The Role of Imaging in Low Back Pain Presentations

Have you experienced low back pain (LBP) before and wondered whether you should be referred for imaging?

Throughout one’s lifetime, 80-85% of the population will experience LBP.1-3 The routine use of imaging in non-traumatic back pain presentations is discouraged, with the literature suggesting that only 5-10% of low back pain presentations require imaging due to the presence of a specific underlying spinal pathology.1-3 The other 90-95% of LBP presentations have no indication of serious pathology and thus should be managed with education, reassurance, exercise prescription and/or pain management (i.e. conservative care).1-3 However, over the previous 20 years there has been over-utilisation of imaging in patients with low back pain, much of which has occurred outside of the appropriateness of guidelines.1-3 Literature has suggested that inappropriate referral for imaging is currently occurring 33% of the time.1-3

Although abnormal imaging findings including disc degeneration, herniated discs, disc protrusions, annular fissures and facet joint degeneration have been recognised as causative factors for pain in patients with LBP, they have also been found and detected in asymptomatic individuals (i.e. those who do not have LBP).1-3 The prevalence of these findings have also been found to increase with increasing age.1-3 Thus, radiological findings may have a poor correlation with the presence or severity of patient symptoms, and may result in the misinterpretation of results by the patient.1-3 In fact, studies have shown that unnecessary imaging for LBP has been correlated with poorer-perceived self-health and health prognosis, increased days absent from work, and the unnecessary utilisation of health services.1-3 However, having mentioned the above, imaging findings should not be considered irrelevant and should always be interpreted in relation to the patients presentation.1-3

You are probably wondering, when is it then appropriate to receive imaging in the presence of LBP?

Guidelines from the United States and United Kingdom recommend that imaging should only be utilised.1-3

  • Where specific and/or serious pathology or disease is suspected (e.g. cauda equina syndrome, radiculopathy, infection, malignancy/cancer, spinal haemorrhage, spinal fracture, osteoporosis, etc).

  • In the presence of red flags. Red flags refer to symptoms and signs that indicate the potential presence of a serious pathology (e.g. history of cancer, unexplained weight loss, recent trauma, urinary retention, weakness in the lower extremities, etc).

  • If the patient is not responding to initial conservative management.

  • If it is expected to change management decisions.

Non-specific and acute low back pain is most commonly benign in nature, with 85% of patients experiencing significant improvements in symptoms within several weeks.3 It often does not require further evaluation through the obtainment of imaging.

*Please note that this blog includes a discussion of the current literature only. Please always follow the advice received from your health or medical practitioner.


1. Cuff A, Parton S, Tyer R, Dikomitis L, Foster N, Littlewood C (2020). Guidelines for the use of diagnostic imaging in musculoskeletal pain conditions affecting the lower back, knee and shoulder. A scoping review. Musculoskeletal Care, 1-10.

2. Hall A, Aubrey-Bassler K, Thorne B & Maher C (2021). Do not routinely offer imaging for uncomplicated low back pain. BMJ, p. n291.

3. Rao, D., Scuderi, G., Scuderi, C., Grewal, R., & Sandhu, S. J. (2018). The Use of Imaging in Management of Patients with Low Back Pain. Journal of clinical imaging science, 8, 30.

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