Diagnostic Imaging Pathways – Low Back Pain

Pathway

Images

Image Gallery   Note: These images open in a new page
1a		L4/L5 Disc Herniation Image 1a and 1b (Computed Tomography): Axial and sagittal images demonstrating a large left sided eccentric disc protrusion at L4/L5 that is compressing the traversing left L5 nerve root.
1b
1c		Image 1c and 1d (Magnetic Resonance Imaging): Axial and sagittal images of the same patient.
1d

Teaching Points

Teaching Points

• The prevalence of previously undiagnosed serious pathology in patients presenting with acute low back pain in the primary care setting is very rare 1
• Most patients with acute low back pain have substantial improvements in pain and function within one month 2
• Routine or immediate lumbar spine imaging for low back pain without indications of serious underlying conditions does not affect management or improve clinical outcomes and is associated with radiation exposure and increased expenses 3,4
• 'Red flags' that prompt imaging include recent significant trauma (mild trauma if age = 50), unexplained weight loss, fever, age 55 years, history of malignancy or immune compromise, intravenous drug use, osteoporosis or glucocorticoid use, suspicion of ankylosing spondylitis and compensation or work injury issues
• If there are no 'red flags', imaging is indicated only after a period of conservative therapy is trialled first 3
• Initial investigation is with plain films

References

References

Date of literature search: May 2013

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

1. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009;60(10):3072-80. (Level I evidence)
2. Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. BMJ. 2003;327(7410):323. (Level I evidence)
3. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463-72. (Level I evidence)
4. Gillan MG, Gilbert FJ, Andrew JE, Grant AM, Wardlaw D, Valentine NW, et al. Influence of imaging on clinical decision making in the treatment of lower back pain. Radiology. 2001;220(2):393-9. (Level II evidence)
5. Expert Panel on Neurologic Imaging:, Davis PC, Franz JW, Cornelius RS, Angtuaco EJ, Broderick DF, et al. Americal College of Radiology Appropriateness Criteria: Low back pain [online publication]. Reston, VA; 2011 [cited 2013 April 4]. (Evidence based guidelines) View the reference
6. van Tulder M, Becker A, Bekkering T, Breen A, del Real M. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15(S2):S169-91. (Evidence based guidelines)
7. Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-94. (Review article)
8. Australian Acute Musculoskeletal Pain Guidelines Group, National Health and Medical Research Council. Evidence-based Management of Acute Musculoskeletal Pain [online publication]. Brisbane: Australian Academic Press Pty Ltd; 2003 [cited 2013 February 26]. (Systematic review; Evidence based guidelines) View the reference
9. Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P, Irwig L. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev. 2013;2:CD008686. (Level II evidence)
10. Williams CM, Henschke N, Maher CG, van Tulder MW, Koes BW, Macaskill P, et al. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst Rev. 2013;1:CD008643. (Level II evidence)
11. van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine (Phila Pa 1976). 1997;22(4):427-34. (Level II evidence)
12. Hollingworth W, Todd CJ, King H, Males T, Dixon AK, Karia KR, et al. Primary care referrals for lumbar spine radiography: diagnostic yield and clinical guidelines..Br J Gen Pract. 2002;52(479):475-80. (Level III evidence)
13. de Schepper EI, Damen J, van Meurs JB, Ginai AZ, Popham M, Hofman A, et al. The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features. Spine (Phila Pa 1976). 2010;35(5):531-6. (Level II evidence)
14. Webster EW, Merrill OE. Radiation hazards. II. Measurements of gonadal dose in radiographic examinations. N Engl J Med. 1957;257(17):811-9. (Level II evidence)
15. Antoku S, Russell WJ. Dose to the active bone marrow, gonads, and skin from roentgenography and fluoroscopy. Radiology. 1971;101(3):669-78. (Level II evidence)
16. Chou R, Qaseem A, Snow V, Casey D, Cross JT, Jr., Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.[Erratum appears in Ann Intern Med 2008;148(3):247-8; PMID: 18257154], [Summary for patients in Ann Intern Med. 2007 Oct 2;147(7):I45; PMID: 17909203]. Ann Intern Med. 2007;147(7):478-91. (Evidence based guidelines)
17. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137(7):586-97. (Review article)
18. Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005;237(2):597-604. (Level II evidence)
19. Carragee E, Alamin T, Cheng I, Franklin T, van den Haak E, Hurwitz E. Are first-time episodes of serious LBP associated with new MRI findings? Spine J. 2006;6(6):624-35. (Level I evidence)
20. Pineda C, Vargas A, Rodríguez AV. Imaging of Osteomyelitis: Current Concepts. Infect Dis Clin North Am. 2006;20(4):789-825. (Review article)
21. Modic MT, Feiglin DH, Piraino DW, Boumphrey F, Weinstein MA, Duchesneau PM, et al. Vertebral osteomyelitis: assessment using MR. Radiology. 1985;157(1):157-66. (Level III evidence)
22. Chiewvit P, Danchaivijitr N, Sirivitmaitrie K, Chiewvit S, Thephamongkhol K. Does magnetic resonance imaging give value-added than bone scintigraphy in the detection of vertebral metastasis? J Med Assoc Thai. 2009;92(6):818-29. (Level III evidence)
23. Thariat J, Toubeau M, Ornetti P, Coudert B, Berrielo-Riedinger A, Fargeot P, et al. Sensitivity and specificity of thallium-201 scintigraphy for the diagnosis of malignant vertebral fractures. Eur J Radiol. 2004;51(3):274-8. (Level II evidence)
24. Aitchison FA, Poon FW, Hadley MD, Gray HW, Forrester AW. Vertebral metastases and an equivocal bone scan: value of magnetic resonance imaging. Nucl Med Commun. 1992;13(6):429-31. (Level III evidence)
25. Algra PR, Bloem JL, Tissing H, Falke TH, Arndt JW, Verboom LJ. Detection of vertebral metastases: comparison between MR imaging and bone scintigraphy. Radiographics. 1991;11(2):219-32. (Level II evidence)
26. Thawait SK, Marcus MA, Morrison WB, Klufas RA, Eng J, Carrino JA. Research synthesis: what is the diagnostic performance of magnetic resonance imaging to discriminate benign from malignant vertebral compression fractures? Systematic review and meta-analysis. Spine. 2012;37(12):E736-44. (Level I evidence)
27. Wassenaar M, van Rijn RM, van Tulder MW, Verhagen AP, van der Windt DA, Koes BW, et al. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J. 2012;21(2):220-7. (Level I/II evidence)
28. Thornbury JR, Fryback DG, Turski PA, Javid MJ, McDonald JV, Beinlich BR, et al. Disk-caused nerve compression in patients with acute low-back pain: diagnosis with MR, CT myelography, and plain CT. Radiology. 1993;186(3):731-8. (Level II evidence)
29. Jensen TS, Karppinen J, Sorensen JS, Niinimaki J, Leboeuf-Yde C. Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain. Eur Spine J. 2008;17(11):1407-22. (Level II evidence)
30. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72(3):403-8. (Level II evidence)
31. Jarvik JJ, Hollingworth W, Heagerty P, Haynor DR, Deyo RA. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine (Phila Pa 1976). 2001;26(10):1158-66. (Level I evidence)
32. Schwarzer AC, Wang SC, O'Driscoll D, Harrington T, Bogduk N, Laurent R. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine (Phila Pa 1976). 1995;20(8):907-12. (Level II evidence)
33. Williams AL, Gornet MF, Burkus JK. CT evaluation of lumbar interbody fusion: current concepts. AJNR Am J Neuroradiol. 2005;26(8):2057-66. (Review article)
34. van Rijn RM, Wassenaar M, Verhagen AP, Ostelo RW, Ginai AZ, de Boer MR, et al. Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J. 2012;21(2):228-39. (Level II evidence)
35. Yussen PS, Swartz JD. The acute lumbar disc herniation: imaging diagnosis. Semin Ultrasound CT MR. 1993;14(6):389-98. (Review article)
36. Albeck MJ, Hilden J, Kjaer L, Holtas S, Praestholm J, Henriksen O, et al. A controlled comparison of myelography, computed tomography, and magnetic resonance imaging in clinically suspected lumbar disc herniation. Spine (Phila Pa 1976). 1995;20(4):443-8. (Level II evidence)
37. Jackson RP, Cain JE, Jr., Jacobs RR, Cooper BR, McManus GE. The neuroradiographic diagnosis of lumbar herniated nucleus pulposus: II. A comparison of computed tomography (CT), myelography, CT-myelography, and magnetic resonance imaging. Spine (Phila Pa 1976). 1989;14(12):1362-7. (Level II evidence)
38. Manchikanti L, Glaser SE, Wolfer L, Derby R, Cohen SP. Systematic review of lumbar discography as a diagnostic test for chronic low back pain. Pain Physician. 2009;12(3):541-59. (Level II evidence)
39. Carragee E, Don A, Hurwitz E, Cuellar J, Carrino J. 2009 ISSLS Prize Winner. Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Spine (Phila Pa 1976). 2009;34(21):2338-45. (Level II evidence)

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