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Spinal radiographic findings and nonspecific low back pain: A systematic review of observational studies

At a glance:
This major review sought to assess the relationship between x-ray findings and back pain. The study found:
  • Degeneration, as defined by 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.
     space narrowing, osteopaths (small, abnormal bony outgrowths), and sclerosis (thickening of the disks in the spine) findings on x-ray meant the patient was somewhat more likely to experience back pain.
  • Spondylolysis, spondylolisthesis, transitional vertebrae, and Scheuermann's disease
    Scheuermann's disease
    A childhood skeletal disorder that causes pain in the spine. The person may have changes to their vertebrae
    (singular: vertebra) The individual irregular bones that make up the spinal column.
     on X-rays.
     did not appear to be associated with increased likelihood of low back pain.
X-rays of patients with back pain have now generally been replaced by MRI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.
 or other scans. However the same issues apply: many people who do not have back pain show some type of abnormality on their x-rays or scans. These findings don't always indicate that there is a significant problem.

When people are experiencing back pain, investigations of the spine are important if there is concern the patient might have a serious condition such as cancer, infection, or a fracture. Often, however, there is no visible cause, and an over reliance on tests or investigation such as imaging can confuse the issue. In treating back pain, it is most important to understand the condition and learn about how to best manage the problem. .
People can rely too heavily on x-rays and scans to discover the cause of back pain. Sometimes people worry when there is no abnormality noted on their x-rays or scans, but it is important to realise that x-ray findings do not necessarily indicate whether there are back pain symptoms. Patients with back pain need understanding and support from you, and good advice about their condition and treatment options from their treating practitioners.
This study suggests that people who have degeneration noted on their x-rays are only a little more likely than others in the community to experience back pain. This study supports other research findings that investigations are useful to exclude serious or worrying pathology, but are not of significant value in the overall assessment of patients with back pain. If investigations are being performed it is important that the patient understand that abnormalities are common, and do not necessarily indicate a serious problem. Degeneration on an x-ray can sound worrying, but this study shows that it is a common finding in people without any pain symptoms.
Whilst x-rays are not done very often for back problems these days, the principles of this study can be applied to other scans, and other research about various investigations of the back has had similar findings. People with back pain often worry about their test results, and can be concerned about x-ray findings. Encourage the employee to discuss any findings with their treating practitioner,
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 to ensure they have a complete understanding of the significance, or lack of significance, of the results of the tests.
Original Article, Authors & Publication Details:
M. W. van Tulder1, W. J. J. Assendelft1, B. W. Koes1 and L. M. Bouter1 (1997).

Spinal radiographic findings and nonspecific
A general problem rather than a specific one. Medical conditions can be described as specific (e.g. biceps tendonitis,
Painful inflammation of a tendon. Tendonitis is often described by the body part affected, such as Achilles tendonitis.
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: disk.
 prolapse) or nonspecific (e.g. nonspecific low back pain).
 low back pain: A systematic review
systematic review
A comprehensive review of research studies in a particular area. The review follows guidelines to ensure the studies included are valid.
 of observational studies.
Spine; 22(4):427-434.

1 Institute for Research in Extramural Medicine, Faculty of Medicine, Vrije Universiteit, Amsterdam, The Netherlands.

Background, Study Objectives, How It Was Done:
It has been common practice to order x-rays for people experiencing low back pain. The main purpose of performing x-rays is to ensure patients do not have a serious medical condition, such as cancer, fractures, or infections. However, X-ray findings of degeneration, congenital, or postural abnormalities in the spine are often found, and a patient may worry that these finding are significant, or indicate disease. The aim of this study was to look at whether x-ray findings and low back pain are related. This study was a systematic review of research articles concerning x-ray findings in cases of low back pain. The authors of the study looked for all research papers where x-rays had been taken in cases of non-specific or common low back pain. Papers that looked at x-rays of cancers, infections, or fractures, were not included. The authors of this study sent the list of research articles they had found in this area to international experts in spinal radiology,
The medical examination or photographing of organs, bones, or other tissues
Collection of cells that perform a similar function. e.g. epithelium (skin), connective tissue (blood, bone), muscle
 with x-rays or other radiation.
 to check that they had included all relevant papers.

Study Findings:
35 studies where there had been some measure of correlation between back pain and x-ray findings were identified. 18 of the studies were considered to be of acceptable quality and included in this review. The authors found that people who had degeneration noted in an x-ray were more likely to have back pain. Degeneration was noted if disk space narrowing, osteophytes (small, abnormal bony outgrowths), and sclerosis (thickening of the disks in the spine) were found in the x-ray. If the person had degeneration, they were somewhat more likely to experience back pain. This finding was consistent across most of the 18 studies. The results were statistically valid: the odds ratios
odds ratio
Measure of how much more likely one group is to have a condition or event than another group. It is defined as the ratio of the odds of a condition occurring in one group to the odds of it occurring in another group. An odds ratio of 1 indicates that the condition or event under study is equally likely in both groups. An odds ratio greater than 1 indicates that the condition or event is more likely in the first group. Also called a measure of likelihood.
 or measures of likelihood were between 1.2 and 3.3. However, these odds ratios are fairly low, showing that patients with degeneration were only slightly more likely to have back pain that those without degeneration. When the radiologists found spondylolysis
A defect in the pars interarticularis (part of the facet joint) of a vertebra. Spondylolysis occurs in three to six percent of the population and may be associated with spondylolisthesis.
 (a stress fracture
A cracked or broken bone.
 in the vertebra) or spondylolisthesis
A condition where one vertebra is not sitting squarely on top of the one underneath. It is usually hereditary but can occur in other situations. The X-rays of about one in twenty people show spondylolisthesis. There is little evidence that it makes a significant difference to back problems.
 (displacement of a vertebra from the spinal column), the patients were not statistically more likely to have back pain (the odds ratios ranged from 0.3 to 2.1). That is, there was no meaningful correlation between these findings and the likelihood the person would experience back pain. There were only a few studies that included x-ray finding of spina bifida (an incompletely formed spinal cord), transitional vertebrae
transitional vertebrae
One of a series of different types of vertebrae people can be born with. The presence of transitional vertebrae does not generally indicate disease.
 and Scheuermann's disease. The authors noted that these x-ray findings do not appear to be associated with non-specific low back pain.
No specific back pain is associated with degeneration seen in x-rays. However, the authors note that the association was not strong, as the odds ratios (or measures of likelihood) were fairly low. Also, most of the studies did not follow people over a time, but only looked at the association between x-ray results and pain at one point in time.
PubMed Abstract
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