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Back Pain Imaging Pearls


Over 80% of adults will have back pain at least once in their life time. Most of the time, it’s self limiting, and not much needs to be done. But, rarely, in can mean something a little more dangerous.

And I think we can all agree we don’t want to miss anything.

But, like I said, most patients have nothing more than musculoskeletal pain and most patients will get better on their own – typically after a couple of weeks.

You do not need to order imaging studies for these patients. There are, however, exceptions (<1%), and these are the patients we have to look out for. So, what are they?

Well, there are four major medical conditions we should be on the lookout for: cauda equina syndrome, cancer, spinal infection, and spinal epidural abscess.

Cauda equina is most commonly a result of metastatic tumor and is actually the initial presentation of cancer in up to 20% of patients. Other things that can lead to cauda equina are hematoma, abscess, and/or disc herniation. Apart from pain, you want to look for weakness, numbness (saddle anesthesia), and parasthesias. Bladder/bowel dysfunction is a late finding.

The bone is the most common site of metastasis. So, anyone with a history of cancer and new onset back pain should be worked up for metastasis/pathological fracture/compression.

Patients with epidural abscess will also present with a fever. There should be suspicion for an abscess in patients who are immunocompromised, are injection drug users, and in those who have had recent spinal injection or epidural catheter placement.

Osteomyelitis presents as a gradual worsening of pain over days. Patients may or may not have any other symptoms and the incidence increases with age.

A few red flags to look out for includes older age (typically over 50), prolonged use of corticosteroids, severe trauma, and presence of contusion or abrasion – these are all risk factors for vertebral compression fracture.

If any red flags are present or if suspicion for the major 4 serious medical conditions exist, then immediate MRI and referral should be done.

Otherwise, conservative management for 4-6 weeks is appropriate.


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