Urgent care radiographs for low-acuity back pain were rarely followed by emergency CT or MRI

Design

Retrospective multisite cohort

Population

2,924 urgent care radiographs and 13,830 emergency CT/MRI studies for low back pain

Primary outcome

Emergency advanced imaging within 30 days of urgent care radiography

Effect

0.82% (95% CI 0.55-1.22%); one judged a true miss

This retrospective study across 23 US urgent care centres and their affiliated emergency departments, 2019 to 2025, looked at adults imaged for low back pain without red-flag indications. It compared 2,924 urgent care radiographs with 13,830 emergency CT and MRI studies.

Within 30 days, 24 urgent care radiographs (0.82%, 95% CI 0.55-1.22%) were followed by advanced imaging in the emergency department, half of them within 24 hours. On review, radiologists judged one a true radiographic miss. Per study, radiography used about a quarter of the resources of emergency CT or MRI.

Red flags were excluded by keyword screening of the order indication, which will miss some. Urgent care patients were younger (median 50 vs 67 years), so the groups are not directly comparable.

Guidelines have not changed: routine imaging is not advised for non-specific low back pain without red flags. Where an image is going to be done, this suggests a radiograph in urgent care rarely leads to escalation.

• Fewer than 1 in 100 urgent care back radiographs led to emergency CT or MRI within 30 days.
• Only one return was judged a missed finding on the radiograph.
• Guidelines still advise no routine imaging for non-specific low back pain without red flags.
• Screen the request for red flags before protocolling any back imaging.
• Advanced imaging in the emergency department cost about 3.5 times as much per study.

Why it matters

It reassures that a radiograph-first pathway outside the emergency department does not push patients into expensive advanced imaging.

Don't overread it

This does not show radiography is needed for low back pain; the guideline advice against routine imaging stands.

The statistics, in plain English

The 0.82% return rate has a narrow interval (0.55-1.22%), so it is a stable estimate. Patients who went to another hospital would not be counted, so the true rate may be slightly higher.

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