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Plain radiography is not indicated as 1st choice imaging modality in children with non-traumatic back pain

Three Part Question

In [a child complaining of lower back pain with no history of trauma] is [plain lumbar spine radiography as sensitive as MRI] at [identifying pathology]

Clinical Scenario

A 5 year old boy attends the emergency department with his parents on a Saturday afternoon. He complains of lower back pain, which his mother states has been present for about 2 weeks, there is no history of trauma. He points to the region of L4/L5 when asked where the pain is. You cannot identify any abnormality on examination but remember that back pain in children has a broad differential diagnosis and a significant incidence of neoplasm. Recalling the induction lecture from the radiology department, highlighting the importance of limiting radiation exposure, you wonder what would be the best way to image his lower back.

Search Strategy

Medline 1966 – 09/04 using the OVID interface.
(back pain OR backache) AND (children OR pediatric OR paediatric) AND (investigation OR imaging OR x-ray OR mri OR radiology).mp. Limit to human and English language.

Search Outcome

Altogether 104 papers were found on medline, none of these directly answered the question or compared the 2 modalities


Lumbar spine x-ray is frequently recommended as 1st line investigation of non-traumatic back pain in individuals younger than 20 years old.[1] No evidence was found to confirm it as being as sensitive as MRI at identifying pathology. Current Royal College of Radiologist guidelines recommend MRI or CT for investigation of non-traumatic back pain.[2] References 1.Oxford Handbook of Accident and Emergency Medicine, pp552-553. Oxford University Press 1999. 2.Making the Best Use of a Department of Clinical Radiology, Guidelines for Doctors, fifth edition, p134 M11. The Royal College of Radiologists, London 2003.

Clinical Bottom Line

Radiological investigation of children presenting with non-traumatic back pain should be discussed with a radiologist to ensure appropriate imaging and limit exposure to radiation.