Shaping better health
REMEDY : BNSSG referral pathways

Spinal Imaging in Primary Care

Checked: 21-05-2018 by Rob.Adams Next Review: 21-05-2019


Spinal imaging can be an overused investigation in primary care and should be reserved for patients with red flags or in patients where it will potentially change management.

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.

Dr Nick Snelling (MSK lead for BNSSG CCG) has proposed the following guide:

Consider spinal imaging in the presence of red flags. Suspicion is proportional to number of these (80% of Low Back Pain will have at least one red flag).

  • presentation under age 20 or over 55

  • 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 cervical spine) 

  • Past History: carcinoma,  (lung, prostate, thyroid, kidney, breast =  mostly metastasise to the spine); steroids, HIV, IVDU, immunosuppression

  • unwell, weight loss, constitutional symptoms

  • Neurology: especially saddle anaesthesia  and bowel and bladder disturbance  (Cauda Equina Syndrome); marked muscle weakness, widespread / progressive  neurology. (Nerve root involvement / cord compression in cervical and thoracic spine) 

  • Prolonged morning stiffness, worse at rest, better with exercise… remember inflammatory arthritides.

If concern about caudal equina, send to A&E.


If sciatica with lower limb neurology, consider MSK referral (MATS/MIS/SATS)


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.

MRI for back pain?

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 Radiology Guidelines suggest that Spinal MRI should be considered if there are red flags or in cases where it will potentially change management.

The following You Tube video is 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?