Tools for Practice

#17 X-rays for Non-specific Low Back Pain: A non-specific pain?

In patients with lower back pain, do lumbar X-rays modify any patient outcome?

In non-specific low back pain, X-rays do nothing to improve outcomes and may worsen some (such as pain).

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A recent meta-analysis, and a closer look at the best randomized controlled trial (RCT), help us here. 
  • Meta-analysis1: 6 trials (1804 patients): MRI/CT 2 trials & X-ray 4 trials.  0-44% had sciatica 
    • Relatively good quality but lots of heterogeneity (except pain). 
    • Short term & long-term outcomes of pain, function, quality of life, mental health and patient satisfaction did not differ significantly 
      • Pain at 3 months borderline worse with x-ray (Standard Mean Difference 0.19, CI -0.01 to 0.39) 
  • RCT,2 UK, 421 general practice patients with low-back pain ≥ 6 weeks  
    • At 3 months statistically significant difference in: 
      • Proportion of patients still in pain: 74% X-ray vs 65%, Number needed to harm (NNH) 12 
      • Proportion of patients requiring follow-up doctor visit: 53% X-ray vs 30%, NNH 5 
      • Self rated health status: 5% worse in X-ray group.   
  • After 6 more months, borderline but not statistically significant 
  • However, ≥ 80% of both groups want X-rays.  
    • Those with x-rays were more satisfied with the visit    
    • X-rays findings did not correlate to clinical findings
  • Early MRI and CT also do not improve outcomes.1 
  • A RCT comparing MRI directly to back X-ray also found no difference.3   
  • Three guidelines from Alberta4, Europe5 and US6 all discourage routine back x-rays for non-specific low back pain. 
  • Non-specific low back pain is low back pain without recognizable or known specific pathology (e.g. infection, tumour, osteoporosis, ankylosing spondylitis, fracture, inflammatory process, radicular syndrome or cauda equina syndrome).4-6  
  • These study results/recommendations do not apply to back pain with suspicion of specific pathology (such as progressive neurologic changes or infection) 
  • These patients warrant further investigation 
updated july 13, 2016 by ricky

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  • G. Michael Allan MD CCFP
  • G. Richard Spooner MD CCFP

1. Chou R, Fu R, Carrino JA, et al. Lancet 2009; 373: 463–72.

2. Kendrick D, Fielding K, Bentley E, et al. BMJ. 2001 Feb 17;322:400-5.

3. Jarvik JG, Hollingworth W, Martin B, et al. JAMA 2003;289:2810–8.

4. Accessed 27-AUG-2013.

5. NonspecificLowBackPain(54paginas).pdf Accessed 27-AUG-2013.

6. Chou R, Qaseen A, Snow V, et al. Ann Intern Med. 2007;147:478-491.

7. Chou R, Qaseem A, Owens DK, et al. Ann Intern Med 2011;154:181-9.

Authors do not have any conflicts of interest to declare.