Low back pain imaging

The evaluation of low back pain by a medical provider should include a complete medical history and examination. It should be established if any “red flag” signs or symptoms are present that could indicate serious underlying pathology.

Serious underlying pathology includes but is not limited to:

• Infection
• Suspected cancer
• Spinal injury
• Spinal cord compression
• Inflammatory conditions
• Patients with cancer and symptoms suggestive of spinal metastases
• Spondyloarthritis in over 16s
• Cauda equina syndrome

This guidance applies to adults aged 19 years and over.

Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica in the absence of red flags, or suspected serious underlying pathology following medical history and examination.

Imaging in low back pain should be offered if serious underlying pathology is suspected. Serious underlying pathology includes but is not limited to: cancer, infection, trauma, spinal cord injury (full or partial loss of sensation and/or movement of part(s) of the body) or inflammatory disease.

Further information can be accessed at the relevant NICE guideline for these conditions.

Patients presenting with low back pain and sciatica should be reviewed in accordance with the low back pain and sciatica guidance [NG59]. Patients presenting with low back pain without sciatica should be reviewed and if none of the above serious underlying pathology are suspected, primary care management typically includes reassurance, advice on continuation of activity with modification, weightloss, analgesia, manual therapy and reviewing patients who are high risk of developing chronic pain (i.e. STaRT Back).

NICE guidelines recommend using a risk assessment and stratification tool, (e.g. STaRT Back), and following a pathway such as the National Back and Radicular Pain Pathway, to inform shared decision making and create a management plan.

Consider a combined physical and psychological programme for management of sub-acute and chronic low back pain (greater than 3 to 6 months duration) e.g. Back Skills Training (BeST). Consider referral to a specialist centre for further assessment and management if required. Imaging within specialist centres is indicated only if the result will change management.

For further information please see the following NICE guidance:

• NICE. Low back pain and sciatica in over 16s: assessment and management [NG59]
• NICE. Low back pain and sciatica in over 16s [QS155]

NICE recommends imaging does not often change the initial management and outcomes of someone with back pain. This is because the reported imaging findings are usually common and not necessarily related to the person’s symptoms. Many of the imaging findings (for example, disc and joint degeneration) are frequently found in asymptomatic people. Requests for imaging by non-specialist clinicians, where there is no suspicion of serious underlying pathology, can cause unnecessary distress and lead to further referrals for findings that are not clinically relevant.

Undertaking imaging when it is not indicated can lead to further additional and unnecessary investigations and treatment, including surgery, increasing the risk of harm to patients and driving up costs.

There is evidence that most patients in whom a serious underlying pathology is not suspected and without red flag symptoms will recover from low back pain within six weeks.

In patients with symptoms suggestive of cauda equina syndrome, imaging should not be delayed. The spinal surgery GIRFT report has recommended there should be a low threshold for investigation and, following urgent referral by a senior clinician, an MRI should be undertaken as an emergency. The decision to perform an MRI does not require discussion with the local spinal services. The MRI must be undertaken as an emergency in the patient’s local hospital and a diagnosis achieved prior to any discussion with the spinal services. The MRI must take precedence over routine cases and any reasons for a delay or a decision not to perform an emergency scan should be clearly documented. Hospitals with MRI facilities that are not providing a 24/7 service (usually due to a lack of radiographer out of hours support) are being encouraged to provide this service.

Information for Patients

Imaging means carrying out x-rays or scans. Imaging of the lower back to investigate the cause of back pain rarely helps decide how your pain is treated. Imaging should therefore only be performed after careful assessment from a clinician when they suspect a serious underlying cause of the back pain.

About the condition

Lower back pain is a very common condition and it can affect a person’s quality of life. However, it is rarely caused by serious disease and will often improve over time or with some changes to lifestyle. A doctor, or other clinician, should carry out an assessment to check there are no signs of serious causes for your lower back pain that may need further investigation.

What are the BENEFITS of the imaging?

Most people do not need imaging for their lower back pain. However, a small number of people may have other symptoms alongside the lower back pain that may suggest a serious underlying cause for their pain. Imaging may then be needed.

What are the RISKS?

Imaging may reveal minor changes that are common in lots of people and are not causing the lower back pain. Being told there are minor changes may cause unnecessary concern for people and may mean further investigations are carried out that do not provide any benefits for them.

Also, some imaging exposes people to potentially harmful radiation.

What are the ALTERNATIVES?

Continuing with day-to-day activities as much as possible can benefit many people. For some people, losing weight, physical exercise, physiotherapy and/or pain killers may also help. You can discuss alternatives, and what is best for you, with your doctor.

What if you do NOTHING?

Most back pain often settles by itself. However, for many people, periods of back pain may come and go throughout their life.

1. NICE Quality standard (2017) Low back pain and sciatica in over 16s [QS155]
2. NICE Clinical guideline (2014) Neuropathic pain in adults: pharmacological management in non-specialist settings [CG173]
3. NICE guideline (2017) Spondylarthritis in over 16: diagnosis and management [NG65]
4. iRefer (2017) Making the best use of clinical radiology. Eighth edition. Royal College of Radiologists
5. Nice Guideline (2016) Low back pain and sciatica in over 16s: assessment and management [NG59] endorse STarT Back resource
6. Lamb S, et al on behalf of the Back Skills Training Trial investigators: Back Skills Training (BeST): Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost effectiveness analysis. The Lancet 2010;375;9718,p916-923. DOI https://doi.org/10.1016/S0140-6736(09)62164-4
7. Williams CM, Maher CG, Hancock MJ, et al. Low Back Pain and Best Practice Care: A Survey of General Practice Physicians. Arch Intern Med. February 8, 2010 2010;170(3):271-277.
8. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low back pain: systematic review and meta-analysis. Lancet. Feb 7 2009;373(9662):463-472.
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10. Kerry S, Hilton S, Patel S, Dundas D et al. Routine referral for radiography of patients presenting with low back pain: Is patients’ outcome influenced by GPs’ referral for plain radiography? Health Technol Assess. 2000; 4 (20):1-129. (UK). National Low Back and Radicular Pain Pathway 2017.
11. Lemmeres GPG, van Lankveld W, Westert GP et al, Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work, European Spine Journal, May 2019, 28(5):937-950.
12. Savigny P, Kuntze S, Watson P, et al. Low Back Pain: early management of persistent non-specific low back pain. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners.

Last revised December 2023