Clinical UM Guideline

This document addresses the use of lumbar (including lumbosacral) x-rays for the evaluation of low back pain.

Note: Please see the following related document for additional information:

• CG-SURG-29 Lumbar Discography
• RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)

Medically Necessary:

Lumbar x-rays are considered medically necessary for the evaluation of low back pain (LBP) when any of the following criteria are met:

1. The individual has a history of subacute (4-12 weeks duration) or chronic (12 or more weeks duration) LBP (with or without radiculopathy); and
   1. Symptoms are persistent or progressive during or following 6 weeks of optimal medical management; and
   2. They are a candidate for a surgical or other interventional procedure;
      or
2. The individual is suspected of having cauda equina syndrome; and
   1. Advanced imaging (MR or CT of the lumbar spine) is contraindicated or not available;
      or
3. The individual has a history of LBP (with or without radiculopathy); and
   1. A history of prior lumbar surgery; and
   2. Is experiencing new or progressive symptoms or clinical findings;
      or
4. The individual is at risk for vertebral compression fracture due to any of the following:
   1. Osteoporosis; or
   2. Prolonged steroid use; or
   3. History of low velocity trauma;
      or
5. The individual has any of the following conditions:
   1. Is immunosuppressed; or
   2. Is suspected of having cancer; or
   3. Is suspected of having a spinal infection (such as epidural abscess or discitis osteomyelitis).

Not Medically Necessary:

Lumbar x-rays are considered not medically necessary for the evaluation of low back pain in individuals not meeting the medically necessary criteria above, including but not limited to those with acute, sub-acute or chronic low back pain, with or without radiculopathy, with no red flags (sign or symptoms suggesting a serious pathology which requires diagnostic imaging) and no prior management.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met.

Summary

In the majority of individuals presenting with complaints of low back pain, no specific pathology for LBP can be identified. In the absence of red flags raising concern for a more serious condition (such as fracture, infection, or underlying malignancy), imaging of uncomplicated LBP, with or without radiculopathy, is not typically warranted. There is a lack of relevant literature to support the use of routine radiography in this setting, with multiple guidelines recommending against the routine use of radiography in this scenario due to the potential harm associated with ionizing radiation and the lack of impact on management.

Imaging is reserved for those individuals who have had up to 6 weeks of physical therapy and medical management that resulted in little or no improvement in LBP symptoms. It is also considered for those individuals who present with red flags, raising suspicion for a significant underlying condition, such as infection, fracture, or malignancy.

Discussion

Low back pain (LBP, or lumbago) refers to pain that is felt between the lower edge of the ribs and the buttock. The pain can vary from a sudden, sharp feeling to a dull and constant ache. The pain may also radiate into other areas of the body, in particular the legs (American College of Radiology [ACR], 2021b; World Health Organization [WHO], 2023). LBP is commonly classified according to its duration. Although there are variations in the definition of ‘acute’ and ‘subacute’ LBP, for the purposes of this guideline, the definitions provided in the ACR Appropriateness Criteria for Low Back Pain are used, which defines acute LBP as 0 to 4 weeks, subacute LBP as 4 to 12 weeks, and chronic LBP as greater than 12 weeks (ACR, 2021b).

According to the WHO, LBP is the leading cause of disability worldwide and is estimated to affect as many as 619 million people. LBP is often associated with loss of work productivity and consequently results in a huge economic burden on individuals and societies. LBP can occur at any age. Most individuals experience LBP at least once in their life. While the prevalence of LBP worldwide increases with age up to 80 years, LBP occurs most frequently in women and individuals between the ages of 50-55 years (WHO, 2023).

In the United States, acute LBP, with or without radiculopathy (injury or damage to nerve roots in the area where they leave the spine), is the fifth most common reason for physician visits and accounts for approximately 3% of visits to the emergency department. Non-specific LBP that cannot reliably be attributed to a specific spinal abnormality or disease is the most common presentation of LBP. More than 85% of individuals presenting to their primary care provider have unspecific LBP. In a small subset of individuals presenting for initial evaluation in the primary care setting, LBP is attributed to a specific disorder, such as compression fracture (4%), cancer (0.7%), ankylosing spondylitis from 0.3% to 5%, and spinal infection (0.01%). Spinal stenosis and symptomatic herniated disc are present in about 3% and 4% of individuals, respectively. Cauda equina syndrome is considered rare, with an estimated prevalence of 0.04% among individuals with low back pain (Deyo, 1992; Chou, 2007; Jarvik, 2002; Underwood, 1995).

Risk factors associated with back pain complaints include age, obesity, smoking, physically strenuous work, Workers' Compensation insurance, job dissatisfaction, and psychological factors such as somatization disorder, anxiety, and depression (ACR, 2021b; Chou, 2007; Hegmann, 2019; Johnson, 2019; Qassem, 2017).

Evaluation of Low Back Pain

Low back pain is frequently classified and treated according to symptom duration, potential cause, presence, or absence of radicular symptoms, and corresponding radiographic or anatomical abnormalities (Qaseem, 2017). As mentioned above, although there are variations in the definition of acute and subacute LBP, for the purposes of this guideline, the definition provided in the ACR Appropriateness Criteria for Low Back Pain (ACR, 2021b) is used. The duration of symptoms can help guide treatment algorithms in individuals with acute, subacute, or chronic LBP (Chou, 2007; Chou, 2011).

Although there are many etiologies of LBP, more than 85% of the individuals presenting in the primary care setting will have nonspecific LBP which resolves on its own over the course of the first month. Less than 1% of the individuals presenting in the primary care setting will have LBP secondary to a serious etiology (metastatic cancer, spinal infection, or cauda equina syndrome) and most of these individuals will have risk factors or other symptoms (Chou, 2011).

For the initial evaluation of LBP, a history and physical examination are essential to evaluate for signs and symptoms that indicate a need for immediate imaging and further evaluation. Individuals presenting with LBP are generally classified into 1 of 3 broad categories (Chou, 2007):

• Nonspecific low back pain
• Back pain potentially associated with radiculopathy or spinal stenosis (suggested by the presence of pseudoclaudication)
• Back pain is potentially associated with another specific spinal cause. This category comprises the small percentage of individuals with serious or progressive neurologic deficits or underlying conditions which require prompt evaluation (such as tumor, infection, or cauda equina syndrome), as well as individuals with other conditions that may respond to specific treatments (such as ankylosing spondylitis or vertebral compression fracture).

Clinicians should inquire about the location, frequency, and duration of LBP, as well as any history of previous symptoms, treatment, and response to treatment. The possibility of LBP due to problems outside the back, such as nephrolithiasis, pancreatitis or aortic aneurysm, or systemic illnesses, such as endocarditis or viral syndromes, should be considered. Evaluations should include assessing for the presence of rapidly progressive or severe neurologic deficits, including motor deficits at more than one level, bladder dysfunction and fecal incontinence. Clinicians should also inquire about risk factors for cancer and infection. (Chou, 2007).

In addition to the history and physical examination, it is recommended that individuals with acute LBP also be evaluated for additional contributing factors such as social or psychological distress. The assessment of psychosocial risk factors when obtaining patient history can be a strong predictor of individuals who are predisposed to developing chronic disabling LBP difficulties. The duration of symptoms can help guide treatment algorithms in individuals with acute, subacute, or chronic LBP. However, radiological imaging is not considered necessary for the initial evaluation of acute, nonspecific LBP (ACR, 2021b; Chou,2007; Chou, 2011).

Completing a medical history and performing a full neurologic exam is particularly important in individuals with acute back pain to determine if there are any “red flags.” The presence of red flags in acute LBP signifies the potential for serious pathology and requires diagnostic imaging and referral to a specialist. Red flags include the following:

• Age (under 18 or over 50 years)
• Drug use (including IV drugs or anticoagulants)
• Trauma (including recent surgery, fractures)
• Fever/infection
• Immunocompromised status
• Personal history of malignancy, and
• Presence of neurological deficits (motor, sensory, and/or bowel/bladder dysfunction, and in particular, cauda equina syndrome) (Gushcha, 2024).

Acute, Nonspecific LBP Without Red Flags

Several professional medical societies and governmental organizations have advised against the routine use of x-rays for the evaluation of acute (less than 4 weeks duration), nonspecific LBP in individuals without red flags or signs or symptoms of a serious underlying condition.

According to the World Federation of Neurosurgical Societies (WFNS; Gushcha,2024):

• Patients with persistent radiculopathic symptoms, severe progressive neurologic deficits, or serious underlying conditions with acute LBP should undergo diagnostic imaging.
• Patients with first-time presentation of acute LBP without red flags do not require radiological investigation.
• There is strong evidence that routine imaging for acute LBP does not provide clinical benefit. Diagnostic imaging studies might reveal incidental findings without pathological value, and should be performed only in selected patients.

The WFNS also provides the following recommendations:

Physicians should determine the most appropriate spinal imaging modality based on the individual clinical situation, with goals of avoiding unnecessary radiation exposure and minimizing cost. In addition, it is important that physicians do not obtain radiologic imaging for non-specific acute LBP without red flags. Imaging in these cases has not been shown to impact the natural course of the disease with regards to pain, function, or quality of life, and rarely affects treatment plans. On the contrary, it may cause negative psychological impact. In particular, becoming aware of clinically irrelevant imaging findings may cause patients to have high levels of anxiety, to focus excessively on minor back symptoms, and to avoid exercise or other recommended activities due to fear of injury. These fears may be further exacerbated by lack of social support, small number of social contacts, low mood/depression, overprotective family members, financial problems, and other so-called “yellow flag” signs.

The ACR has issued the following guidance (ACR, 2021b):

Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags, raising suspicion for a serious underlying condition, such as cauda equina syndrome, malignancy, fracture, or infection.

In their evidence-based guidelines on the evaluation and treatment of low back disorders, the American College of Occupational and Environmental Medicine (ACOEM; Hegmann, 2019) states:

Lumbar spine x-rays are not recommended in patients with LBP in the absence of red flags for serious spinal pathology within the first 4 to 6 weeks. Among patients with evidence of radiculopathy, imaging in the acute pain setting is also not recommended as the natural history is for such problems to resolve with conservative care... An imaging study may be appropriate for a patient whose limitations due to consistent symptoms have persisted for 1 month or more to further evaluate the possibility of potentially serious pathology such as a tumor or with progressive neurologic deficit(s).

Similarly, the American Academy of family Physicians (AAFP; Casazza, 2012) cautions that:

Imaging is not warranted for most patients with acute low back pain. Without signs and symptoms indicating a serious underlying condition, imaging does not improve clinical outcomes in these patients.

In a collaborative publication, the American College of Physicians (ACP) and the American Pain Society (APS) (Chou, 2007) issued the following guidance:

Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence) …

There is no evidence that routine plain radiography in patients with nonspecific low back pain is associated with a greater improvement in patient outcomes than selective imaging. In addition, exposure to unnecessary ionizing radiation should be avoided. This issue is of particular concern in young women because the amount of gonadal radiation from obtaining a single plain radiograph (2 views) of the lumbar spine is equivalent to being exposed to a daily chest radiograph for more than 1 year.

Individuals with Red Flags or Signs/Symptoms of Serious Underlying Condition

While professional medical societies have recommended against the use of routine spinal x-rays in individuals presenting with acute, nonspecific LBP, several medical societies have also issued guidance supporting the use of radiologic examinations of the spine in individuals who present with red flags or signs or symptoms of a serious underlying condition. For example, in its criteria for Suspected Spine Infection, the ACR (ACR, 2021c) recommends the following:

Radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants… Initial radiography imaging of the area of the spine of interest may be appropriate in individuals with suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new or worsening back or neck pain, with or without fever, who may have one or more of the following red flags (diabetes mellitus, IV drug use, cancer, HIV, or dialysis) or abnormal lab values.

The ACP and APS (Chou, 2007) issued the following guidance:

Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).

Plain radiography is recommended for initial evaluation of possible vertebral compression fracture in selected higher-risk patients, such as those with a history of osteoporosis or steroid use. Evidence to guide optimal imaging strategies is not available for low back pain that persists for more than 1 to 2 months despite standard therapies if there are no symptoms suggesting radiculopathy or spinal stenosis, although plain radiography may be a reasonable initial option.

Clinicians should also ask about risk factors for cancer and infection…There is insufficient evidence to guide precise recommendations on diagnostic strategies individuals who have risk factors for cancer but no signs of spinal cord compression. Several strategies have been proposed for such individuals, but none have been prospectively evaluated. Proposed strategies generally recommend plain radiography …For patients older than 50 years of age without other risk factors for cancer, delaying imaging while offering standard treatments and reevaluating within 1 month may also be a reasonable option.

Features predicting the presence of vertebral infection have not been well studied but may include fever, intravenous drug use, or recent infection. Clinicians should also consider risk factors for vertebral compression fracture, such as older age, history of osteoporosis, and steroid use, and ankylosing spondylitis, such as younger age, morning stiffness, improvement with exercise, … alternating buttock pain, and awakening due to back pain during the second part of the night only, as specific treatments are available for these conditions.

Individuals with Subacute or Chronic LBP and Persistent or Progressive Symptoms

For individuals with chronic LBP and no red flags, first-line treatment remains conservative therapy with both pharmacologic and nonpharmacologic (e.g., remaining active, exercise) therapy. However, individuals presenting with subacute or chronic LBP, with or without radiculopathy, who have failed 6 weeks of conservative therapy should be imaged if they are believed to be candidates for surgery or intervention or if diagnostic uncertainty persists. The purpose of imaging is to identify potential actionable pain generators that might be targeted for surgery or intervention. In this group of individuals, MRI of the lumbar spine has become the preferred initial imaging modality. Although lumbar x-rays alone are not sufficient to provide guidance on surgical or interventional options without MRI and/or CT imaging, it may be considered complementary (ACR, 2021b).

Individuals with Suspected Cauda Equina Syndrome

The ACR has indicated that in individuals with symptoms of cauda equina, “there is no relevant literature to support the use of radiography in the initial imaging of suspected CES.” The ACR has specified that MRI with and without contrast, CT without contrast, and CT myelography are the appropriate imaging options for this population of individuals (ACR, 2021b).

Individuals with History of Lumbar Surgery and New or Progressing Symptoms or Clinical Findings

Hardware failure refers to the malfunction of a device or implant that was designed to support and stabilize the spine. Unfortunately, when these spinal devices fail to perform as expected, the consequences can be severe. Premature wearing, loosening, fracture, or dislodgement of hardware can result in nerve compression, chronic pain, and limited mobility. In these instances, revision surgery may be necessary to correct the problems and restore function. The ACR (ACR, 2021b) has determined that spinal x-rays may be useful in evaluating the following:

… alignment and hardware integrity in individuals with new or progressing symptoms and previous lumbar fusion. Upright radiographs provide useful functional information about axial loading. Flexion and extension radiographs can be used to look for abnormal motion/increased dynamic mobility.

Individuals at High Risk for Spinal Compression Fracture

Lumbar imaging using x-rays may be useful in individuals with history of steroid use and osteoporosis. Both long and short-term use of corticosteroids can increase the risk of osteoporosis. Compression fractures in older adults usually result from osteoporosis, but only approximately 30% of this population presents with identifiable trauma. The prevalence of this condition occurs more frequently in certain races. For example, African American and Mexican American women have 25% fewer compression fractures than Caucasian women. The ACR has deemed the use of lumbar x-rays useful in assessing LBP in individuals suspected of having a possible vertebral compression fracture but who are not believed to have sustained trauma and have a history of steroid use or osteoporosis. (ACR, 2021b; Jarvik, 2002).

Individuals with Suspicion of Cancer, Infection, or Immunosuppression

The sensitivity of x-ray is limited for identifying metastatic cancer. Advanced imaging such as MRI is preferred to x-ray due to higher sensitivity and specificity for identifying osseous lesions and the ability to appraise soft-tissue abnormalities. Owing to the lack of medical literature evaluating the use of x-rays in this specific population, the ACR (ACR, 2021b) concluded that:

There is insufficient medical literature to conclude whether or not these patients would benefit from radiography lumbar spine. This procedure in this patient population is controversial but may be appropriate.

Individuals with Suspected Spine Infection with New or Worsening Back or Neck Pain and Concerning Underlying Conditions

For the group of individuals with suspected spinal infection with new or worsening back or neck pain and concerning underlying conditions (such as dialysis, diabetes mellitus, IV drug use, cancer, or HIV) or abnormal lab values, the ACR provides determined that lumbar x-rays “may be appropriate” as part of the initial evaluation, however, lumbar x-rays in this population may be normal in early stages of the condition or infection (ACR, 2021c).

Clinically, it may be difficult to differentiate spine infection from other causes of neck or back pain such as degenerative disease, trauma, inflammatory spondyloarthropathy, or neoplastic involvement of the spine. As any one of these clinical entities has the potential to mimic the imaging appearance of spine infection, it is important to use the combination of clinical presentation, laboratory values such as an elevated ESR and CRP and imaging findings in order to consider the diagnosis of spine infection…

Radiography can be used as part of the initial evaluation in patients with suspected spine infection. Radiographs may not show any abnormalities during the early course of spine infection. Imaging findings such as disc space narrowing, vertebral endplate erosion, and gross paraspinal soft tissue changes that can be seen on radiography lag behind the clinical course of spine infection by at least 2 to 8 weeks. Nevertheless, the possible presence of one or more of these findings may increase the clinical suspicion for infection and may help guide subsequent imaging management. Radiographs, however, provide an overall view of the status and alignment of the vertebral column and can be used to assess for spinal instability (ACR 2021c).

Individuals with Suspected Spine Infection and Invasive Intervention (Surgery with or Without Hardware, Pain Injection, or Stimulator Implantation) Conditions

The ACR has determined that lumbar x-rays may be appropriate for individuals with suspected spine infections (such as epidural abscess or discitis osteomyelitis), with invasive intervention (such as surgery with or without hardware, pain injection, or stimulator implantation). Regarding this specific population, the ACR (ARC, 2021c) states:

The diagnosis of postintervention spine infection is a clinical challenge given an overlap of clinical symptoms such as neck or back pain between postoperative and spine infection patients. The identification of abnormal laboratory parameters, such as leukocytosis or elevated ESR or CRP, may increase the clinical suspicion for spine infection in the postintervention patient [8,9]. The timing of the imaging examination with respect to when the spine intervention is performed is particularly important, because expected findings such as alteration of soft tissue and osseous structures, edema, and small paraspinal fluid collections such as seromas may represent the normal sequelae of an intervention shortly (a few days to weeks) after the procedure …

Radiographs are insensitive during the early course of spine infection. In the subacute or chronic phase of infection, radiographs can be helpful in the follow-up evaluation of the posttreatment spine because serial radiographic studies may show new abnormalities such as implant loosening or alteration in spinal alignment that might be caused by infection.

Individuals with Suspected Spine Infection with Decubitus Ulcer or Wound Overlying Spine

The ACR provides the following information regarding the utility of x-rays for the evaluation of individuals suspected of having a spine infection in addition to a decubitus ulcer or wound covering the spine (ACR, 2021c).

Decubitus ulcers are often encountered at the level of the sacrum in chronically bedridden patients but may also be seen at other pressure sites along the back in immobile patients. When there is a clinical concern for possible spine infection extending from a decubitus ulcer or wound due to surgery or other causes, imaging may be necessary for further evaluation of the involved spinal segment. Imaging can be utilized to distinguish between superficial infection or cellulitis and deeper infections including osteomyelitis and paraspinal or epidural abscess formation…

Radiography provides a quick survey of the soft tissues and underlying osseous structures at the site of suspected spine infection when either a decubitus ulcer or wound is present. Radiography can be used to tailor a subsequent cross-sectional imaging examination especially in patients with prior spine surgery or interventions.

Cauda equina syndrome: A condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina become compressed or damage causing signs and symptoms such as LBP, pain that radiates down the leg, numbness around the anus, and fecal or bowel incontinence or urinary retention. Cauda equina syndrome may be caused by several conditions including disc herniation, spinal, stenosis and cancer.

Traumatic injury: Any sudden and severe damage to the body caused by energy (chemical, electrical, nuclear, and thermal) transfer. Traumatic injury occurs as a result of various incidents such as falls, accidents, sports injuries, or violence. Information regarding the type of trauma (penetrating or blunt, mechanism of injury, velocity, and direction of impact) is used to predict the type and extent of injury (Almigdad, 2022; Kuhajda, 2014; Varma, 2022; Young, 2015).

• Low velocity trauma is caused by events or objects that do not involve kinetic energy or high speeds. Examples of low velocity trauma include falls from standing height (ground level), assaults with blunt weapons like hammers or knives and automobile accidents at speeds below 10 mph (Young, 2015; Varma, 2022).
• Medium velocity trauma is frequently caused by most types of handguns and air-powered pellet guns and are characterized by much less primary tissue destruction than wound caused by high-velocity forces (Kuhajda, 2014).
• High-velocity trauma includes injuries sustained as a result of falling from height, motor vehicle accidents, as well as wounds caused by rifles, military weapons, and industrial injuries (Almigdad, 2022; Kuhajda, 2014).

Pseudoclaudication: A condition caused by spinal nerve compression, that triggers pain, weakness or numbness in the legs when walking or standing for extended periods. Pseudoclaudication is also referred to as neurogenic claudication and may be caused by lumbar spinal stenosis.

Radiculopathy: Injury or irritation to a spinal nerve root, typically caused by compression which leads to symptoms such as pain, numbness, or muscle weakness in the areas of the body supplied by the affected nerve. Radiculopathy is often caused by disc herniation or degenerative changes in the spine.

Red flags: Sign or symptoms suggesting a serious pathology which requires diagnostic imaging imaging).

Somatization disorder: A mental illness that produces one or more bodily symptoms, including pain. The cause of the symptoms may or may not be traceable to a medical condition, mental illnesses, or substance abuse.

Peer Reviewed Publications:

1. Almigdad A, Mustafa A, Alazaydeh S, et al Bone fracture patterns and distributions according to trauma energy. Adv Orthop. 2022; 2022:8695916.
2. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992; 268(6):760-765.
3. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002; 137(7):586-597.
4. Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015; 313(11):1143-1153.
5. Kuhajda I, Zarogoulidis K, Kougioumtzi I, et al. Penetrating trauma. J Thorac Dis. 2014; 6(Suppl 4):S461-S4655.
6. Underwood MR, Dawes P. Inflammatory back pain in primary care. Br J Rheumatol. 1995; 34(11):1074-1077.
7. van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine. 1997; 22:427-34.
8. Varma D, Brown P, Clements W. Importance of the mechanism of injury in trauma radiology decision-making. Korean J Radiol. 2023; 24(6):522-528.
9. Young L, Rule GT, Bocchieri RT, et al. When physics meets biology: low and high-velocity penetration, blunt impact, and blast injuries to the brain. Front Neurol. 2015; 6:89.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Radiology (ACR):
   • Expert Panel on Musculoskeletal Imaging; Czuczman GJ, Mandell JC, Wessell DE, et al. ACR appropriateness criteria^® inflammatory back pain: known or suspected axial spondyloarthritis: 2021 Update. J Am Coll Radiol. 2021a; 18(11S):S340-S360.
   • Expert Panel on Neurological Imaging; Hutchins TA, Peckham M, Shah LM, et al. ACR appropriateness criteria^® low back pain: 2021b Update. J Am Coll Radiol. 2021b; 18(11S):S361-S379. PMID: 34794594.
   • Expert Panel on Neurological Imaging; Ortiz AO, Levitt A, Shah LM, et al. ACR appropriateness criteria^® suspected spine infection. J Am Coll Radiol. 2021c; 18(11S):S488-S501.
2. Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012; 85(4):343-350.
3. Chou R, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011; 154(3):181-1189.
4. Chou R, Qaseem A, Snow V, et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147(7):478-491.
5. Gushcha AO, Sharif S, Zileli M, et al. Acute back pain: clinical and radiologic diagnosis: WFNS Spine Committee recommendations. World Neurosurg X. 2024; 22:100278.
6. Hegmann KT, Travis R, Belcourt RM, et al. Diagnostic tests for low back disorders. J Occup Environ Med. 2019; 61(4):e155-e168.
7. Johnson SM, Shah LM. Imaging of acute low back pain. Radiol Clin North Am 2019; 57:397-413.
8. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2017; 166(7):514-530.
9. World Health Organization. Low back pain. June, 2023. Available at: https://www.who.int/news-room/fact-sheets/detail/low-back-pain. Accessed on July 22, 2025.

1. American Association of Neurological Surgeons (AANS). Low Back Pain. April 5, 2024. Available at: https://www.aans.org/patients/conditions-treatments/low-back-pain/. Accessed on July 22, 2025.

Plain Radiograph
Low Back Pain
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