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What to Consider Before Ordering Diagnostic Imaging Tests

Diagnostic imaging tests for patients presenting with spinal pain is a controversial topic. The federal Agency for Healthcare Research and Quality (AHRQ) formerly the Agency for Health Care Policy and Research (AHCPR), evaluated thousands of spinal articles and published guidelines that it felt were substantiated by the scientific literature. The following is an amalgam of AHRQ statements combined with some practical considerations from Allina Medical Clinic’s Adult Spinal Pain Task Force.

As with any test, imaging should not be ordered unless the results will change your treatment plan.

Guidelines for routine testing 

• Routine testing such as plain X-rays of the spine and/or other imaging is not recommended during the first month unless your history and exam raises suspicions of "bad things.”
  
  
• If no "red flags" are present, waiting four weeks (eight weeks for worker’s compensation cases) allows patients to recover and avoids unnecessary procedures. This also reduces the potential confusion of falsely labeling age-related changes on imaging studies (commonly seen in patients older than age 30 without spinal symptoms) as the cause of acute symptoms.  Red flags explained.
  
  
• Other "red flags" that may precipitate ordering early plain films include, but are not limited to:
  - recent significant trauma
  - mild trauma (50-70 years of age) with H/O prolonged steroid use or risk of osteoporosis
  - mild trauma in patients over age 70 
  - prior H/O cancer 
  - fever higher than 100 degrees Fahrenheit
  - IV drug use 
  - spinal pain worse with rest 
  - unexplained weight loss.
  
  
• When to order plain films/CT scan/MRI:
  - plain films -- if there are no "red flags" present, wait at least four to eight weeks before ordering plain spine films. They may not be needed if the patient recovers.
  - CT/MRI -- if specific conditions outlined in the operational definitions of the advanced imaging collection tool are met, then a CT or MRI could be 
  ordered in the first eight weeks.  

Patients with acute radicular symptoms
For information, see "Managing Acute Disc Herniations.” 

Patients younger than age 20

• Patients less than 20 years old carry a different imaging threshold. If the history and /or physical exam are negative for "red flags," aggressive conservative care can be attempted
  
  
• If the patient does not respond quickly (or gets worse), early imaging may be necessary.  
  
  
• Congenital/developmental problems need to be considered. Also, secondary causes of spinal pain could be present.  If you are contemplating an imaging test, a discussion with a radiologist or consultant may be beneficial to insure that the most appropriate test for your suspicions is performed, i.e. CT scan, MRI, bone scan.

Patients with chronic spinal pain

• Avoid ordering diagnostic imaging for patients with chronic spinal complaints unless there are "red flags.” The procedure can be very confusing and stressful for the patients.  
  
  
• Many chronic pain patients improve with an aggressive active rehab program. For those who don't, imaging tests still may not be necessary.
  
  
• Imaging tests for chronic spinal complaints should imply that the patient's quality of life is poor enough to warrant surgery AND that the patient would undergo surgery if imaging tests identify an obvious surgical lesion.

Cost effectiveness of spinal diagnostic imaging

Payers have not noted a decrease in spinal medical costs in spite of all the sophisticated spinal imaging options now available. In addition, lost work time and short/long term disability costs have actually increased despite improved "diagnostic" capabilities.

First published: 03/05/2002
Last updated: 06/01/2002

Reviewed by: Paul Kleeberg, MD