Lumbar Spine Imaging - Guidance for GPs and Referring Clinicians

Publication: 25/06/2015  --
Last review: 24/09/2018  
Next review: 24/09/2021  
Referral Guideline/Pathway
CURRENT 
ID: 4245 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Referral Guideline/Pathway is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Lumbar Spine Imaging - Guidance for GPs and Referring Clinicians

Background

We perform approximately 3000 lumbar spine X rays per year for GPs in Leeds Teaching Hospitals NHS Trust (Total number of plain X rays is 300,000).
To ensure the best service to our referring GPs and clinicians, it is important that these, and indeed all X rays, are only performed when appropriate, when they are likely to help in the diagnostic pathway.

Plain X rays are rarely required in the investigation of back pain in the absence of trauma. This is particularly true when there is a typical history with no concerning features (Red Flags). They are an important first line investigation in the investigation of suspected osteoporotic collapse however (see below).

Where MRI is suggested but contraindicated e.g. due to a pacemaker, we suggest discussion with a Radiologist regarding the best imaging modality on a case by case basis.

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Diagnosis

The table below has been adapted from the Royal College of Radiologists guidelines which are available to all NHS staff, covering all commonly performed imaging investigations:  http://www.irefer.org.uk/

These guidelines are drawn up by expert panels with reference to the literature and a consensus opinion reached, updated on a regular basis to reflect changing evidence.

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Investigation

Guidelines for Spinal Imaging Referral

Dose key
*   <1 mSv The average annual background radiation dose in most of Europe is between 1-5 mSv.
   1-5 mSv  

 

 

Modality

Radiation dose

Recommendation

Comment

Chronic lumbar back pain with no Red flags

(see below for list of Red Flag symptoms)

MRI

None

Imaging only indicated in specific circumstances

For surgical planning

XR

For ? osteoporotic collapse in the elderly

CT

 

When MRI contraindicated

Thoracic spine pain without trauma: degenerative disease

MRI

None

Specialist investigation

If local pain persists or there are long tract signs

XR

Indicated for ? osteoporotic collapse

Not useful for assessing degenerative disease which is invariable in middle age and older adults

Acute back pain with Red Flag symptoms

MRI

None

Indicated

Urgently required in those with neurological signs, and suspected malignancy or infection

XR

Rarely indicated

May be required preoperatively

Acute back pain without Red Flag symptoms

MRI / CT

None/  
 

Indicated in specific circumstances, e.g. postoperatively

Disc herniation may be demonstrated but may be asymptomatic, specialist review required

XR

Rarely indicated

Acute back pain is usually as a result of conditions that X ray cannot diagnose, so a normal X ray can be falsely reassuring

Suspected osteoporotic collapse, with or without trauma

XR

Indicated

Lateral thoraco-lumbar spine XR is the first line investigation in suspected osteoporotic collapse

MRI

None

Specialised investigation

May distinguish between acute and chronic collapse and malignant and benign collapse

Skeletal metastases from known primary tumour

MRI

None

Indicated

More sensitive and specific than nuclear medicine or XR

Spinal Trauma with pain but NO neurological defecit

XR

Indicated

Low threshold to XR if there is pain / tenderness after a significant fall or other trauma e.g. RTC.

If XR is abnormal CT and / or MRI is indicated.

Spinal Trauma WITH  neurological deficit, with or without pain

(should be referred via the Emergency Department)

XR

CT

MRI

 

Indicated

Indicated

Indicated

XR used as initial investigation

CT gives detailed analysis of bone injury

Whole spine MRI is indicated with multilevel or ligamentous injuries and cauda equina injuries

Red Flag Symptoms  
These may indicate serious pathology. If back pain is present with any one of these then imaging is usually indicated as above.

Neurological

Other

Sphincter and gait disturbance

Age <20 or >55 years

Saddle anaesthesia

Previous malignancy

Severe or progressive motor loss

Systemic illness / weight loss

Widespread neurological deficit

HIV

 

IV Drug use

 

Steroid use

 

Structural deformity

 

Non mechanical pain (no relief with bed rest)

 

Fever

 

Thoracic pain

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Treatment / Management

Positive findings on imaging should be discussed with the appropriate clinical team, e.g. Spinal Surgery for fractures or dislocations, Oncology for metastatic deposits causing symptoms.

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Provenance

Record: 4245
Objective:

Aims
To streamline and improve the imaging pathway of the lumbar spine

Objectives
To reduce unnecessary imaging investigations.
To ensure patients have appropriate imaging that will help in the diagnostic pathway.

Clinical condition:

Lumbar back pain and trauma

Target patient group: Adults
Target professional group(s): Primary Care Doctors
Secondary Care Doctors
Adapted from:

Evidence base

These guidelines are drawn up by expert panels with reference to the literature and a consensus opinion reached, updated on a regular basis to reflect changing evidence.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.