Choosing Wisely:

Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis).

Rationale and Comments: Low back pain without trauma is a common presenting complaint in the emergency department. Most of the time, such pain is caused by conditions such as a muscle strain or a bulging disc that cannot be identified on an X-ray or CT scan. When a patient has symptoms or physical findings of a serious or progressive neurological condition, or is suspected of having a serious underlying condition such as cancer or a spinal infection, imaging may be appropriate and may include plain X-rays or advanced imaging (e.g., MRI or CT scan). Diagnostic imaging does not accurately identify the cause of most low back pain and does not improve the time to recovery. The vast majority of cases of back pain in the emergency department are related to muscle strain or inflammation. As a result, routine imaging of the low back should be avoided in order to reduce ionizing radiation exposure and unnecessary cost.
Sponsoring Organizations:
  • American College of Emergency Physicians
  • Sources:
  • ACP/APS guidelines
  • Disciplines:
  • Neurologic
  • Orthopedic
  • References: • Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. 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 Oct 2;147(7):478-91.
    • Adult low back pain, 12th edition. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2006 Sep. 37 p.
    • van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, Koes B, Laerum E, Malmivaara A; COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. 2004. Eur Spine J. 2006 Mar;15 Suppl 2:S169-91.
    • Australian Acute Musculoskeletal Pain Group. Evidence-based Management of Acute Musculoskeletal Pain. Acute Low Back Pain. Chapters 4 & 9, pg 25-62 and 183-188. 2003.
    • Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults -an evidence-based approach part 3: spinal disorders. J Manipulative Physiol Ther. 2008 Jan;31(1):33-88.
    • Tracey NG, Martin JB, McKinstry CS, Matthew BM. Guidelines for lumbar spine radiography in acute low back pain: effect of implementation in an accident and emergency department. Ulster Med J. 1994 Apr;63(1):12-17.

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