Lumbar spine plain film radiography in the investigation of back pain

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Lumbar spine plain film radiography in the
investigation of back pain
Back pain and its management Guidance on
investigating back pain Lumbar spine x-rays -
usage - benefits - risks - effects Change
agenda
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Back Pain
Common clinical problem 7 of adult population
consult every year Nearly everyone has back pain
at some time Back pain is rarely due to any
serious disease
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Management of back pain
Exclude potentially serious causes Biopsychosocial
model of back pain (BMJ 2002, Clinical review
musculo-skeletal pain) Stay active and resume
ordinary activity (Buchbinder,
BMJ, 2001) Multidisciplinary rehabilitation is
effective (Guzman, BMJ 2001, Cochrane
collaboration back review group) Analgesia,
activity and manual therapy recommended (www.
workingbackscotland.com)
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Investigation of backache
Recent Practice 80 of doctors sometimes or
always refer patients with recurrent backache for
lumbar spine x-rays Reasons given - Exclude
serious pathology - Reassure patient - Reassure
themselves (Owen, Br J Gen. Pract, 1990)

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Advice on lumbar spine radiography

Is recent practice appropriate? Agency for
health care policy Clinical standards advisory
group Royal College of General Practitioners Royal
College of Radiologists
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Royal College of Radiologists Guidelines

Adopted locally as referral guidance Agreed as
part of IR(ME)R 2000 Guidance on imaging
investigation of back pain
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Royal College of Radiologists Guidelines

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Royal College of Radiologists Guidelines

Clinical Problem Chronic back pain with no
pointers to infection or neoplasm
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Chronic back pain with no pointers to infection
or neoplasm

Investigation Recommendation XR Indicated
only in specific circumstances MRI
Specialised investigation
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Chronic back pain with no pointers to infection
or neoplasm
Comment X-ray - Degenerative changes are
common and non- specific. -
Main value in younger patients (e.g. less than
20, spondylolisthesis, ankylosing
spondylitis, etc.) or in
older patients e.g. gt 55. MRI - Imaging
findings need to be interpreted with
caution. Their significance depends upon
correlation with clinical signs. - Negative
findings may be helpful.

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Royal College of Radiologists Guidelines

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Royal College of Radiologists Guidelines

• Clinical Problem
• Back pain with possible serious features such
  as
• Onset lt 20, gt55 yrs
• Sphincter or gait disturbance
• Saddle anaesthesia
• Severe or progressive motor loss
• Widespread neurological deficit
• Previous carcinoma
• Systemic unwellness
• HIV
• Weight loss
• Intravenous drug abuse
• Steroids
• Structural deformity
• Non-mechanical pain

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Back pain with possible serious features

Investigation Recommendation MRI and
NM Indicated
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Back pain with possible serious features
Comment Together with urgent specialist
referral MRI is usually the best
investigation. Imaging should not delay
specialist referral. NM is also widely used for
possible bone destruction due to metastasis,
where infection is suspected, or in some cases of
chronic pain. (NORMAL PLAIN XR MAY BE
FALSELY REASSURING)

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Royal College of Radiologists Guidelines

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Royal College of Radiologists Guidelines

Clinical Problem Acute back pain - disc
herniation - sciatica with no adverse
features
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Acute back pain

Investigation Recommendation XR Indicated
only in specific circumstances MRI or
CT Specialised investigation
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Acute back pain
Comment X-ray Acute back pain is usually due to
conditions which cannot be diagnosed on plain XR
(osteoporotic collapse is an exception).

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Acute back pain
Comment MRI/CT Normal plain XRs may be
falsely reassuring. Demonstration of disc
herniation requires MRI or CT and should be
considered after failed conservative
management. MRI generally preferred (wider field
of view, conus, post-operative changes etc.) and
avoids x-irradiation. Clinico-radiological
correlation is important as a significant number
of disc herniations are asymtomatic

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Lumbar spine radiography
Radiographic features do not correlate with
symptoms - 85 - 95 of over 55s have OA at
post mortem (Quintet,
Semi Arthritis, Rheum, 1979) - Most patients
with radiographic OA are pain free
(Waddell, Br J Hosp Med, 1982) Relatively
insensitive for serious pathology Low yield of
findings which affect clinical management
(Halpin, BMJ 1991)

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Lumbar spine radiography
Usage Tayside 4,000 lumbar spine x-rays 1,300
between age 20-55 750 lumbar spine MRI, 75
lumbar spine CT

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Lumbar spine radiography
Benefits Patient more satisfied with care
(Kendrick, BMJ, 2001) Can detect serious
pathology 1 in 2,500 chance of detecting
unexpected serious pathology (Nachemson,
The lumbar spine, 1976)

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Lumbar spine radiography
Risks Direct effects of radiation Chest x-ray
- 0.3 mGy AP and lateral lumbar spine
- mGy

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Lumbar spine radiography
Risks Direct effects of radiation dose Chest
x-ray - 0.3 mGy AP and lateral
lumbar spine - 40.0 mGy Risk of cancer
induction is related to radiation dose. In
Tayside, lumbar spine x-rays cause 1 fatal
cancer every 5 years. In the UK, lumbar spine
x-rays cause 19 fatal cancers per
year. (Halpin,BMJ 1991)

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Lumbar spine radiography
Risks Effects due to gonadal dose of
radiation Hereditary effect from parental
irradiation 16 per million
examinations Effect on fetus if directly
irradiated - cancer 200 per million
examinations - mental retardation 1560 per
million examinations

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Blast from the past a cautionary tale

Radiation risks Denise Adams, GP, Newcastle,
BMJ, 2002 Strawberrry naevus treated with low
dose radiation 40 years later developed thyroid
and breast cancer
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Blast from the past a cautionary tale

Spinal radiography exposes our patients to
higher doses of radiation than we think. Do we
constantly ask ourselves if the investigation is
necessary? My case serves to illustrate that
radiation really does cause cancer. Remember
what happened to me and reconsider the options
before finally signing the form.
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Effects of lumbar spine x-rays on patients when
compared to patients managed without x-rays

Kendrick et al (BMJ, 2001) reported on
a randomised controlled trial of radiography
involving 420 patients managed in 73 general
practices Pain scores -
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Effects of lumbar spine x-rays on patients when
compared to patients managed without x-rays

Randomised controlled trial of radiography
involving 420 patients managed in 73 general
practices Pain scores - Higher
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Effects of lumbar spine x-rays on patients when
compared to patients managed without x-rays

Randomised controlled trial of radiography
involving 420 patients managed in 73 general
practices Pain scores - Higher Consultations
with G.P. -
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Effects of lumbar spine x-rays on patients when
compared to patients managed without x-rays

Randomised controlled trial of radiography
involving 420 patients managed in 73 general
practices Pain scores - Higher Consultations
with G.P. - More
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Effects of lumbar spine x-rays on patients when
compared to patients managed without x-rays

Randomised controlled trial of radiography
involving 420 patients managed in 73 general
practices Pain scores - Higher Consultations
with G.P. - More Health status -
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Effects of lumbar spine x-rays on patients when
compared to patients managed without x-rays

Randomised controlled trial of radiography
involving 420 patients managed in 73 general
practices Pain scores - Higher Consultations
with G.P. - More Health status - Worse
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Effects of lumbar spine x-rays on patients when
compared to patients managed without x-rays

Randomised controlled trial of radiography
involving 420 patients managed in 73 general
practices Pain scores - Higher Consultations
with G.P. - More Health status -
Worse Radiography reinforces patient belief they
are unwell (Kendrick, BMJ 2001)
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Summary of lumbar spine radiography in backache
Appropriate usage from RCR guidelines Risks
- Unreliable in excluding serious disease
- Poor correlation with symptoms -
High radiation dose Effects - Encourages
patients belief they are unwell Benefits -
Improve patient satisfaction with their care

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MRI for back pain
Is rapid MRI more effective than radiographs for
low back pain? 380 patients randomised to XR or
MRI MRI - increases costs - no benefit in
relieving pain - no improvement in long term
function - higher patient and referrer
satisfaction Hollingworth et al. JAMA 2003 BMJ
poem (Patient Orientated Evidence that matters)

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Lumbar spine radiography

Challenge is to develop GP/radiology shared
change agenda
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Lumbar spine plain film radiography in the
investigation of back pain
Back pain and its management Guidance on
investigating back pain Lumbar spine x-rays -
usage - benefits - risks - effects Change
agenda