My doctor didn’t order an x-ray for my back pain…

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Question: I consulted a doctor for back pain of a couple days’ duration which started after a long day of work. He just sent me home on pain relievers. He didn’t even order for x-rays! Is this acceptable?

Answer: The need for imaging tests (x-rays, MRIs, etc.) largely depends on the characteristics of back pain, other accompany symptoms and findings on the doctor’s physical exam. Contrary to popular belief, there is no “routine” set of tests needed when a patient comes to the doctor for back pain.

In 70-80% of cases, back pain is expected to resolve in 2-4 weeks from onset. During such time, pain relievers are prescribed to promote functioning. Complete bed rest beyond 48 hours is not advisable as it may be more counter-productive – causing deconditioning of back muscles.

However, some causes of back pain may need immediate management. These include back pain caused by cancer, infection, trauma/ fracture and cauda equina syndrome. These conditions may be suggested when the following features (so called RED FLAGS)  are present:

  • Age>50-70 years
  • Unexplained weight loss
  • Pain that is worse at night, not relieved by rest
  • Fever (T>37.5oC)
  • History of trauma
  • History of prolonged steroid use
  • History of illicit drug use
  • Use of immunosuppresant drugs
  • Past or current history of cancer
  • History of trauma prior to onset of back pain
  • Incontinence – either bowel or bladder
  • Weakness of either or both legs
  • Loss of sensation in the pelvic region

If any of these are present as assessed by the physician, either x-rays or CT Scans or MRI may be requested. Prompt surgical evaluation may also be needed.

However, in the absence of the above red-flags or other features of nerve involvement (to be discussed in another post), the request for x-rays, MRI and CT scan exams must be weighed.

So in patients with low back pain of less than 2 weeks duration and no red flag signs or features suggestive of nerve involvement, imaging tests may not be necessary.

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