Choosing Wisely:

Don’t obtain spinal imaging for patients with acute low-back pain during the six weeks after onset in the absence of red flags.

Rationale and Comments: In the absence of red flags, evidence-based guidelines do not support the routine use of spinal imaging for patients with acute back pain of less than six weeks duration. Red flags include history of cancer, fracture or suspected fracture based on clinical history, progressive neurologic symptoms, and infection, as well as conditions that potentially preclude a dynamic thrust to the spine, such as osteopenia, osteoporosis, axial spondyloarthritis, and tumors. Unnecessary imaging incurs monetary cost, exposes the patient to ionizing radiation, and can result in labeling patients with conditions that are not clinically meaningful, creating a false sense of vulnerability and disability. Indeed, several studies have shown that the routine use of radiographs in the care of low-back pain may result in worse outcomes than without their use.
Sponsoring Organizations:
  • American Chiropractic Association
  • Sources:
  • Systematic review
  • Disciplines:
  • Orthopedic
  • Neurologic
  • References: • Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72.
    • Bussières 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.
    • Kendrick D, Fielding K, Bentley E, Miller P, Kerslake R, Pringle M. The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial. Health Technol Assess. 2001;5(30):1-69.
    • Vining RD, Potocki E, McLean I, Seidman M, Morgenthal AP, Boysen J, Goertz C. Prevalence of radiographic findings in individuals with chronic low back pain screened for a randomized controlled trial: secondary analysis and clinical implications. J Manipulative Physiol Ther. 2014 Nov-Dec;37(9):678-87.
    • National Guideline Clearinghouse (NGC). Guideline summary: ACR Appropriateness Criteria® low back pain. In: National Guideline Clearinghouse (NGC) [Website]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [2016 Jan 22]. Available from: https://www.guideline.gov/summaries/summary/49915.
    • Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6.

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