Back pain choices

Back pain choices

Assess for serious pathology

Serious conditions such as vertebral infection, cancer, fracture, ankylosing spondylitis or cauda equina syndrome are rare causes of back pain (<1% of cases) in Australian primary care. Imaging and laboratory tests are only required when you suspect that the cause of the patient’s low back pain is a serious condition or the patient has radiculopathy or spinal stenosis AND is a candidate for surgery. The table below outlines these clinical scenarios and an appropriate imaging strategy.

Note: Imaging is not required for patients with non-specific low back pain.

Timing Imaging strategy Clinical Situation
Immediate imaging Radiography plus erythrocyte sedimentation rate†
  • Major risk factors for cancer (new onset of low back pain with history of cancer, multiple risk factors for cancer, or strong clinical suspicion for cancer)
Magnetic resonance imaging
  • Risk factors for spinal infection (new onset of low back pain with fever and history of intravenous drug use or recent infection)
  • Risk factors for or signs of the cauda equina syndrome (new urine retention, faecal incontinence, or saddle anaesthesia)
  • Severe neurologic deficits (progressive motor weakness or motor deficits at multiple neurologic levels)
Defer imaging after a trial of therapy Radiography with or without erythrocyte sedimentation rate
  • 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 women or >75 y for men])
Magnetic resonance imaging
  • 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
  • Risk factors for or symptoms of spinal stenosis (radiating leg pain, older age, or pseudoclaudication) in patients who are candidates for surgery
No imaging  
  • No criteria for immediate imaging and back pain improved or resolved after a 1-month trial of therapy
  • Previous spinal imaging with no change in clinical status

† Consider magnetic resonance imaging if the initial imaging result is negative but a high degree of clinical suspicion for cancer remains.

Source: This table is adapted from The American College of Physicians Clinical Guideline for Diagnostic Imaging for low back pain (Ann Intern Med 2011; 154:181-189.)