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Spinal imaging - is it a help or a hindrance?

At a glance:
  • This article looks at the use of Magnetic Resonance Imaging (MRI) and computed tomography (CT) scans in the diagnosis
    diagnosis
    The process of identifying a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of various diagnostic procedures.
     of back pain.
  • The evidence is that scans of lower backs without pain often look the same as those with pain, making interpretation of the results difficult for doctors and radiologists.
  • The authors conclude that over use of imaging can lead to unnecessary concern, and that in most cases lower back pain will improve without imaging and specific treatment.
Perspectives:
Employee
What is the usefulness of diagnostic
diagnostic
Used to identify a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of X-rays, scans, or other tests.
 imaging, specifically MRI
MRI
Magnetic resonance imaging (MRI) is used in medical imaging and works by applying a magnetic field to the body and observing how the atoms behave in the field in order to create an image. Whilst an X-ray shows bones, MRI scans can show soft tissues and are used to examine tissues such as discs in the back, cartilage lining a joint, muscles and tendons.
 and CT
CT
Computed tomography (CT), originally known as computed axial tomography (CAT or CT scan) is a medical imaging method. The images can show soft tissues such as lumbar discs.
 scans, in the treatment of back pain?

This article points out that a large number of the “abnormalities' shown in spinal images are also present in people who do not have any symptoms of back pain, and that people with and without pain can in fact show very similar spinal images. Some scan findings can be important, for example if a disc
disc
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae.  Disks
disk
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae. Disks have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disc.
  have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disk.
 is pressing on the nerve root and causing pain to spread into the leg.

Most people do not need a scan; it does not generally alter the treatment and does not tell us much about how your back will improve. If you do have a scan make sure you discuss the findings with your treater. For the majority of people the scan findings should not stop you trying to manage your back pain and continue with normal activities.
Employer
This article was written by radiologists and suggests that very sensitive imaging such as MRI and CT scans are commonly used in the diagnosis and treatment of lower back pain, but are often not very helpful for treatment. Employers should be aware that in most cases imaging contributes little to recovery, but adds to costs.

Employees may be left worried about scan findings. Some scan results are of significance and require specific treatments such as surgery. Encourage your employee to discuss the scan results with their treaters, and to understand whether their scan findings are of significance.
Treater
This article by radiologists highlights previous studies which indicate that results often described as “abnormalities' on CT scans and MRI may well be normal. There is considerable similarity between scans of those with and without back pain.30-70% of people who have never had back pain have a scan that is described as “abnormal" Disc herniations, disc degeneration, and annular tears
annular tear
Tear in the outer shell of the disc in the spine. Annular tears can be seen on MRI scans of the spine.
 are common findings even in those without back pain.

Reporting the results of a scan to the patient as significant, or as indicative of an underlying problem, can prolong what is generally a self limiting episode. Some scan findings are of significance, such as disc prolapse
disc prolapse
When a disc has extended out from its normal position. A disc prolapse can be normal (30-80% people without back pain have some degree of disc bulge
disc bulge
When a disc has extended out from its normal position. A disc bulge can be normal (30-80% people without back pain have some degree of disc bulge on a back scan). In other cases the disc can press on the nerve and cause sciatica
sciatica
Pain caused by pressure on a branch of the sciatic nerve, which starts in the lower back and runs through the legs. The pain is felt in the leg and foot. There may also be numbness, weakness or difficulty moving the leg.
 or leg pain. Also called a disc prolapse or disc herniation.
 on a back scan). In other cases the disc can press on the nerve and cause sciatica or leg pain. Also called a disc herniation or disc bulge.
 where there is pressure on the exiting nerve roots, and the findings correlate with the patient's symptoms.
Insurer
This article shows that imaging tends to be overused and, in early stages, does not contribute significantly to the diagnosis and treatment back pain.

Scans do not assist in defining the nature of the back problem for most people with back pain, although they can be very useful in certain cases.

Scans do not help clarify the persons capacity to work, and don't indicate the likely recovery period.

Doctors, insurers and patients may request testing because they feel uncomfortable with uncertainty about the cause, or outlook of the back complaint. As a result spinal imaging is often ordered when simply waiting, or commencing treatment would improve health.
Original Article, Authors & Publication Details:
J. Breslau1 and D. Seidenwurm1 (2000).

Socioeconomic aspects of spinal imaging: impact of radiological diagnosis on lumbar
lumbar
relating to the part of the back between the ribs and the hipbones
 spine-related disability
. Topics in Magnetic Resonance Imaging 11(4): 218-23.

1Radiological Associates of Sacramento, Sacramento, Califonia, U.S.A.
Background, Study Objectives, How It Was Done:
This article is a review of research studies that have looked at MRI and CT scan results in people with and without back pain. The authors then discuss the implications of the research findings. They suggest when scans can be useful, and raise concerns about the problems caused by ambiguous MRI findings, which can affect the individual and also the community.
Study Findings:
This review examined studies of MRI and CT imaging in people with and without back problems to look at how useful these scans are in predicting the presence of back pain.

The following four studies were reviewed:

Study 1

A major study of low back CT scans revealed:

  • 35% of those who did not recall ever having had back pain were found to have “abnormalities' on their scan
  • More than half of these abnormalities were classified as disc herniations
    disc herniation
    When a disc has extended out from its normal position. A disc herniation can be normal (30-80% people without back pain have some degree of disc bulge on a back scan). In other cases the disc can press on the nerve and cause sciatica or leg pain. Also called a disc bulge or disc prolapse.
     (a split in one of the bones in the spine).
Study 2

An important study of MRI scans found that of 67 individuals who did have back pain:

  • 20% of those less than age 60 had disc herniations
  • 36% of those 60 years and older had disc herniations.
Study 3

A study of 98 people without symptoms of back pain and found:

  • only 36% had what was describe as a normal lumbar MRI
  • 28% had disc herniations.
Study 4

This study of MRI scans of people without back pain found

  • 56% had “annular tears' (tears in the fibrous tissue
    tissue
    Collection of cells that perform a similar function. e.g. epithelium (skin), connective tissue (blood, bone), muscle
     around the disc)
  • 33% had disc protrusions (where the disc or jelly like material that acts as a cushion between the vertebrae
    vertebrae
    (singular: vertebra) The individual irregular bones that make up the spinal column.
     of the spines protrudes out of its normal space)
Advances in imaging have increased the ability to detect small spinal abnormalities, but these small differences do not necessarily indicate increased likelihood of back problems or a more serious condition. The authors point out that use of CT scans and MRIs has not been shown to have a positive impact on treatment.

They suggest that patients can become incorrectly labelled as having a serious back problem, and that this can encourage disability. For example, a person with back pain may reasonably think a disc bulge apparent in their spinal image is the cause of their pain, and therefore think that they have a permanent condition, or the label “degeneration of the disc' may cause a patient to worry excessively and worsen their outlook.

Some patients with low back pain become long term sufferers and account for a large fraction of the costs associated with treatment of back pain. These patients are not pretending to be ill. They are normal humans responding to labels and diagnoses supplied by their physicians, including their radiologists.

If a patient is told they have a disc bulge or tear, they will often be very concerned not to make that problem worse. However, as this study indicates, the scans finding may be within norms, and not indicate a problem.

Guidelines for the treatment of back pain recommend no imaging for back pain of less than 4–6 weeks duration, unless there are “red flags' present, including the following:

  • Recent significant trauma, or milder trauma for people aged >50 years
  • Unexplained weight loss
  • Unexplained fever
  • Loss of immune function
  • History of cancer
  • Intravenous drug use
  • Prolonged use of corticosteroids,
  • Osteoporosis
  • People aged >70 years.
The authors note that:

  • There is increasing use of scans for back pain over the last decade
  • Healthy backs often look the same as problem backs on MRI and CT scans
  • Many patients with lower back problems do not benefit from scans as treatment is the same for back pain from most common causes
  • Lower back pain will most often improve without a scan being performed
  • Guidelines recommend no imaging, or X-ray, for back pain of less than 4–6 weeks duration, unless there are “red flags' present.
The authors of this paper encourage radiologists to simplify reports of lower back scans. They recommend that scan results be separated into two classes:

    1. Spine MRIs or CT scans with significant spinal abnormalities that are relevant to the patients symptoms (which means the radiologists need to have a good picture of the persons symptoms)
    2. Spine MRIs or CT scans without significant abnormalities.
Conclusions:
Patients with back pain may think that they are not being treated properly if they don't have a scan of their spine. Further, there may be pressure from employers or insurers for a worker to have a scan in order to ‘sort out the condition.

The authors note a high level of

  • Disc bulges
  • Disc herniations
  • Annular tears
reported in scans of people without back pain. They recommend that these types of scan results be interpreted and communicated to the patient with caution. Some people are left worried after being shown what may be a normal finding, and for some people being told they have a spinal abnormality may contribute to them avoiding activity and becoming more disabled.

A significant proportion of the disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 and expense related to low back pain may be the result of well-intended diagnostic and therapeutic efforts misapplied. Radiologists can help solve this problem by understanding the frequency of back pain and interpreting scans carefully, with an understanding of the issues surrounding reporting abnormalities to patients.
References:
PubMed abstract
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