Imaging for lower back pain

For typical mechanical low back pain without alarming features, the American College of Radiology Appropriateness Criteria and the Choosing Wisely campaign both discourage imaging in the first six weeks. Studies have repeatedly shown that early MRI does not improve outcomes for uncomplicated back pain — and may even prolong recovery by encouraging treatments that don't move the needle.

Imaging is appropriate sooner when 'red flag' features are present:

• Major trauma (a fall from height, a high-speed motor vehicle collision)
• Progressive neurologic weakness in a leg, or new bowel or bladder dysfunction
• Suspected infection (recent IV drug use, immunosuppression, fever with focal back pain)
• History of cancer that can spread to bone
• Unexplained weight loss or night pain
• Age over 70 with new pain, or age under 18 with persistent pain

Imaging is also reasonable after four to six weeks of pain that hasn't responded to first-line treatment (activity modification, NSAIDs, physical therapy) when a structural cause would change management — for example, a patient who is considering an epidural injection or surgical consultation.

The choice of scan depends on what your doctor is trying to rule in or out.

MRI of the lumbar spine is the workhorse for evaluating back pain that may be coming from soft tissue — disc herniation, nerve root compression, spinal stenosis, infection, or tumor. It shows discs, nerves, the spinal cord, ligaments, and the marrow inside the vertebrae without using ionizing radiation. For most patients referred for persistent pain or radiating leg symptoms, lumbar MRI is the recommended study.

X-ray of the lumbar spine is best when the question is bony alignment after trauma, suspected fracture in an at-risk patient, or follow-up of a known structural problem (spondylolisthesis, prior surgery, scoliosis). X-rays don't show discs, nerves, or the spinal cord directly, so they're rarely sufficient on their own for radiating pain.

CT of the lumbar spine is useful when MRI is contraindicated (some pacemakers, certain implants, severe claustrophobia that sedation cannot manage) or when bony detail is the priority — complex fractures, hardware evaluation, or pre-operative planning.

Precise offers each of these studies. The referring provider chooses the modality based on the clinical question.

A lumbar MRI produces detailed cross-sectional images of every level from the bottom of the thoracic spine through the sacrum. The radiologist evaluates:

• Each intervertebral disc for height, hydration, bulges, herniations, or tears
• The neural foramina (where nerve roots exit) for narrowing
• The central spinal canal for stenosis
• Facet joints for arthritis
• The conus medullaris and cauda equina for compression
• Vertebral bodies for fractures, marrow lesions, or signs of infection

It is normal to see age-related disc degeneration even in patients with no pain at all — by age 60, the majority of asymptomatic adults have at least one bulging disc. A good radiology report will distinguish incidental degenerative findings from features that correlate with your specific symptoms.

Disc bulge or protrusion — a portion of the disc extends beyond its normal border. Most are asymptomatic; a focal protrusion contacting a nerve root may explain radiating pain.

Lumbar disc herniation — disc material has displaced through the outer annulus. May resolve on its own over weeks to months; rarely requires surgery unless neurologic symptoms progress.

Spinal stenosis — narrowing of the spinal canal, typically from a combination of disc bulging, facet arthritis, and ligamentous thickening. Often causes leg pain with walking that is relieved by sitting or leaning forward.

Spondylolisthesis — one vertebra has slipped forward relative to the next. Graded I through IV; many cases are stable and managed conservatively.

Facet arthropathy — arthritis of the small joints at the back of the spine. A common pain generator in older patients.

Compression fracture — collapse of a vertebral body, usually from osteoporosis or trauma. May benefit from kyphoplasty in selected cases.

Your imaging report is sent to the referring provider, usually within 24 hours for routine outpatient studies and within four hours for STAT requests. The radiologist's job is to describe what is and is not present — your provider integrates the report with your symptoms, exam, and goals to recommend next steps.

Most lumbar MRI findings are managed without surgery. A typical pathway after a positive MRI for radiculopathy is six to twelve weeks of structured physical therapy, oral anti-inflammatories, and sometimes a transforaminal epidural steroid injection. Surgical consultation is reserved for patients with persistent symptoms despite conservative care, or those with progressive weakness or a true cauda equina syndrome.

Precise Imaging operates outpatient MRI, CT, X-ray, and ultrasound centers across California. To schedule:

1. Ask your physician to send the prescription or referral directly to a Precise location, or bring it with you.
2. Confirm whether the order specifies contrast (gadolinium for MRI, iodinated for CT). Most lumbar MRIs are performed without contrast.
3. Schedule online through the patient portal, or call the location nearest you.

Precise Imaging is a self-pay practice — we do not bill insurance, and attorney-lien arrangements are available for personal-injury cases. Call 800-558-2223 for a transparent self-pay quote on a routine lumbar MRI. Visit our lumbar spine MRI page for exam details and locations. Most exams are completed in 30 to 45 minutes and reports are typically available the same day.