An audit of lumbar spine radiography for low back pain


An audit tool to evaluate the appropriateness of lumbar spine radiography requests for low back pain with reference to the 2009 NICE guidance on the management of persistent non-specific low back pain and 2011 Royal College of Radiologists’ referral guidance "iRefer".


The 2009 NICE guidance on management of persistent non-specific low back pain proposes no useful role for lumbar radiography. iRefer limits indications for lumbar radiography in chronic pain with no red flags if "... presentation suggests osteoporotic collapse in the elderly." By reducing the number of lumbar radiographs performed inappropriately for non-specific low back pain patients can reach important points in the care pathway more rapidly also avoiding unnecessary radiation dose.

The Cycle

The standard: 

The 2009 NICE guidance defines non-specific low back pain as back pain lasting longer than six weeks but less than twelve months with no specific cause suspected such as fracture, infection, malignancy or inflammatory disorder (for example ankylosing spondylitis) [1]. This definition does not include radicular pain resulting from possible nerve root compression or cauda equina syndrome. iRefer provides guidance on the indications for lumbar radiography [2]. According to guidance, no lumbar radiographs for non-specific low back pain should be performed [1]. Specific causes of low back pain for which lumbar radiography may be indicated can be found within existing guidance, but are summarised above [1,2].


• 0% lumbar radiographs performed for non-specific low back pain

• 100% of lumbar radiographs performed for low back pain judged as indicated with reference to existing guidance, i.e. "osteoporotic collapse in the elderly"

• 0% of lumbar radiographs for low back pain performed with insufficient clinical details

Assess local practice


• The percentage/proportion of lumbar radiographs performed if the clinical details on the request form suggest a diagnosis of non-specific low back pain

• The percentage/proportion of lumbar radiographs performed if clinical details suggest a specific low back pain cause judged as appropriate with reference to existing guidance

• The percentage/proportion of lumbar radiographs for low back pain performed despite insufficient clinical information included on the request

Data items to be collected: 

The request forms for lumbar radiographs undertaken are to be collected. The clinical details reviewed and evaluation made as to which of the following outcome groups the request be classified in:

a) Non-specific low back pain

b) Low back pain; clinical details reviewed radiograph appropriate

c) Insufficient clinical information provided to classify

Suggested number: 

100 consecutive lumbar radiographs for low back pain. Data may be collected prospectively or retrospectively. The referral base examined can be primary care, secondary care or both depending on local requirements.

Suggestions for change if target not met: 

• Amend departmental justification procedures, policies, rules and standards for lumbar radiography

• Circulate to referrers the May 2009 NICE guidance and additional iRefer guidelines for rational use of lumbar radiography in low back pain

• Make all referrers aware of amended departmental policies and rules

• Re-audit aiming for 100% compliance with standards


Time for request card collection; review by experienced radiologist; report writing and presentation.

  1. Low back pain: early management of persistent non-specific low back pain. Full guideline May 2009. National Collaborating Centre for Primary Care.

  2. iRefer - The Royal College of Radiologists Imaging Referral Guidelines.

Published Date: 
Sunday 25 October 2009

Last Reviewed: 
Sunday 25 October 2015