Which imaging modalities are recommended for evaluating thoracic back pain in primary care settings?

In primary care settings, the recommended initial imaging modality for evaluating thoracic back pain, when spinal column injury is suspected without abnormal neurological signs or symptoms, is a plain X-ray of the thoracic spine (T1–L3). If the X-ray is abnormal or clinical signs or symptoms of spinal column injury are present, a CT scan should be performed next. MRI is reserved for cases with neurological abnormalities or suspicion of spinal cord injury, typically after CT imaging. Plain X-rays are not recommended for diagnosing spinal metastases or metastatic spinal cord compression (MSCC). If spinal metastases or MSCC are suspected, urgent MRI is the preferred imaging modality, but this is usually arranged in secondary care rather than primary care. Therefore, in primary care, initial imaging for thoracic back pain primarily involves plain X-rays, with CT or MRI reserved for more severe or suspicious cases referred to secondary care.