It is commonly taught that radiographs are not needed in non-traumatic back pain unless the patient is <18 or > 65 years old. Several studies have started to disprove this in the pediatric population, and a recent study in JAMA is giving some weight to not having to do this in the eldery.
The JAMA study was a prospective cohort of 5239 patients over age 65 who presented to a PCP or urgent care center in three different health systems from 2011-2013 with a complaint of back pain without radiculopathy. Patients were determined to have early imaging if they had a plain films, CT, or MRI done within 6 weeks of their initial visit for back pain. The primary outcome measure was back or leg-pain related disability at 12 months when comparing those that had early imaging versus late (> 6 weeks). They excluded patients with prior surgery, prior back pain, or if they had a cancer visit in the prior year.
At one year they found that there was no statistical difference in the primary outcome of back or leg-pain related disability at one year. The early imaging did pick up more fractures of the spine, but again no change in long term outcomes. The serious diagnoses were summarized in this graph.
This study was not done in the Emergency Medicine setting, and our patients may not be equivilant, but it suggests that we do NOT have to get radiographs on all patients over 65 years old with non-traumatic back pain without radiculopathy. If you are not going to get radiographs make sure your patient has clear discharge instructions on what to return for and that they should follow up with their primary care provider within a week.
A link to the full article is here http://jama.jamanetwork.com/article.aspx?articleid=2203801
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):1143–11. doi:10.1001/jama.2015.1871.
