Utility of imaging for assessment of back and neck pain

van Tulder, 1997

Investigations that may assist in the diagnosis of specific causes of back and neck pain are guided by clinical assessment.

If no serious pathology is suspected (ie the person has nonspecific back or neck pain), early imaging (eg X-ray, computed tomography [CT], magnetic resonance imaging [MRI]) has no clinical utility.

Radiological findings are poorly correlated with symptoms in people with back and neck pain. Many commonly reported abnormalities on spinal imaging are age related and not related to the experience of pain. For example, intervertebral-disc abnormalities, facet-joint arthropathy, annular tears and spondylolisthesis occur frequently in adults without back pain. Giving people a diagnostic label (eg a ruptured, torn, prolapsed or herniated intervertebral disc) based on radiological findings is unhelpful and often leads to fear-avoidance behaviour, worsening disability and unwarranted further investigation and treatment.

Note: X-ray, CT and MRI have no utility for the early investigation of nonspecific back or neck pain. Radiological findings are poorly correlated with symptoms in people with back and neck pain. If serious pathology is suspected, obtain urgent imaging.
If serious back or neck pathology is suspected (see Serious pathologies requiring urgent management in patients with back and neck pain and their alerting features (‘red flags’) for examples), obtain urgent imaging.

If there is a history of recent trauma or a fracture is suspected, plain X-ray may be adequate. If no fracture is seen on the X-ray, and there is high suspicion of fracture, MRI may be appropriate.

Magnetic resonance imaging is the preferred investigation for all other spinal pathologies because of its accuracy in diagnosis and lack of radiation exposure. If MRI is not accessible or appropriate, CT scan is an appropriate alternative.

If other serious medical pathology is suspected (see Serious pathologies requiring urgent management in patients with back and neck pain and their alerting features (‘red flags’) for examples), seek guidance on the most appropriate investigations for that condition.