When to xray low back pain?

First off why lumbar xray is discouraged?
1) Mostly non-contributory
2) 65x CXR radiation (1.3 vs 0.02 mSv)
- for young female, gonadal radiation is even higher = 2-view LXR is equivalent to more than one year of daily CXR (Neuroimaging Clin N Am. 2003;13:293-305)

Indications:
(1) ICSI
(2) Australian
(3) ACP/APS

(1) ICSI
• unrelenting night pain or pain at rest (increased incidence of clinically significant pathology),
• history of or suspicion of cancer (rule out metastatic disease),
• fever above 38°C (100.4°F) for greater than 48 hours,
• osteoporosis,
• other systemic diseases,
• neuromotor or sensory deficit,
• chronic oral steroids,
• immunosuppression,
• serious accident or injury (fall from heights, blunt trauma, motor vehicle accident) – this does
not include twisting or lifting injury unless other risk factors are present (e.g., history of osteo-
porosis), and
• clinical suspicion of ankylosing spondylitis
• Over 50 years old (increased risk of malignancy, compression fracture)
• Failure to respond to four to six weeks of conservative therapy
• Drug or alcohol abuse (increased incidence of osteomyelitis, trauma, fracture)

(2) AUSTRALIAN

Red Flags in LBP F-I-T-A-C
* Australian Acute Musculoskeletal Pain Guidelines Group. EBM of acute musculoskeletal pain. Bowen Hills: Australian Academic Press; 2003. Available from: www.nhmrc.gov.au link

1) Fracture

• Major trauma
• minor trauma if >50, history of osteoporosis, and/or taking steroid
  

2) Infection

• Symptoms of infection (eg fever)
• Risk for spinal infection (IVDU, immunosuppression, underlying disease, penetrating wound)

3) Tumor/Malignancy

• Hx of malignancy
• >50 yo
• Unexplained weight loss (eg 4.5 kg in 6 months)
• Pain at multiple sites
• Pain at rest

4) AAA leak or rupture

• sudden onset
• collapse, syncope, hypotension
• pain not aggravated by spinal movement
• abdominal pain radiating to the back

5) Cauda Equina Syndrome

• Saddle anesthesia
• Bowel/Bladder incontinence of recent onset
• Widespread motor and/or sensory weakness

Clinical guidelines dictate that imaging is discouraged in the absence of redflags

(3) ACP/APS

Algorithm #1 of Initial Evaluation of LBP (link here)

• American College of Physicians and American Pain Society
  - web link: http://www.annals.org/cgi/content/full/147/7/478
  - pdf link: http://www.annals.org/cgi/reprint/147/7/478.pdf
  
• Do not use this algorithm for back pain associated with major trauma, nonspinal back pain, or back pain due to systemic illness

Algorithm #2 Management of LBP (link here)



Links:
ICSI LBP (pdf)
EBM of Acute MSK pain, Australia (pdf)