MRI if the initial imaging result is negative but a high degree of clinical suspicion for cancer remains.
4
