Lumbar Spine Imaging - Guidance for GPs and Referring Clinicians

Publication: 25/06/2015

Next review: 28/09/2024

Referral Guideline/Pathway

CURRENT

ID: 4245

Approved By: Trust Clinical Guidelines Group

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

Pertinent aspects of history and examination
Key diagnostic criteria
Investigations required
Treatment / Management

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.

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.

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
Acute back pain with Red Flag symptoms	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
Acute back pain without Red Flag symptoms	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
Suspected osteoporotic collapse, with or without trauma	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

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.

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.