X-ray

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Obtain x-ray spine (AP/lateral) (Class II)

For patients with a red flag, radiographs are the best initial imaging, as they are cost-effective, relatively easy to obtain, and will identify up 77% of pathologic back pain.$^{17,18,20,25,67}$ This is likely because bony pathology (such as spondylolysis) is the most common cause of pediatric back pain, and radiographs are very good—though not perfect—at detecting those injuries.$^{17,28}$ Spinal radiographs may also identify signs of oncologic invasion of bony structures, bone cysts, lytic lesions, or findings suggesting subacute osteomyelitis or spondyloarthritis. Nonspinal etiologies of back pain may also be identified, such as pneumonia, pleural effusion, and renal calculi.$^{17}$ It should also be noted that while the standard for spinal radiographs previously included 4 views (anterior-posterior, lateral, and bilateral obliques), it has been argued that oblique views add little diagnostic benefit but add the equivalent radiation of 5 chest radiographs.$^{67-70}$