Low Back Imaging

Aka: Low Back Imaging, Lumbar Back Imaging

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II. Precautions

  1. Avoid catastrophizing imaging findings
    1. Imaging often demonstrates asymptomatic changes unrelated to the patients symptoms and signs
    2. Describing imaging as normal with age related changes benefits patient outcomes
      1. Better treatment efficacy and higher resulting function
      2. Rajasekaran (2021) Eur Spine J 30(7): 2069-81 [PubMed]
  2. Imaging of the spine has an increasing False Positive Rate in older patients
    1. Correlate findings with Low Back Pain History and Low Back Pain Exam
    2. Cheung (2009) Spine 34(9): 934-40 [PubMed]

III. Imaging

  1. See Low Back Pain Red Flags
  2. Precautions
    1. A careful history and examination is the most important evaluation measure in Low Back Pain
    2. Most patients with Acute Low Back Pain will have Musculoskeletal Low Back Pain (95% will resolve within 6 weeks)
  3. Indications
    1. Low Back Pain Red Flags
    2. Prolonged Low Back Pain >6 weeks
    3. Preoperative spine evaluation
  4. Lumbar Spine XRay Indications
    1. Consider in age over 50 years or under 18 years old, or acute Lumbar Spine Trauma
    2. Vertebral Fracture
    3. Spondylolisthesis
  5. Lumbar Spine CT Indications
    1. Spinal Trauma
    2. Vertebral Fracture
    3. Vertebral dislocation
    4. Spondylolisthesis
  6. Lumbar Spine MRI Indications (MRI is preferred study in most cases)
    1. Lumbosacral Radiculopathy >6 weeks despite conservative management
    2. Spinal Epidural Abscess (Spinal Osteomyelitis)
    3. Spinal Cord Tumor
    4. Cauda Equina Syndrome (or spinal stenosis)
    5. Nontraumatic vascular injuries of the spine
  7. Other Imaging
    1. Lumbar Spine CT Myelogram (when MRI is contraindicated)
    2. Spine Bone Scan

IV. Diagnostics: Electrophysiologic Tests

  1. Indications: Radiculopathy, Neuropathy, Myelopathy, Myopathy
    1. Persistent symptoms >6 weeks AND
    2. Suspected nerve root dysfunction with neuromuscular deficit
      1. Radicular Pain
      2. Muscle Weakness
      3. Sensory Loss
      4. Muscle atrophy
    3. Not recommended if radiculopathy is obvious from exam
  2. Testing
    1. H-Reflex Tests
    2. Needle Electromyelogram (EMG)

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