Assessment of a single lumbar spine radiograph in low back pain

The diagnostic contribution of the frontal lumbar spine radiograph in community referred low back pain--a prospective study of 1030 patients

AIM

The diagnostic contribution of the anteroposterior (AP) view was studied to assess whether this view could be omitted safely, thus reducing the radiation burden received by patients undergoing lumbar spine radiography.

MATERIALS AND METHODS

Prospective analysis of 1030 consecutive referrals for lumbar spine radiography from general practice.

RESULTS

In the majority of cases (90.5%) the AP view was non-contributory. In 4.2% the diagnosis was strengthened and it was altered in 4.6%. However, in the latter group only 1.3% of the total were considered significant alterations. These were cases of possible, but not definite, pars defects and sacroiliitis. Specific important conditions such as infection, malignancy and benign tumours were not missed on the lateral view alone, in our study population. The radiation burden is reduced by 75% by omitting the AP view.

CONCLUSION

A single lateral view is an adequate examination, with the proviso that sacroiliac joint disease is not assessed on this view and some pars defects and facet joint degenerative changes may be overlooked. The radiation protection gains are considerable. A single lateral lumbar view is now our routine practice unless sacroiliitis is a specific clinical concern.

Value of cervical spine radiographs as a screening tool

A review of the reports of 848 cervical spine radiographs was done to assess the yield of useful and critical information in a group of patients without trauma. In 470 of these patients the clinical record also was reviewed; 54.2% of the radiographs were read as having degenerative change, 35% were read as normal, and 8.5% were read as being consistent with muscle spasm. The remaining 2.3% included diagnoses of anatomic or congenital variants, soft tissue calcification, or old compression fractures. There were no serious diagnoses such as acute fracture, dislocation, or neoplasm that, had they not been identified, would have put the patient in jeopardy. Thus, for most outpatients with nontraumatic symptoms of a nonspecific or nonlocalizing nature, the use of cervical spine radiographs as a screening tool is not justified.

Short communication: a lateral will do?

Efforts to reduce the dose of diagnostic medical irradiation by applying selective criteria for radiographic examinations have been addressed by the Royal College of Radiologists in their Guidelines. Reduction of the number of views of an area has also been suggested by some authors. Deviating from one of the fundamentals of skeletal radiology which requires at least two views of any part of the skeleton may lead to misdiagnosis. This concept is considered in relation to the lumbar spine. Continued routine acquisition of at least two views for the radiographic examination of the lumbar spine is stressed.

Detection of significant abnormalities on lumbar spine radiographs

The purpose of this study was to determine the proportion of significant abnormalities detected on anteroposterior (AP) and lateral radiographs of the lumbar spine when viewed separately, in a series of cases where the prevalence of abnormalities had been artificially increased. Five radiologists of varying experience were required to report separately on the AP and lateral films of 300 cases in which randomly included were 30 cases with metastatic disease, a disc infection or an inflammatory spondylitis. At a later date, unaware of their initial observations, the radiologists repeated the exercise reviewing all the films together. As might be expected the false positive rate was relatively high, particularly in the least experienced radiologists' responses. Nevertheless the overall results indicate that the majority of early inflammatory spondylitis cases will be missed on a solitary lateral film as will many of the metastases. Conversely, fractionally more of the disc infections were observed on the lateral film than on the AP. Further analyses in terms of sensitivity, specificity, positive and negative predictive values are presented. The authors conclude that it is preferable to reduce the overall number of lumbar spine examinations performed, by adherence to accepted guidelines, than to prejudice the detection of significant, albeit rare, abnormalities by restricting the routine series of radiographs.

Is the coned lateral lumbosacral junction radiograph necessary for radiological diagnosis?

The lumbar spine radiographs of 400 orthopaedic outpatients were reviewed to determine if the absence of the coned lateral lumbosacral junction radiograph would lead to a loss in diagnostic accuracy. In 84 (21%) patients the antero-posterior and lateral lumbar spine radiographs failed to visualize adequately the lumbosacral junction. In these patients the coned lateral lumbosacral junction radiograph resulted in 17 (4.5%) diagnoses which would otherwise have been missed. The diagnoses were spondylosis (11), spondylolisthesis (3), spondylolysis (1), Paget's disease (1) and infection (1). Absence of the coned lateral lumbosacral radiograph will result in inadequate demonstration of the lumbosacral junction and a loss in diagnostic accuracy.