Taylor et al conducted a study comparing students, clinicians, radiology residents and radiologists in the interpretation of abnormal lumbosacral spine radiographs in medicine and chiropractic. The data revealed a substantial increase in the percentage of correct diagnoses in interpretations by radiologists and radiology residents compared to interpretations by chiropractors, medical clinicians, and students.
The study reinforced the need for radiologic specialists to reduce missed diagnoses, misdiagnoses, and medicolegal complications [ 58 ]. The Clinical Guidelines Committee of the American College of Physicians ACP concluded that diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition.
In other patients, evidence indicates that routine imaging is not associated with clinically meaningful benefits but can lead to harms. They concluded that more testing does not equate to better care and that implementing a selective approach to low back imaging, as suggested by the ACP and American Pain Society guideline on low back pain, would provide better care to patients, improve outcomes, and reduce costs [ 59 ]. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.
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In and the authors published diagnostic imaging practice guidelines for musculoskeletal complaints in adults of all ages [ 52 , 60 - 62 ]. It is important to understand, however, that some red flags are associated with significantly high false-positive rates, indicating that, when used in isolation, they have little diagnostic value in the primary care setting [ 63 ]. As a result, the year old criterion proposed in many earlier guidelines has been questioned.
Two recent high quality national guidelines have considered the field of manual therapy when making recommendations:. For acute LBP, immediate imaging is recommended in patients who have major risk factors for cancer, risk factors for spinal infection, risk factors for or signs of the cauda equina syndrome, or severe or progressive neurologic deficits.
Repeat imaging is only recommended in patients with new or changed low back symptoms, such as new or progressive neurologic symptoms or recent trauma [ 59 ].
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Further, a combination of red flags significantly increases the likelihood of finding a serious pathology [ 60 ]. Clinical decision rules for cervical spine trauma patients also use age 65 or older as one high risk factor that warrants obtaining radiographs [ 66 - 68 ]. A similar ongoing debate concerns the symptom duration necessary to warrant the recommendation of lumbar spine radiographs in LBP.
More recent reviews however suggest that clinicians should refrain from ordering lumbar radiographs for non-specific LBP i. One question that remains then is: How many weeks of conservative care are appropriate before one proceeds with further investigations? Should it be four weeks or perhaps seven weeks?
It may be that the pain is unresponsive to physical and pharmaceutical intervention because it now results from ineffective endogenous pain control and central sensitization in which case imaging studies would be of little help [ 69 ]. Obviously, further research is necessary before making a useful recommendation. In any event, a conservative approach to imaging is warranted at this time.
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An initial trial of therapy of four weeks using low force, low velocity techniques may be offered in patients with: 1 minor risk factors for cancer initial imaging can include lumbar radiography and evaluation of erythrocyte sedimentation ; and 2 non progressive signs or symptoms of radiculopathy or spinal stenosis.
For patient with risk factors for vertebral compression fracture, dual energy x-ray absorptiometry DXA is indicated to detect and quantify osteoporosis see osteoporosis section below. Gentle techniques should be used if an initial trial of therapy is suggested for these patients. Decisions regarding repeated imaging should be based on the development of new or changed clinical features. Rib fractures are difficult to visualize. Clinical suspicion warrants altering treatment plan in such patients use low force, low velocity techniques ;.
CT or MRI should also be considered in the above settings. Nuclear medicine bone scan may be helpful when radiographs are normal or equivocal for fracture.
Reinus and colleagues studied indications for lumbosacral spine radiographs in patients presenting to a Level II emergency department. They concluded that their data supported the use of lumbosacral spine radiographs for patients with a history of trauma, even if relatively minor, in elderly patients and in patients with lower back pain who have a history of neoplasm. However, the data revealed that lumbosacral radiographs obtained for an isolated complaint of lower back pain or isolated neurologic abnormalities generally provide no clinically useful information.
They concluded that such patients are better examined although not necessarily at the time of emergency department evaluation with techniques such as MR imaging that reveal soft-tissue lesions. In alert and stable cervical spine trauma patients, radiographs are only routinely indicated in patients with positive high-risk factors on the Canadian Cervical Spine Rule for Radiography in Alert and Stable Trauma Patients CCSR [ 66 , 71 ]. One of those factors is age over Therefore, all patients over age 65 should get a 3-view routine cervical spine radiographic series anterior-posterior, lateral, and anterior-posterior open mouth , in acute cervical spine trauma.
If fracture is suspected, CT is recommended rather than oblique, pillar or flexion-extension radiographs. MRI may also be indicated in certain cases to evaluate soft tissue, cord or nerve root injury. Cervical Spine Trauma. A lateral cervical spine radiograph reveals a C4 spinous process fracture with inferior displacement. The C5 vertebral body is slightly compressed with a tiny teardrop fragment anteriorly black arrow.
The prevertebral soft tissue margin is clearly visualized and there is a suggestion of widening secondary to edema. A sagittal reconstruction of a CT scan reveals the same findings as the radiograph but in much more detail. A sagittal T2-weighted MR image reveals high signal intensity in the C5 vertebral body black arrow , in the posterior soft tissues, and within the cord itself. An axial CT image shows a complete vertical fracture arrows through the C5 vertebral body, a finding not seen on the lateral radiograph or sagittal CT display.
Images courtesy of Lindsay J. Rowe, Newcastle, Australia.
There is no evidence, on the other hand, that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. Furthermore, flexion-extension radiographs and 5-view radiographs cross table lateral, anterior-posterior, bilateral oblique, and odontoid views in the acute stage of blunt neck trauma add little to static radiography in predictability and accuracy [ 31 ]. Defined as nontraumatic mechanical pain that varies with time and activity with no neurologic component and a good general health status.
Conventional radiographs are not initially indicated in adult patients with acute, subacute, or persistent uncomplicated LBP with no neurologic deficits or red flags. However, since age 65 or over is considered a red flag, radiographs are often indicated at the time of initial presentation, especially if the patient has at least one additional red flag.
Additionally, lumbar spine radiographs are indicated in patients over 65 or those who have progressive neurologic deficits with suspected degenerative spondylolisthesis, lateral stenosis, or central stenosis.
These guidelines further recommend that CT myelography is useful in patients who have contraindications to MRI, patients with MRI findings that are inconclusive, or patients with a poor correlation between symptoms and MRI findings. CT without myelography is useful in patients who have contraindications to MRI, patients with MRI findings that are inconclusive, or patients with a poor correlation between symptoms and MRI findings and those who are not candidates for CT myelography. CT without myelography is a useful noninvasive study in patients who have contraindications to MRI, patients with MRI findings that are inconclusive, or patients with a poor correlation between symptoms and MRI findings and those who are not candidates for CT myelography [ 73 ].
In this patient, severe osteoporosis has led to a fragility fracture of the L3 vertebral body.
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Conventional radiographs are not initially indicated in suspected acute lumbar disc herniation protrusion, extrusion, sequestration unless the patient is over age 50 or has progressive neurologic deficits. While degenerative disc bulges are more likely to occur in older individuals, they are not visible on radiographs either [ 52 ].
One of the difficulties in evaluating the utility and validity of MRI in LBP is the high prevalence of abnormal findings in asymptomatic individuals. A recent systematic review and meta-analysis by Endean et al concluded that MRI findings of disc protrusion, nerve root displacement or compression, disc degeneration, and high intensity zone are all associated with LBP, but that individually, none of these abnormalities provides a strong indication that LBP is attributable to underlying pathology [ 74 ]. Disc Bulge. Axial and B. Sagittal T2-weighted images reveal a focal right-central disc bulge at L that slightly indents the thecal sac and extends into the right nerve root canal white arrow on A, black arrow on B.
A more focal protrusion and associated annular tear is present at L5-S1 white arrow on B. While degenerative changes such as disc bulges are extremely prevalent, the only degenerative feature associated with LBP is spinal stenosis.
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While disc herniations such as protrusions, extrusions, and sequestrations are more likely to result in direct nerve compression and chemical radiculitis resulting in lower extremity symptoms, they occur less frequently in elderly patients. Images courtesy of Brian A. Howard, Charlotte, NC. Kalichman et al retrospectively evaluated spinal degeneration in a subset of participants with a mean age of While degenerative changes were extremely prevalent, the only degenerative feature associated with self-reported LBP was spinal stenosis.
Intervertebral disc space narrowing present in Conventional radiographs or special investigations are not initially indicated in uncomplicated no neurologic deficits or red flags , nontraumatic neck pain of less than four weeks duration. Radiographs are indicated, however, for patients with nontraumatic neck pain and radicular symptoms. This category includes patients with suspected acute cervical disc herniation or suspected acute cervical spondylotic radiculopathy or lateral canal stenosis. While the three-view series of radiographs are suggested, oblique or swimmer spot lateral cervicothoracic views may also be included.
Cervical spine MRI should be considered after a failed four-week trial of conservative therapy. Spine , 15 ;33 4 Suppl :S Defined as the presence of red flag clinical indicator s that should alert the clinician to possible underlying pathology. Advanced imaging including MRI, CT or nuclear medicine NM bone scan are recommended in all adult patients with complicated thoracic or lumbar spine pain with red flags and indicators of contraindication to SMT [ 52 ]. There is no value in obtaining imaging prior to the referral as the imaging studies will likely be repeated at the emergency facility [ 65 ].
AAA commonly presents as back pain and therefore may be encountered in elderly patients seeking chiropractic care. They emphasized that 70 percent of men in this age group have smoked and would benefit from routine screening to check for aneurysms. In the US, Medicare covers the cost of this one-time screening DUS in patients with a family history of AAA or who have smoked at least cigarettes in their lifetime [ 77 ]. Abdominal Aortic Aneurysm. In another patient, observe the metallic mesh of an aortic and iliac artery graft. This patient also has skeletal metastasis with osteoblastic lesions within the L2 and L5 vertebral bodies.
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A longitudinal diagnostic ultrasound image through the center of an aneurysm same patient as in A documents that the diameter of the lumen at its maximum width is 9. Suspected acute AAA or thoracic aortic aneurysm, dissection, rupture, occlusion or traumatic injury in any patient requires immediate emergency referral without imaging [ 52 ]. Conventional radiographs are notoriously unreliable for assessing bone mineral density BMD. In elderly patients with or without fragility fractures, dual energy x-ray absorptiometry DXA is indicated to detect and quantify osteoporosis.
The decision to test BMD should be based on a woman's clinical risk profile, as well as the potential impact of results on management [ 78 ]. Regardless of clinical factors, all women over age 65 and all males over age 70 should be tested for BMD. BMD testing is also recommended for postmenopausal women younger than 65 with osteoporotic risk factors and in men aged 50—69 if at least one major or two minor risk factors for osteoporosis are present [ 78 ].
Several of these important osteoporosis risk factors have been identified that place elderly patients, especially postmenopausal females, at risk. It is validated to be used in untreated patients only. The current National Osteoporosis Foundation Guide is based on individual patient models that integrate the risks associated with clinical risk factors as well as BMD at the femoral neck. For most people, an interval of at least two years is an appropriate duration for repeating BMD testing. Important Osteoporosis Risk Factors [ , ].
This DXA display printout shows the results of a typical normal study. DXA scans are used to quantify bone mass that is expressed in standard deviations from the normal. This information can be applied to management, prognosis, and estimation of fracture risk in patients with osteopenia or osteoporosis.