The RCGP - Clinical and Special Projects, Clinical Guidelines, Acute Low Back Pain. Contents, Index page
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Chapter 2

Evidence Review

Diagnostic Triage

Initial Assessment Methods
(Adapted from AHCPR 1994)


Psychosocial Factors

Risk factors for chronicity


Information to Patients



The recommendations on X-rays from the AHCPR guidelines are offered in their original form. No further review of evidence was undertaken.

Plain X-rays are not recommended for routine evaluation of patients with acute low back problems within the first month of symptoms unless a red flag is noted on clinical examination. (B)

Plain X-rays of the lumbar spine are recommended for ruling out fractures in patients with acute low back problems when any of the following red flags are present: recent significant trauma (any age), recent mild trauma (patient over age 50), history of prolonged steroid use, osteoporosis, patient over age 70. (C)

Plain X-rays in combination with FBC and ESR may be useful for ruling out tumour or infection in patients with acute low back problems when any of the following red flags are present: prior cancer or recent infection, fever over 100° F, IV drug abuse, prolonged steroid use, low back pain worse with rest, unexplained weight loss. (C)

In the presence of red flags, especially for tumour or infection, the use of other imaging studies such as bone scan, CT, or MRI may be clinically indicated even if plain X-rays are negative. (C)

A bone scan is recommended to evaluate acute low back problems when spinal tumour, infection, or occult fracture is suspected from red flags on medical history, physical examination, corroborative lab test or plain X-ray findings. Bone scans are contraindicated during pregnancy. (C)

The routine use of oblique views on plain lumbar X-rays is not recommended for adults in light of the increased radiation exposure. (B)


Deyo & Diehl 1988

Guidelines have been produced by the Royal College of Radiologists (RCR), that include recommendations about lumbar X-rays.

The Royal College of Radiologists’ guidelines (2nd, 3rd and 4th editions) are based on consensus and are not directly linked to evidence.

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