Radiologists from Leeds, U.K., are using audits to reduce the alarming number of lumbar spine radiographs that may be unnecessary, thereby reducing radiation exposure to patients and freeing up x-ray machines and radiographers for more urgent examinations.
Long-term low back pain remains a common presentation for practitioners to deal with in both primary care and musculoskeletal services. As a result, there is a high number of referrals for lumbar spine radiographs that are of little diagnostic value and result in exposure to a significant radiation dose (range 3-4 units), Dr. M. C. Cooke, from the Leeds Teaching Hospitals National Health Service (NHS) Trust, told delegates at last week's U.K. Radiological Congress (UKRC) in Manchester.
Despite the publication of guidelines, such as those from the U.K. National Institute for Health and Clinical Excellence (NICE), on the imaging of long-term low back pain, a significant number of lumbar spine film referrals remains. This leads to unnecessary radiation exposure for patients and significant costs, Cooke noted.
The Leeds group carried out an audit that retrospectively analyzed 120 general practitioner (GP) referrals for lumbar spine radiographs in patients between ages 19.6 years and 58.3 years. They looked at a one-week period in September 2011. Information was collected from the request card, the report findings for each radiograph, and any subsequent follow-up in secondary care. Requests were grouped into categories according to NICE guidelines: acute, suspected fracture, suspected malignancy, radiculopathy, and nonspecific low back pain.
The researchers found that a total of 81% of referrals did not meet the guidelines set out by NICE. About 63% of referrals had no indication for any imaging, while the remaining 18% met indications for suggested MRI consideration without unnecessary radiographs. Of the patients, 46 had request cards for multiple radiographs, and 13 were followed up with further imaging, nine of which included MRI.
When referral requests were grouped according to NICE guidelines, 11 were acute, 74 were nonspecific low back pain, 16 were radiculopathy, 11 were suspected fractures, and six were suspected malignancies.
The report findings were degenerative changes (65% of patients), normal (25%), old fracture (4%), osteoporosis (2%), malignancy (2%), and acute fracture (2%).
"The data were presented at the local audit meeting," Cooke noted. "GPs have previously been informed of similar results from other audits via a letter or message attached to reports, which highlighted salient points and directed them to guidelines which proved to be ineffective at reaudit. Ongoing discussion is therefore under way considering implementation of various interventions, such as radiographers screening radiograph requests and information being returned to the GP/patient if the requested imaging modality is not deemed appropriate."
The anticipated outcome of the process is a reduction in radiation exposure to patients. The aim is also to free up radiographers and x-ray machines, given that the evidence suggests approximately 5,054 potentially unnecessary lumbar spine films per annum are performed in the city of Leeds. Cooke also hopes the audit will reduce time spent reporting lumbar spine films for radiologists and save the trust money associated with the investigation of long-term, nonspecific lower back pain. The plan is to reaudit six months postfinalized intervention.
To read the NICE guidelines from 2009, click here.
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&fit=crop&h=100&q=70&w=100)
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
