• Choosing Wisely®

    Imaging for Low Back Pain


    Don't do imaging for low back pain within the first six weeks, unless red flags are present. (Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected.)

    Low back pain is the fifth most common reason for all physician visits. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs.

    Sources: Agency for Health Care Research and Policy (AHCPR), Cochrane Reviews

    Supporting Information

    Low back pain is one of the most common reasons for an outpatient visit. The evaluation for low back pain should include a complete, focused medical history looking for red flags, which include, but are not limited to: severe or progressive neurologic deficits (e.g., bowel or bladder function), fever, sudden back pain with spinal tenderness, trauma, and indications of a serious underlying condition (e.g., osteomyelitis, malignancy). It is also important to rule out nonspinal causes of back pain, such as pyelonephritis, pancreatitis, penetrating ulcer disease or other gastrointestinal causes, and pelvic disease. Fractures are an uncommon cause of back pain; they are associated with risk factors such as osteoporosis and steroid use. (1,2,3,4)

    Most patients with radicular symptoms will recover within several weeks of onset.(5) The majority of disc herniations will regress or reabsorb within eight weeks of onset. In the absence of progressive neurologic deficits or other red flags, there is strong evidence to avoid CT/MRI imaging in patients with non-specific low back pain. (6,7)


    Studies have shown that patients with no back pain often show anatomic abnormalities on imaging.(8) Risks associated with routine imaging include unnecessary radiation exposure and  patient labeling.(9) The labeling phenomenon of patients with low back pain has been studied and shown to worsen  patients’ sense of well-being.(10) In addition studies have linked the increase rate of imaging with the increase rate of surgery. (9) A study by Webster et al showed that patients with occupation-related back pain who had early magnetic resonance imaging (MRI) had an eightfold increased risk of surgery.(11) A study by Jarvik et al showed that patients with low back pain who had an MRI were more than twice as likely to undergo surgery compared with patients who had plain film imaging.(12)
    A meta-analysis by Chou et al found no clinically significant difference in patient outcomes between those who had immediate lumbar imaging versus usual care.(7) The imaging of the lumbar spine before 6 weeks does not improve outcomes, but it does increase costs. In general, imaging should be saved for patients for whom noninvasive, conservative regimens have failed and surgery or therapeutic injection are being considered.

    Red Flags

    • Severe or progressive neurologic deficits (e.g., bowel or bladder function, saddle parasthesia)
    • Fever
    • Sudden back pain with spinal tenderness (especially with history of osteoporosis, cancer, steroid use)
    • Trauma
    • Serious underlying medical condition (e.g., cancer)

    Key Communication Concepts

    • Provide Clear Recommendations
      The majority of patients want information about their health, illness and decision options.

      “The good news is that based on your history and your normal physical examination I do not think that you need an x-ray.”

       “I would not recommend an x-ray at this point given these findings and the fact that except for having pain in the back from muscle spasm your examination is normal.”

    • Elicit Patient Beliefs/Questions
      Understanding patients’ treatment goals and perspectives about their health during the visit will help improve patient satisfaction and can shorten visits.

       Find out where the patient is coming from

      “You look concerned do have any questions for me?”

       “Is there anything you are concerned about? “

       “What do you think is going on and what are you worried about?

    • Provide Empathy, Partnership, Legitimation
      Patients are more satisfied and are more likely to adhere to recommendations if they feel understood, supported, and a sense of partnership with their physicians.

       Make it clear that you are on the patient’s side (provide empathy and partnership)

      “I certainly understand that you want to get better?”

       “I want to reassure you that your symptoms are very different from those of your brother or someone with a herniated disc”
    • Confirm Agreement/Overcome Barriers
      Finding common ground and understanding patient perspective and barriers will help reach agreement and provide patient satisfaction and hopefully improve patient health outcomes.

      “I want to be sure you are comfortable with this plan. I do not think you need a plain x-ray as they show us the boney problem which is unlikely to be the problem. A CT scan is not particularly helpful and exposes you to a lot more radiation. An MRI is the gold standard but the problem is that even in healthy patients we see abnormal discus so we are never sure that the finding on the MRI are related to your symptoms. ”

       “There are things we can do to help your symptoms to help you feel better . Let’s try this treatment and I will see you back in 6 weeks. If you develop any new symptoms like weakness in your legs, numbness or pain down the leg you should call me. However I expect like most people with low back pain you will start to feel better with the treatment.”


    1. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, Md.: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994. Accessed November 21, 2012.
    2. Goertz M, Thorson D, Bonsell J, et al. Institute for Clinical Systems Improvement. Adult acute and subacute low back pain. Updated November 2012.  Acessed March 18, 2013.
    3. National Institute for Health and Clinical Excellence: Low back pain: Early management of persistent non-specific low back pain May 2009. Acessed March 18, 2013.
    4. 2011 American College of Radiology ACR Appropriateness Criteria® low back pain guideline; Accessed March 2013.
    5. Pengal LH, Herbert RD, Maher CG, Refshange KM,. Acute Low Back Pain. A Systematic Review of its Prognosis. BMJ 2003:326 (7401):323.
    6. Chou R, Qaseem A, Owens DK, et al. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154:181-189.
    7. Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463-472.
    8. Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. NEJM. 1994:331;69-73.
    9. Shubha SV, Deyo RA, Berger ZD. Appllication of “less is MNore” to Low Back Pain. Arch Intern Med 2012;172(13):1016-1020.
    10. Modic MT, Obuchowski NS, Ross JS et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology 2005;237 (2):597-604.
    11. Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52:900-907.
    12. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289;2810-2818.

    More About Choosing Wisely®

    About Choosing Wisely®

    The Choosing Wisely®  campaign was created as an initiative of the American Board of Internal Medicine (ABIM) Foundation to improve health care quality. More than 70 specialty societies have identified commonly used tests or procedures within their specialties that are possibly overused.

    Learn more about the AAFP support of the Choosing Wisely® campaign.

    This recommendation is provided solely for informational purposes and is not intended as a substitute for consultation with a medical professional. Patients with any specific questions about this recommendation or their individual situation should consult their physician.