When Imaging is Necessary

by Michael Zychowicz, DNP
by Michael Zychowicz, DNP

I am sure at one time or another in all of our careers, we struggle with conflict in what we should do and what we actually do for a patient. The patient may be requesting an antibiotic when it is not really necessary, but you may prescribe it “to make the customer happy”. Or you do a diagnostic test not because it is medically indicated but you feel more secure medicolegal by performing the test.
In taking care of patients with acute low back pain, we struggle with patient requests for imaging when it may not be necessary. The patient may be requesting an MRI, CT scan or an x-ray. When confronted with these conflicts we have to lean on the evidence and accepted treatment algorithms. For back pain, remember to test selectively. There is evidence in the literature that routine x-rays for non-specific or mechanical low back pain has no has no outcome benefit. For patients with no red flags, most treatment algorithms do not indicate obtaining lumbar spine x-rays for non-specific back pain until four weeks after the onset of pain. These algorithms take into account the benefit of the lumbar spine imaging as well as the large amount of radiation exposure with these images. One source states that gonadal radiation from a 2 view lumbar spine x-ray is equal to a daily chest x-ray for a full year!
Other imaging should be used selectively to look for pathology such as cancer, infection, cauda equina, fractures, or herniated disc. The downside of all imaging is that we can find pathology that is really not the cause of the patient’s pain. Just as with the x-rays, the literature supports that there is no outcome benefit to non-selective imaging of our patients.
If you are struggling with what imaging to obtain or even if you should obtain an image, rely on the evidence, your H&P, and accepted treatment algorithms.