The therapeutic impact of lumbar spine MRI on patients with low back and leg pain

Axially Loaded Magnetic Resonance Imaging Identification of the Factors Associated with Low Back-Related Leg Pain

This retrospective observational study was conducted to identify factors associated with low back-related leg pain (LBLP) using axially loaded magnetic resonance imaging (AL-MRI). Ninety patients with low back pain (LBP) underwent AL-MRI of the lumbar spine. A visual analog scale and patient pain drawings were used to evaluate pain intensity and location and determine LBLP cases. The values of AL-MRI findings were analyzed using a logistic regression model with a binary dependent variable equal to one for low back-related leg pain and zero otherwise. Logistic regression results suggested that intervertebral joint effusion (odds ratio (OR) = 4.58; p = 0.035), atypical ligamenta flava (OR = 5.77; p = 0.003), and edema of the lumbar intervertebral joint (OR = 6.41; p = 0.003) were more likely to be present in LBLP patients. Advanced disc degeneration (p = 0.009) and synovial cysts (p = 0.004) were less frequently observed in LBLP cases. According to the AL-MRI examinations, the odds of having LBLP are more likely if facet effusion, abnormal ligamenta flava, and lumbar facet joint edema are present on imaging than if not. The assessment of lumbar spine morphology in axial loaded MRI adds value to the potential understanding of LBLP, but further longitudinal and loaded–unloaded comparative studies are required to determine the role of acute dynamic changes and instability in LBLP development.

Patients with predominantly back pain at the time of lumbar fusion for low-grade spondylolisthesis experience similar clinical improvement to patients with predominantly leg pain: mid-term results

BACKGROUND CONTEXT

Patients with back pain predominance (BPP) have traditionally been thought to derive less predictable symptomatic relief from lumbar fusion surgery.

PURPOSE

To compare postoperative clinical outcomes as well as degree of improvement in clinical outcome measures between patients with BPP and patients with leg pain predominance (LPP) undergoing open posterior lumbar fusion.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Analysis of patients who underwent an open posterior lumbar fusion for low-grade (Meyerding Grade I or II) degenerative or isthmic spondylolisthesis from 2011 to 2018 was conducted. Surgery was indicated after failure of conservative treatment to address radiculopathy and/or neurogenic claudication. Patients were excluded if they were under 18 years of age at the time of surgery, had less than 6 months of follow-up, presented with a lumbar vertebral body fracture, tumor, or infection, or underwent a fusion surgery that extended to the thoracic spine, high-grade spondylolisthesis, or concomitant deformity.

OUTCOME MEASURES

Radiographs obtained at preoperative, immediate postoperative, and final visits were evaluated for presence or absence of fusion. Patient-reported outcomes were recorded at preoperative and final clinic visits that included: visual analog scale (VAS) back/leg pain, and Oswestry disability index (ODI). Achievement of minimal clinically important difference (MCID) was analyzed, along with rates of postoperative complication and reoperation.

METHODS

Preoperative and final patient-reported outcomes were obtained. Achievement of MCID was evaluated using following thresholds: ODI 14.9, VAS-back pain 2.1, VAS-leg pain 2.8. For analysis, patients were divided into two groups based on predominant location of pain: predominantly VAS-back pain (BPP) and predominantly VAS-leg pain (LPP).

RESULTS

One hundred forty-one patients met inclusion criteria. Of these, 71 had LPP, and 70 had BPP. Patients with preoperative LPP experienced greater improvements in VAS-leg (p<.001) compared to those with BPP, whereas patients with preoperative BPP experienced greater improvements in VAS-back (p=.011) postoperatively compared to those with LPP. There were no differences in the final clinical outcomes. Additionally, LPP achieved MCID for VAS-leg (p=.027) at significantly higher proportion than BPP and BPP achieved MCID for VAS-back (p=.050) at significantly higher proportion than LPP.

CONCLUSIONS

Patients with low-grade spondylolisthesis who underwent an open posterior lumbar fusion had improvement in symptoms regardless of presentation with BPP or LPP. In properly indicated patients, posterior spinal fusion is effective for those with BPP in the setting of experiencing both leg and back pain, and clinicians can use this information for perioperative discussions and surgical decision-making.

Can you diagnose for vertebral fracture correctly by plain X-ray?

INTRODUCTION

A wrong diagnosis of latent vertebral fracture is often made when it is based on plain X-ray imaging. Magnetic resonance imaging (MRI) has a high degree of accuracy for the definite diagnosis. This study was designed to identify ways to support improvements in the diagnostic accuracy of plain X-ray (X-P).

METHODS

We studied X-P and MRI images of 120 women and men (age range: 50-96 years). Five orthopedists and two radiologists interpreted front and lateral thoracolumbar X-Ps and MRI images. The correct diagnosis rate for the presence and location of incident vertebral fractures and the correct diagnosis rate according to morphological classifications were analyzed.

RESULTS

A correct diagnosis of incident fractures was made in 51.5% of cases overall. Diagnoses of non-incident fracture based on X-P in those cases with incident fracture based on MRI (false positive) occurred in 24.8% of the patients, while diagnoses of incident fracture based on X-P in those cases without incident fracture based on MRI (false negative) occurred in 6.5% of the patients. The application of morphological classifications (the primary osteoporosis diagnostic criteria and Yoshida's classification) resulted in the correct diagnosis rate being significantly higher in the group without prevalent fracture even when there were morphological changes (wedge, indented, protruding type) in the anterior bone cortex. Odds ratios were investigated for factors that would affect the correct diagnosis rate, including age, body weight, lumbar vertebrae bone mineral density, and examiner ability. In an overall investigation, age (OR=0.660), body weight (OR=2.082), and examiner ability (p=0.0205) affected the correct diagnosis rate.

CONCLUSION

The correct diagnosis rate for incident vertebral fractures with X-Ps was low (24.8%) and in cases with prevalent fractures, the rate was even lower (16.8%), but the number of prevalent fractures and BMD did not exert an effect. One key improving the correct diagnosis rate may be to pay attention to morphological changes in the anterior bone cortex.

What diagnostic tests are useful for low back pain?

Low back pain (LBP) is a common problem that poses some interesting and difficult diagnostic problems. It is typically benign and self-limited, but it is occasionally the presenting symptom of serious systemic disease. The general diagnostic approach to low back pain is to check for 'red flags' in the history and physical that suggest the presence of malignancy, infection or spondyloarthridites, and for neurological compromise that could indicate that surgery is required (cauda equina syndrome) or may be beneficial (such as herniated discs or spinal stenosis that have not improved with conservative care). In the absence of these features, imaging is of limited value. Recent research has begun to evaluate subgroups with 'non-specific' low back pain that seem to benefit from specific interventions such as median branch or sacroiliac joint injections, manipulation, or specific exercises, but these require further investigation and validation.

Influence of imaging on clinical decision making in the treatment of lower back pain

PURPOSE

To assess the impact of cross-sectional imaging with magnetic resonance (MR) imaging or computed tomography (CT) on clinical decision making for patients with lower back pain (LBP).

MATERIALS AND METHODS

A randomized controlled before-and-after study was performed in 145 patients who had symptomatic lumbar spinal disorders and had been referred to orthopedists or neurosurgeons. Participants were a subgroup within a multicenter pragmatic randomized comparison of two imaging policies on LBP treatment: "imaging" versus "no imaging," unless a clear indication developed. Paired assessments were made of diagnosis, diagnostic confidence, proposed treatment, treatment confidence at trial entry and follow-up, and expectations of imaging. Data were analyzed according to the groups as randomized.

RESULTS

At follow-up, there were no statistically significant differences between the groups with respect to diagnosis or treatment plans. Significant increases in diagnostic and therapeutic confidence between trial entry and follow-up were observed for both groups, with a significantly greater increase in diagnostic confidence (P =.01) in the imaging group.

CONCLUSION

Imaging may increase diagnostic confidence but has minimal influence on diagnostic or therapeutic decisions for patients with LBP. The results highlight the need for evidence-based guidelines for imaging in LBP treatment.

The diagnostic and therapeutic impact of MRI: an observational multi-centre study

AIM

To provide information about the diagnostic and therapeutic impact of magnetic resonance imaging (MRI) and to compare the findings across diagnostic groups.

MATERIALS AND METHODS

A prospective, observational study of 2017 consecutive referrals for MRI of the head, spine or knee at four imaging centres. Clinicians completed questionnaires before MRI stating initial diagnoses, diagnostic confidence and treatment plans. After imaging, a second questionnaire evaluated clinicians' revised diagnosis and treatment plans in the light of imaging findings. Patients were grouped into nine diagnostic categories for analysis. Comparison between pre- and post-imaging was used to assess the diagnostic and therapeutic impact of MRI.

RESULTS

In seven of nine diagnostic groups MRI findings were associated with a diagnostic impact. Diagnoses were revised or discarded following normal MR findings and diagnostic confidence was increased by confirmative MR findings. There was no statistically significant diagnostic impact for suspected pituitary or cerebello-pontine angle lesions. In five of nine diagnostic groups (knee meniscus, knee ligament, multiple sclerosis, lumbar and cervical spine) MRI findings had a clear impact on treatment plans.

CONCLUSION

This study demonstrates that in most diagnostic categories, MRI influences diagnosis and treatment. However, experimental studies are needed to prove that these diagnostic and therapeutic impacts lead to improved health.Hollingworth (2000). Clinical Radiology55, 825-831.