Home > Adults > Radiology imaging >

Spinal Imaging in Primary Care

Checked: 23-08-2020 by Vicky Ryan Next Review: 23-08-2021

Overview

Imaging for spinal pain is rarely indicated. Spinal imaging is an overused investigation in primary care and should be reserved for patients with red flags where serious underlying pathology is suspected or in patients where it will potentially change management. X-Ray is rarely indicated but may be helpful if osteoporotic fracture is suspected for example.

Inappropriate use of xray and MRI is a financial burden on CCG resources and may lead to findings that are incidental or not relevant that in turn can lead to increased patient anxiety and unnecessary referral into secondary care.

Consider spinal imaging in the presence of red flags. Suspicion is proportional to number of these (the presence of one red flag does not necessarily trigger imaging, it just raises clinical suspicion). Please refer to the spinal/back pain page for more detail:

Non-mechanical pain, night pain
History of trauma - fracture?, osteoporosis? (Consider age versus force)
Structural deformity
Persistent thoracic pain (mets prevalence highest in thoracic spine, lowest in cervical spine)
Past history: carcinoma, (lung, prostate, thyroid, kidney, breast - mostly metastasise to the spine); steroids, HIV, IVDU, immunosuppression
Unwell, weight loss, constitutional symptoms
NEW presentation under age 20 or over 55
Neurology: especially saddle anaesthesia, bowel and bladder disturbance (Cauda Equina Syndrome); muscle weakness, widespread / progressive neurology (Nerve root involvement / cord compression in cervical and thoracic spine.

Cauda equina sydrome (CES): If caudal equina syndrome is suspected, see the spinal/back pain page for red flags. If indicated, direct the patient to the nearest emergency department for immediate imaging.
Sciatica with lower limb neurology: see spinal/back pain page for advice on appropriate investigation and management.
Inflammatory back pain: If concerns about inflammatory back pain, refer to spinal/back pain page.
Spinal malignancy. If spinal malignancy or metastatic spinal cord compression is suspected then book MRI directly (stating suspected cancer and detailing your concerns) or refer to emergency department if any progressive neurological dysfunction. See NICE guidelines which give advice on early detection and imaging of suspected MSCC. Also see link to Brain and CNS 2WW guidelines.
Spinal infection. For suspected spinal infection, book MRI directly and perform WCC and CRP. Refer to the emergency department if any progressive neurological dysfunction or if patient is systemically unwell.

Remember, osteoarthritic changes, disc narrowing, protrusions, and herniations are all a normal part of ageing, and don't necessarily correlate with symptoms or change management. Be prepared to explain to your patients in non-threatening language the above changes which are likely to be seen on most spinal imaging.

For further advice on imaging of the spine please see the Radiology Guidelines for Primary Care section.

For further advice on spinal pain, go to Spinal/back pain page of REMEDY.

MRI for back pain?

Information leaflets for patients and clinicians to support appropriate use of spinal MRI have been published by NHSE (December 2022)

In 2017/18 the CCG spent £1.7million on MRI direct access and this year it is predicted to increase by 22% to £2.1million. 50% of this cost is due to spinal MRI.

The following You Tube video is also a useful guide to referrers and patients on appropriate use of MRI in management of back pain:

Should you have a MRI for Low Back Pain?

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.