This document discusses imaging of the lumbar spine, specifically MRI scanning. It provides context on when MRI scans are clinically indicated and notes that psychosocial factors are better predictors of disability than anatomical findings alone. The document summarizes guidelines from NICE on imaging for non-specific low back pain and provides definitions. It discusses clinical indications and contraindications for MRI scans, as well as limitations such as false positives and overuse leading to unnecessary interventions. References are presented showing no benefit of early MRI for low back pain without red flags.

1. Imaging of the lumbar spine
Dr Selwyn Richards

2. Why scan?
• Clinically indicated
• Patient and refer pressure and
expectations

3. Patient and society expectations
Can we scan everyone?
• Lifetime prevalence of back pain 85%
• True instantaneous prevalence c. 14%
adults LBP, 2% sciatica
• 1 year follow up on GP consulters
–72% fully recovered, 83% no or mild pain, 86%
no or minimal disablity

4. Psychosocial factors greater predictor of
disability than anatomic findings
Systematic review of 20 prospective studies
• patients presenting with acute low back pain
predictors of disabling chronic low back pain at
one year follow-up included
• maladaptive pain coping behaviours,
• functional impairment,
• poor general health status,
• presence of psychiatric comorbidities,
• nonorganic signs
• Will this patient develop persistent disabling low back pain? Chou R, Shekelle PSO
JAMA. 303(13):1295.

5. Clinical indications for MRI scan Lumbar
spine
• NICE for non specific low back pain
• Inflammatory back pain
• Overall guidelines

7. Who are the NICE guidelines aimed at?
NICE definition of non-specific low back
pain:
• NSLBP is tension and /or soreness in the
lower back region for which it isn’t
possible to identify a specific cause of the
pain. Several structures in the back,
including the joints, discs and connective
tissues, may contribute to symptoms.

8. Specific causes of low back pain
mentioned are:-
–Malignancy
–Infection
–Fracture
–Ankylosing Spondylitis and related disorders
• The guideline does not include
degenerative conditions as specific causes
of low back pain.

9. NICE recap on imaging in low back pain

10. So who with low back pain may benefit
form surgery ?
• Single level degenerative change in disc. Changes to include one or
more features with +ve discogram
– Loss of disc height
– Annular tear
– Modic bone changes
• Mobile spondylolisthesis
• Post surgical pain up to 3 years post operation
– Enhanced MRI scan for infection
– X-ray for instability
• Annular tears with positive discogram and history of recurrent
episodes of pain.
• Large central disc prolapse with persisting pain.
• Tight stenotic spinal canal with back pain on standing and walking.

11. Who with low back pain should not be
considered for surgery
• Patients with a normal MRI scan of lumbar spine.
– And flexion/extension view X-ray of lumbar spine
• Patients with multiple levels of degenerative change in lumbar discs on MRI
scan,
– Patients with ≥ 2 level degenerative disc changes require further investigation and
MDT review
• Patients who have a chronic and more widespread pain syndrome.
– These patients require a specialist pain MDT review.
• Patients with lumbar facet joint pain.
• Patients with BMI 35 or over
• Patients who continue to smoke.
• Patients with severe scoliosis
• Patients with ASA4 co-morbidities
• Patients with poor bone quality due to osteoporosis, osteomalacia or Paget’s
disease.
• Patients at extreme ends of age spectrum.

12. ankylosing spondylitis
• a form of spinal
inflammatory arthritis,
chiefly affecting young
males, that eventually
causes ankylosis of
vertebral and sacroiliac
joints.

14. Early Late

15. Inflammatory back pain definition:-
• at least four of the five following criteria:
symptom onset before age 40,
insidious onset,
morning stiffness,
duration >3 months,
improvement with exercise
• or three out of five of these plus night pain
(second half)
• +/- alternating buttock pain, dramatic
improvement with anti-inflammatories and HLA
B27 positive

16. Traditional diagnsosis of Anklosing
spondylitis
The modified New York criteria are currently used to
diagnose ankylosing spondylitis. A patient should have one
or more of the following clinical criteria:
• 1. Low back pain of at least 3 months’ duration that is
alleviated by exercise and is not relieved by rest.
• 2. Restricted lumbar spinal motion.
• 3. Decreased chest expansion relative to normal values for
age and sex.
• In addition, the patient must have definitive radiographic
evidence of sacroiliitis (i.e., bilateral sacroiliitis of grade II to IV
or unilateral sacroiliitis of grade III or IV)

17. Do I have inflammatory back pain?
You may have inflammatory back pain if you answer
yes to at least 4 of the 5 of the statements below.
• Back pain of more than 3 months duration is
inflammatory if:
• Age at onset less than 40 years
• The pain started slowly
• Improvement with exercise
• No improvement with rest
• Pain at night (with improvement on getting up)

18. Spondyloarthritis
Inflammatory back pain is the main symptom of a group
of conditions called spondyloarthritis.
• Four main conditions make up the spondyloarthritis
family.
• Axial spondyloarthritis / ankylosing spondylitis
• Enteropathic arthritis
• Psoriatic arthritis
• Reactive arthritis which is also known as Reiter's
syndrome

19. Axial Spondyloarthritis
includes:
• Ankylosing Spondylitis (AS) : Where
changes to the sacroilliac joints and /or the
spine can be seen on x-ray.
• Non-radiographic axial spondyloarthritis:
Where x-ray changes are not present but you
have symptoms.

20. Prevalence of
inflammatory sacroiliitis
• About 1/3 Arthritis Res Ther.
2006;8(1):R11.
• Site of inflammation
fits with symptoms
location Ann Rheum Dis
doi:10.1136/annrheumdis-2012-
201427
• T1 and T1 plus Gd

21. Indications for when to get an MRI scan
include:
• After 4 to 6 weeks of leg pain, if the pain is severe enough to
potentially warrant surgery
• After 3 to 6 months of low back pain, if the pain is severe enough to
potentially warrant surgery
• If the back pain is accompanied by constitutional symptoms (such as
loss of appetite, weight loss, fever, chills, shakes, or severe pain
when at rest) that may indicate that the pain is due to a tumour or an
infection
• For patients who may have lumbar spinal stenosis and are
considering an epidural injection to alleviate painful symptoms
• For patients who have not done well after having back surgery,
specifically if their pain symptoms do not get better after 4 to 6 weeks
• Inflammatory back pain

22. MRI Contraindications
• Patients who have a heart pacemaker, spinal cord stimulators,
cochlear implants if not MRI safe may not have an MRI scan
• Patients who have a metallic foreign body (metal sliver) in their eye,
or who have an aneurysm clip in their brain, cannot have an MRI scan
since the magnetic field may dislodge the metal
• Patients with severe claustrophobia may not be able to tolerate an
MRI scan, although more open scanners are now available, and
medical sedation is available to make the test easier to tolerate
• Patients who have had metallic devices placed in their back (such as
pedicle screws or anterior interbody cages) can have an MRI scan,
but the resolution of the scan is often severely hampered by the
metal device and the spine is not well imaged.

23. Limitations of MRI scanning
• False positives
• Complex reasons why pain exists
• No scan for pain
• Creating victims of modern medical
imaging technology (Vommit)
• Validating sick role, external locus of
control, belief in need for surgery to fix it

24. Why is MRI not used as the routine initial
test for patients with LBP?
• Several randomized clinical trials have
shown that among patients without red
flags—clinical signs and symptoms
indicating serious underlying conditions
early imaging (vs conservative treatment
without imaging) does not improve patient
outcomes

25. References to say no benefit from early MRI
• 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; 289:2810 –2818
• Chou R, Fu RW, Carrino JA, et al. Imaging strategies for low-back pain:
systematic review and meta-analysis. Lancet 2009; 373:463 –472
• 11. Gilbert FJ, Grant AM, Gillan MG, et al. Does early imaging influence
management and improve outcome in patients with low back pain? A
pragmatic randomised controlled trial. Health Technol Assess 2004; 8:iii , 1–
131
• Gilbert FJ, Grant AM, Gillan MG, et al. Low back pain: influence of early MR
imaging or CT on treatment and outcome—multicenter randomized trial.
Radiology 2004; 231:343–351
• Ash LM, Modic MT, Obuchowski NA, et al. Effects of diagnostic information,
per se, on patient outcomes in acute radiculopathy and low back pain. AJNR
2008; 29:1098 –1103
• Modic MT, Obuchowski NA, Ross JS, et al. Acute low back pain and
radiculopathy: MR imaging findings and their prognostic role and effect on
outcome. Radiology 2005; 237:597–604

26. MRI not a cost effective way to find
cancer in the spine
• Study compared the cost-effectiveness of MRI compared
with a conventional cancer screening program using
history, physical examination, erythrocyte sedimentation
rate, and radiography for detecting spine malignancies
among patients seen in a primary care clinic with low
back pain
• the cost of finding each extra patient with a spine
malignancy in MRI group exceeded $625,000 per case
(2001 US costs)
• 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

27. False positive findings
• MRI has high prevalence of abnormal
findings among individuals without LBP
• makes it difficult, or possibly even
perilous, to attribute a patient's symptoms
to certain imaging findings.
• Moreover, irrelevant findings can result in
emotional stress, utilization of
unnecessary downstream resources and
even unnecessary interventions, such as
surgery

28. Prevalence of MRI findings in 20 year old
healthy individuals
• DD was significantly more frequent in men
(54% vs. 42%)
• was multiple DD (21% vs. 14%).
• The prevalence of disc bulges and radial
tears were 25% and 9.1%,
• Disc herniations M 5.6% vs. F 2.5%
• 1 in 400 had disc extrusions
SPINE Volume 34, Number 16, pp 1716 –1721

31. False Positive Rates for Lumbar MRI
Investigation: Disc
Protrusion
Disc
Extrusion
Disc Pathology (Bulge,
Protrusion,extrusion,
sequestration)
Root
Deviation or
Compression
Boden et al. 20% NA
Jensen et al. 27% 1% 64%
Boos et al.* 63% 13% 4%
Greenberg et al. 18% 57%
Weishaupt et al. 40% 18% 4%
Wood et al (11)* 37% 63%
* Because these investigation used a 'high risk' asymptomatic groups of
people, i.e., people whose occupation required frequent heavy lifting,
twisting, and bending; frequent exposure to vibration; and sedimentary
occupations - EXCLUDED the results from the averaging below.

32. More scan more surgery no better
outcome
• Deyo and colleagues showed a higher rate
of spinal surgeries for LBP in states with a
higher utilization rate of advanced imaging
technology. However, this higher utilization
rate was not associated with better patient
outcome in these states
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

33. Good prognosis of disabling back pain
Low-back pain resulting in significant
disability,
• 95% of these patients return to their
previous employment within 3 months of
symptom onset.
• In patients who experience total disability
after 1 year, the likelihood of returning to
work is less than 20%.
• After 2 years of disability, the probability of
returning to work is less than 2%

34. Disk Herniation With Sciatica
• 90% of ruptured disks
at L4-L5 and L5-S1
• 90% of patients with
back pain and sciatica
will recover without
surgery
– At least 50% within 6
wk

35. Back Pain and Sciatica
MRI of the spine if patient demonstrates
• “Red flags”
• Neurologic deficits or progressive
neurologic signs and symptoms
• Pain persisting more than 6 wk

36. Worsening sciatica
Lymphoma

37. Failed-Back-Surgery Syndrome
Reoperations
• 60% due to post–spinal surgery
complications
• 40% due to uncorrected or new structural
abnormalities of the spine
• 20% of lumbar disc hernia surgery have
second operation within 9 years
• Spine: 15 June 2000 - Volume 25 - Issue 12 - pp 1500-1508

38. Don’t operate on prolapsed discs as they
get better
• Numerous imaging studies have
demonstrated that with nonsurgical
treatment lumbar disc herniations will
subside over time in the majority of cases.
• Komori H, Shinomiya K, Nakai O, et al: The natural history of herniated nucleus
pulposus with radiculopathy. Spine 21: 225-229, 1996
• Saal JA, Saal JS, Herzog RJ: The natural history of lumbar intervertebral disc
extrusions treated nonoperatively. Spine 15: 683-686, 1990

39. Failed-Back-Surgery Syndrome
Postsurgical causes of back pain
• Recurrent or retained disk fragment
• Postoperative instability
• Dural adhesions
• Root injury
• Arachnoiditis
• Pseudomeningocele
• Failure to relieve the original pathologic condition
• Postoperative wound and disk infection

40. Back Pain and Sciatica:
Imaging Evaluation
• Lumbosacral x-ray studies with flexion/
extension/oblique views
• MRI of the spine
• CT with 3-D reconstruction
• CT plus myelography

41. Assessment of Chronic Back Pain and
Sciatica: Diagnostic Blocks
• Facet blocks to rule out facet joint pain
• Provocative diskograms or disk blockade
to rule out discogenic pain and pain
associated with segmental spinal
instability
• Selective root blocks to determine location
of root pain generator

42. Example 1 – weak red flags
• 72 year old
• 2 year history
• Back pain buttock bilateral
• and bilateral burning foot pain.
• Type II diabetes, osteoarthritis and hiatus
hernia
• Can walk 50 yards before pain

43. • T2 and STIR
no spinal
stenosis , but
hot vertebrae
• Increased
PSA and ALP

44. Example 2
• Disabling back and leg pain only able to
walk 50 yards
• Mainly L3 symptoms left leg
• Known prostate cancer

45. T2 and T1 sag and
T9/10 and L3/4
axials

46. Resolved sciatica and back pain with
residual exertional paraesthesia
• 55 year old man
• 2 previous episodes of back pain and
sciatica all settled
• now paraesthesia in left leg on walking
1km

47. Tight L4/5

48. Disabling pain with red flags
• 56 year old man
• 2 year history
• Incontinent of urine, impotent, severe low
back pain, some leg pains
• 3 MRI scans 1CT scan and NCS

49. • Normal
scan

50. Minor L4/5 HIZ, left
Bertolotti’s syndrome

51. What about other findings
• Diagnoses that patients can grab onto as
cause of symptoms when not e.g.
– Tarlov cysts
– Hamangiomas
– Modic type 2 changes
• Things we don’t know what they mean e.g.
– Anterior disc prolapses

52. Tarlov cyst +

53. • Modic type 2

54. So if doing a test
• Most important is pre
test counselling and
• Person who
understands that
patients and the test
gives the results

55. Indications for imaging
• Best to have local policy
• Lots available
• Improving access does not improve
outcome
• MRI findings in healthy pain free
individuals common
• Only one domain of assessment of spinal
presentation