Rethinking X-Rays and MRIs for Low Back Pain

Radiographic imaging, like X-rays, are seldom beneficial in the evaluation of acute low back pain. Low back pain is incredibly common, and just about everyone can expect to have an episode (if not multiple episodes) of back pain at some point in their lifetime. In the United States, low back pain is the second most common reason (after upper respiratory infections) for people to go to the healthcare provider.

Doctor showing a patient a spine model in exam room

ADAM GAULT / SPL / Getty Images

Your low back pain can feel like a deep aching sensation that is hard to relieve, and you could worry that something is seriously wrong with your spine.

When evaluating your low back pain, your clinician will examine you to see if you have signs or symptoms of a more worrisome problem. The reality is that there is rarely a serious cause of low back pain, even when symptoms are severe. That said, your healthcare provider might decide that an X-ray or MRI of your lower back could be helpful in your evaluation.

The Recommendations

Professional societies have recommended that imaging studies should not be obtained in the early stages of typical low back pain. So your healthcare provider is unlikely to order imaging unless you have a particularly unusual history or physical examination.

Recommendations include:

  • The North American Spine Society: "Don’t recommend advanced imaging (e.g., MRI) of the spine within the first six weeks in patients with non-specific acute low back pain in the absence of red flags."
  • American College of Emergency Physicians: "Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition."
  • American College of Family Physicians: "Don’t do imaging for low back pain within the first six weeks unless red flags are present."

There are situations in which imaging may be helpful, but these are typically the exception rather than the rule. 

Issues that often warrant diagnostic imaging studies include:

  • Tumors
  • Infection
  • Fracture
  • Severe neurologic compromise

Symptoms of these conditions include fever, recent weight loss, history of cancer, history of intravenous drug use, history of severe trauma, and urinary retention or incontinence. These signs, often described as "red flags," are not frequent.

Rationale From Recommendations

Imaging studies do not usually provide value in terms of helping people who have low back pain find relief from their discomfort. The treatment of acute low back pain does not typically change based on X-ray and MRI results. Even if the underlying diagnosis is not entirely clear, the treatment recommendations are not usually altered.

An imaging test is obtained when the results of that test are likely to help in deciding between different treatment paths. If the result of the test is unlikely to change the treatment path, then the test should not be performed.

Furthermore, sometimes imaging studies can complicate the situation. An imaging test may lead to unnecessary invasive procedures or additional tests, which may not ultimately help relieve your symptoms. The treatment of acute low back pain is focused on relieving symptoms with strategies like gentle, targeted movements, avoidance of aggravating activities, and tailored therapies that may provide relief including:

Each of these treatment modalities has been shown to provide pain relief for acute low back pain. Professional societies advise avoiding prescription medications, especially narcotic medications, for the treatment of back pain. Over-the-counter medications, including nonsteroidal anti-inflammatory medications and/or Tylenol, are considered first-line medication treatment for low back pain.

A Word From Verywell

Low back pain can be a frightening experience, especially when it seemingly comes out of nowhere. The pain can feel unusual, uncomfortable, and frightening. You might wonder if imaging tests are necessary to evaluate your spine. The reality is, except in specific circumstances, imaging of the spine with X-rays, MRIs, or other tests is typically not necessary. In fact, numerous professional societies have made specific recommendations that patients should avoid these types of imaging tests. While imaging may ultimately become necessary, the vast majority of people with low back pain will never require imaging to help relieve their symptoms.

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By Jonathan Cluett, MD
Jonathan Cluett, MD, is board-certified in orthopedic surgery. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams.