Although back pain is the most common and expensive cause of work disability in the United States, our understanding of low back pain (LBP) is limited despite the advantages of advanced imaging technologies. Diagnostic studies often are requested for fear of missing serious or occult pathology or to reassure patients but have a low likelihood of identifying a specific cause for the reported symptoms in patients who present with nonspecific LBP. From a clinical perspective, the information provided in lumbar imaging, whether plain X rays or magnetic resonance imaging (MRI), has not been found either to influence treatment recommendations or improve outcomes. Further, routine advanced imaging is not associated with improved outcomes and identifies many radiographic findings that correlate poorly with symptoms; imaging is recommended when severe or progressive neurologic deficit is present or if serious underlying disease is suspected. Surgery rates are highest where imaging rates are highest, and a significant proportion of the variation in rates of spine surgery can be explained by differences in the rates of advanced spinal imaging. Because imaging has no role in the impairment rating of nonspecific LBP, an individual's having a work injury that requires an impairment rating is not a reason to order spinal imaging. To answer the question in this article's title, the answer usually is not to order a spinal image.

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