1. Imaging of Low Back Pain
Dinesh Rao MD
Assistant Professor
Department of Radiology
Neuroradiology and Musculoskeletal Radiology
University of Florida College of Medicine - Jacksonville

2. Disclosures
I have no disclosures

3. Overview Types of Low Back Pain (LBP) Modalities of Imaging
Risks of Inappropriate Imaging
Review MRI/CT findings in patients with LBP with neurological symptoms

4. Low Back pain – 3 Types Uncomplicated low back pain
Low back pain associated with neurological symptoms
Low back pain with “red flags”
Trauma, infection, tumor, acute neurological symptoms

5. Modalities of Imaging Plain Film:
"…the value of a lumbar spine radiograph is to establish the presence of a spine.” – Michael Modic MD

6. Modalities of Imaging CT Workhorse for trauma CT myelogram
Problem solving (tumor, etc.)
Surgical planning

7. Modalities of Imaging MRI – for neurological symptoms
Myelopathy – spinal cord disease
Neurogenic claudication – canal stenosis below conus
Radiculopathy – after failed conservative treatment if patient is considering surgery or pain intervention

8. Uncomplicated Low Back Pain
Poorly understood, multifactorial
In young adults, likely related to weak core muscles, weight, bad posture, muscle strain 1
Usually self limiting with conservative treatment
1 Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363–370

9. MRI for LBP is Inappropriate
Fewer than 1% of patients in primary care setting have “red flags” 1
Up to 38% of lumbar MRI not indicated 2
Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363–370
Swedlow A, Johnson G, Smithline N, Milstein A. Increased costs and rates of use in the California workers’ compensation system as a result of self-referral by physicians. N Engl J Med. 1992;327:1502–6.

10. Risks of Inappropriate Imaging
Costs
Much higher costs with early imaging
Direct costs of scan
Up to 10x as much cost compared to conservative management and testing. 3
No difference in outcome between early MRI and usual care 4
3. Joines JD, McNutt RA, Carey TS, et al. Finding cancer in primary care outpatients with low back pain: a comparison of diagnostic strategies. J Gen Intern Med 2001; 16:14–23
4. Deyo RA, Mirza SK, Turner JA, et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22:62–68

11. Risks of Inappropriate Imaging
Increased rate of surgery
Lumbar MRI leads to more surgery without better outcome
2 times more likely to have surgery with plain film 5
8 times more likely to have surgery with MRI 6
5. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289;
6. Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52:

12. Risks of Inappropriate Imaging
False positives – 57% of patients without back pain have a herniated disk 7
“Many imaging based degenerative features are likely part of normal aging and unassociated with pain.” 8
Degenerative changes correlate poorly with pain and disability 1
7. Modic, M. T., Obuchowski, N. A., Ross, J. S., Brant-Zawadzki, M. N., Grooff, P. N., Mazanec, D. J., & Benzel, E. C. (2005). Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology, 237(2),
8. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR. 2015
Apr;26(4):811-6.
1. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363–370

13. Risks of Inappropriate Imaging
Patient Labelling – patients become less happy with their life 9
Longer work disability and higher treatment costs
Increased fear and avoidance of activities 10
9. Sloan TJ, Walsh DA. Explanatory and diagnostic labels and perceived prognosis in chronic low back pain. Spine 2010;35:E1120–5.
10. Webster, BS, Bauer AZ, Choi YS. Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain. SPINE Volume 38, (22)

14. LBP with Neurological Symptoms
Radiculopathy
Usually recover within a few weeks
Imaging useful for surgical or pain intervention in cases refractory to conservative treatment.
Neurogenic Claudication – chronic spinal stenosis
Cauda Equina – acute injury/stenosis
Myelopathy

15. Radiculopathy

17. 1 month post op

18. 1 year post op

19. Neurogenic Claudication

20. Myelopathy

21. Low Back Pain with Red Flags
Trauma
Infection
Immunosuppresion
Suspicion/history of malignancy
Anticoagulation

22. Type 1 DJD
Radiologykey.com

23. Discitis/Osteomyelitis (bacterial)

24. Discitis/Osteomyelitis (atypical)

25. Hemorrhage

26. Trauma

27. Tumor

28. Summary Plain film not useful CT for trauma or specialized issue MRI
“red flags”
Neurological symptoms possibly requiring surgery