Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging
Publication: Annals of Internal Medicine
Volume 137, Number 7
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Abstract
Purpose:
To review evidence on the diagnostic accuracy of clinical information and imaging for patients with low back pain in primary care settings.
Data Source:
MEDLINE search (January 1966 to September 2001) for articles and reviews relevant to the accuracy of the clinical and radiographic examination of patients with low back pain.
Study Selection:
The authors reviewed abstracts and selected articles for review on the basis of a combined judgment. Data on the clinical examination were based primarily on recent systematic reviews; data on imaging tests were based primarily on original articles.
Data Extraction:
Diagnostic results were extracted by one or the other author. Quality of methods was evaluated informally. Major potential biases were identified, but neither quantitative data extraction nor scoring was done.
Data Synthesis:
Formal meta-analysis was not used because the diagnostic hardware and software, gold standards, and patient selection methods were heterogeneous and the number of studies was small. Sensitivity for cancer was highest for magnetic resonance imaging (0.83 to 0.93) and radionuclide scanning (0.74 to 0.98); specificity was highest for magnetic resonance imaging (0.9 to 0.97) and radiography (0.95 to 0.99). Magnetic resonance imaging was the most sensitive (0.96) and specific (0.92) test for infection. The sensitivity and specificity of magnetic resonance imaging for herniated discs were slightly higher than those for computed tomography but very similar for the diagnosis of spinal stenosis.
Conclusions:
The data suggest a diagnostic strategy similar to the 1994 Agency for Health Care Policy and Research guidelines. For adults younger than 50 years of age with no signs or symptoms of systemic disease, symptomatic therapy without imaging is appropriate. For patients 50 years of age and older or those whose findings suggest systemic disease, plain radiography and simple laboratory tests can almost completely rule out underlying systemic diseases. Advanced imaging should be reserved for patients who are considering surgery or those in whom systemic disease is strongly suspected.
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References
1.
Frymoyer JW. Back pain and sciatica. N Engl J Med. 1988;318:291-300. [PMID: 2961994]
2.
Barondess JA. The future of generalism. Ann Intern Med. 1993;119:153-60. [PMID: 8512164]
3.
Salkever D. Morbidity Cost: National Estimates and Economic Determinants. 1985. Report No. (PHS) 86-3343.
4.
Deyo RA. Early diagnostic evaluation of low back pain. J Gen Intern Med. 1986;1:328-38. [PMID: 2945917]
5.
Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344:363-70. [PMID: 11172169]
6.
Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine. 1995;20:11-9. [PMID: 7709270]
7.
Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268:760-5. [PMID: 1386391]
8.
Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988;3:230-8. [PMID: 2967893]
9.
White AA 3rd, Gordon SL. Synopsis: workshop on idiopathic low-back pain. Spine. 1982;7:141-9. [PMID: 6211779]
10.
van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine. 1997;22:427-34. [PMID: 9055372]
11.
Carragee EJ, Tanner CM, Khurana S, Hayward C, Welsh J, Date E, et al. The rates of false-positive lumbar discography in select patients without low back symptoms. Spine. 2000; 25:1373-80; discussion 1381. [ 10828919]
12.
Smith SE, Darden BV, Rhyne AL, Wood KE. Outcome of unoperated discogram-positive low back pain. Spine. 1995; 20:1997-2000; discussion 2000-1. [ 8578375]
13.
Waldvogel FA, Papageorgiou PS. Osteomyelitis: the past decade. N Engl J Med. 1980;303:360-70. [PMID: 6993944]
14.
Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine. 1987;12:264-8. [PMID: 2954221]
15.
Spangfort EV. The lumbar disc herniation. A computer-aided analysis of 2,504 operations. Acta Orthop Scand Suppl. 1972;142:1-95. [PMID: 4516334]
16.
Katz JN, Dalgas M, Stucki G, Katz NP, Bayley J, Fossel AH, et al . Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination. Arthritis Rheum. 1995;38:1236-41. [PMID: 7575718]
17.
Gran JY. An epidemiological survey of the signs and symptoms of ankylosing spondylitis. Clin Rheumatol. 1985;4:161-9.
18.
Bauer RL, Deyo RA. Low risk of vertebral fracture in Mexican American women. Arch Intern Med. 1987;147:1437-9. [PMID: 3498450]
19.
Calin A, Kaye B, Sternberg M, Antell B, Chan M. The prevalence and nature of back pain in an industrial complex: a questionnaire and radiographic and HLA analysis. Spine. 1980;5:201-5. [PMID: 6446164]
20.
Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72:403-8. [PMID: 2312537]
21.
Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331:69-73. [PMID: 8208267]
22.
Boos N, Rieder R, Schade V, Spratt KF, Semmer N, Aebi M. 1995 Volvo Award in clinical sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine. 1995;20:2613-25. [PMID: 8747239]
23.
Jarvik JJ, Hollingworth W, Heagerty P, Haynor DR, Deyo RA. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine. 2001;26:1158-66. [PMID: 11413431]
24.
Currey HL, Greenwood RM, Lloyd GG, Murray RS. A prospective study of low back pain. Rheumatol Rehabil. 1979;18:94-104. [PMID: 156391]
25.
van den Hoogen HM, Koes BW, van Eijk JT, Bouter LM. On the accuracy of history, physical examination, and erythrocyte sedimentation rate in diagnosing low back pain in general practice. A criteria-based review of the literature. Spine. 1995;20:318-27. [PMID: 7732468]
26.
Turner JA, Ersek M, Herron L, Deyo R. Surgery for lumbar spinal stenosis. Attempted meta-analysis of the literature. Spine. 1992;17:1-8. [PMID: 1531550]
27.
Robbins SE, Morse MH. Is the acquisition of a separate view of the sacroiliac joints in the prone position justified in patients with back pain? Clin Radiol. 1996;51:637-8. [PMID: 8810693]
28.
Scavone JG, Latshaw RF, Weidner WA. Anteroposterior and lateral radiographs: an adequate lumbar spine examination. AJR Am J Roentgenol. 1981;136:715-7. [PMID: 6784466]
29.
Bigos S, Bowyer O, Braen G, Brown K, Deyo RA, Haldeman S, et al. Acute Low Back Problems in Adults. Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Clinical Practice Guideline No. 14. Report No. 95-0642. December 1994.
30.
Hall FM. Overutilization of radiological examinations. Radiology. 1976;120:443-8. [PMID: 778913]
31.
Webster E, Merrill O. Radiation hazards: II. Measurements of gonadal dose in radiologic examinations. N Engl J Med. 1957;257:811-9.
32.
Antoku S, Russell WJ. Dose to the active bone marrow, gonads, and skin from roentgenography and fluoroscopy. Radiology. 1971;101:669-78. [PMID: 5129110]
33.
Sartoris DJ, André M, Resnik CS, Resnick D, Resnick C. Trabecular bone density in the proximal femur: quantitative CT assessment. Work in progress. Radiology. 1986;160:707-12. [PMID: 3755536]
34.
Sartoris DJ, Clopton P, Nemcek A, Dowd C, Resnick D. Vertebral-body collapse in focal and diffuse disease: patterns of pathologic processes. Radiology. 1986;160:479-83. [PMID: 3726130]
35.
Modic MT, Feiglin DH, Piraino DW, Boumphrey F, Weinstein MA, Duchesneau PM, et al . Vertebral osteomyelitis: assessment using MR. Radiology. 1985;157:157-66. [PMID: 3875878]
36.
Cooper C, Shah S, Hand DJ, Adams J, Compston J, Davie M, et al . Screening for vertebral osteoporosis using individual risk factors. The Multicentre Vertebral Fracture Study Group. Osteoporos Int. 1991;2:48-53. [PMID: 1790421]
37.
Spector TD, McCloskey EV, Doyle DV, Kanis JA. Prevalence of vertebral fracture in women and the relationship with bone density and symptoms: the Chingford Study. J Bone Miner Res. 1993;8:817-22. [PMID: 8352064]
38.
Nevitt MC, Ettinger B, Black DM, Stone K, Jamal SA, Ensrud K, et al . The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med. 1998;128:793-800. [PMID: 9599190]
39.
Yamato M, Nishimura G, Kuramochi E, Saiki N, Fujioka M. MR appearance at different ages of osteoporotic compression fractures of the vertebrae. Radiat Med. 1998;16:329-34. [PMID: 9862153]
40.
Marc V, Dromer C, Le Guennec P, Manelfe C, Fournie B. Magnetic resonance imaging and axial involvement in spondylarthropathies. Delineation of the spinal entheses. Rev Rhum Engl Ed. 1997;64:465-73. [PMID: 9338928]
41.
Thornbury JR, Fryback DG, Turski PA, Javid MJ, McDonald JV, Beinlich BR, et al . Disk-caused nerve compression in patients with acute low-back pain: diagnosis with MR, CT myelography, and plain CT. Radiology. 1993;186:731-8. [PMID: 8267688]
42.
Jackson RP, Cain JE Jr, Jacobs RR, Cooper BR, McManus GE. The neuroradiographic diagnosis of lumbar herniated nucleus pulposus: II. A comparison of computed tomography (CT), myelography, CT-myelography, and magnetic resonance imaging. Spine. 1989;14:1362-7. [PMID: 2694389]
43.
Hellström M, Jacobsson B, Swärd L, Peterson L. Radiologic abnormalities of the thoraco-lumbar spine in athletes. Acta Radiol. 1990;31:127-32. [PMID: 2372454]
44.
Hitselberger WE, Witten RM. Abnormal myelograms in asymptomatic patients. J Neurosurg. 1968;28:204-6. [PMID: 5643913]
45.
Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas N. A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine. 1984;9:549-51. [PMID: 6495024]
46.
Weinreb JC, Wolbarsht LB, Cohen JM, Brown CE, Maravilla KR. Prevalence of lumbosacral intervertebral disk abnormalities on MR images in pregnant and asymptomatic nonpregnant women. Radiology. 1989;170:125-8. [PMID: 2521192]
47.
Burns JW, Loecker TH, Fischer JR Jr, Bauer DH. Prevalence and significance of spinal disc abnormalities in an asymptomatic acceleration subject panel. Aviat Space Environ Med. 1996;67:849-53. [PMID: 9025800]
48.
Stadnik TW, Lee RR, Coen HL, Neirynck EC, Buisseret TS, Osteaux MJ. Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology. 1998;206:49-55. [PMID: 9423651]
49.
Weishaupt D, Zanetti M, Hodler J, Boos N. MR imaging of the lumbar spine: prevalence of intervertebral disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers. Radiology. 1998;209:661-6. [PMID: 9844656]
50.
Carragee EJ, Paragioudakis SJ, Khurana S. 2000 Volvo Award winner in clinical studies: lumbar high-intensity zone and discography in subjects without low back problems. Spine. 2000;25:2987-92. [PMID: 11145809]
51.
Kent DL, Haynor DR, Larson EB, Deyo RA. Diagnosis of lumbar spinal stenosis in adults: a metaanalysis of the accuracy of CT, MR, and myelography. AJR Am J Roentgenol. 1992;158:1135-44. [PMID: 1533084]
52.
Porter RW, Bewley B. A ten-year prospective study of vertebral canal size as a predictor of back pain. Spine. 1994;19:173-5. [PMID: 8153826]
53.
Wilmink JT. CT morphology of intrathecal lumbosacral nerve-root compression. AJNR Am J Neuroradiol. 1989;10:233-48. [PMID: 2494846]
54.
Schwarzer AC, Wang SC, O'Driscoll D, Harrington T, Bogduk N, Laurent R. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine. 1995;20:907-12. [PMID: 7644955]
55.
Pui MH, Husen YA. Value of magnetic resonance myelography in the diagnosis of disc herniation and spinal stenosis. Australas Radiol. 2000;44:281-4. [PMID: 10974720]
56.
Kikkawa I, Sugimoto H, Saita K, Ookami H, Nakama S, Hoshino Y. The role of Gd-enhanced three-dimensional MRI fast low-angle shot (FLASH) in the evaluation of symptomatic lumbosacral nerve roots. J Orthop Sci. 2001;6:101-9. [PMID: 11484093]
57.
Lane JI, Koeller KK, Atkinson JL. Enhanced lumbar nerve roots in the spine without prior surgery: radiculitis or radicular veins? AJNR Am J Neuroradiol. 1994;15:1317-25. [PMID: 7976944]
58.
Crisi G, Carpeggiani P, Trevisan C. Gadolinium-enhanced nerve roots in lumbar disk herniation. AJNR Am J Neuroradiol. 1993;14:1379-92. [PMID: 8279335]
59.
Algra PR, Bloem JL, Tissing H, Falke TH, Arndt JW, Verboom LJ. Detection of vertebral metastases: comparison between MR imaging and bone scintigraphy. Radiographics. 1991;11:219-32. [PMID: 2028061]
60.
Avrahami E, Tadmor R, Dally O, Hadar H. Early MR demonstration of spinal metastases in patients with normal radiographs and CT and radionuclide bone scans. J Comput Assist Tomogr. 1989;13:598-602. [PMID: 2745777]
61.
Carroll KW, Feller JF, Tirman PF. Useful internal standards for distinguishing infiltrative marrow pathology from hematopoietic marrow at MRI. J Magn Reson Imaging. 1997;7:394-8. [PMID: 9090597]
62.
Carmody RF, Yang PJ, Seeley GW, Seeger JF, Unger EC, Johnson JE. Spinal cord compression due to metastatic disease: diagnosis with MR imaging versus myelography. Radiology. 1989;173:225-9. [PMID: 2675185]
63.
Kosuda S, Kaji T, Yokoyama H, Yokokawa T, Katayama M, Iriye T, et al . Does bone SPECT actually have lower sensitivity for detecting vertebral metastasis than MRI? J Nucl Med. 1996;37:975-8. [PMID: 8683325]
64.
Gillams AR, Chaddha B, Carter AP. MR appearances of the temporal evolution and resolution of infectious spondylitis. AJR Am J Roentgenol. 1996;166:903-7. [PMID: 8610571]
65.
Smith AS, Weinstein MA, Mizushima A, Coughlin B, Hayden SP, Lakin MM, et al . MR imaging characteristics of tuberculous spondylitis vs vertebral osteomyelitis. AJR Am J Roentgenol. 1989;153:399-405. [PMID: 2750627]
66.
Brant-Zawadzki MN, Jensen MC, Obuchowski N, Ross JS, Modic MT. Interobserver and intraobserver variability in interpretation of lumbar disc abnormalities. A comparison of two nomenclatures. Spine. 1995; 20:1257-63; discussion 1264. [ 7660234]
67.
Janssen ME, Bertrand SL, Joe C, Levine MI. Lumbar herniated disk disease: comparison of MRI, myelography, and post-myelographic CT scan with surgical findings. Orthopedics. 1994;17:121-7. [PMID: 8190676]
68.
Beattie PF, Meyers SP, Stratford P, Millard RW, Hollenberg GM. Associations between patient report of symptoms and anatomic impairment visible on lumbar magnetic resonance imaging. Spine. 2000;25:819-28. [PMID: 10751293]
69.
Vroomen PC, de Krom MC, Wilmink JT. Pathoanatomy of clinical findings in patients with sciatica: a magnetic resonance imaging study. J Neurosurg. 2000;92:135-41. [PMID: 10763682]
70.
Rankine JJ, Fortune DG, Hutchinson CE, Hughes DG, Main CJ. Pain drawings in the assessment of nerve root compression: a comparative study with lumbar spine magnetic resonance imaging. Spine. 1998;23:1668-76. [PMID: 9704374]
71.
Aprill C, Bogduk N. High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol. 1992;65:361-9. [PMID: 1535257]
72.
Lam KS, Carlin D, Mulholland RC. Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source. Eur Spine J. 2000;9:36-41. [PMID: 10766075]
73.
Sandhu HS, Sanchez-Caso LP, Parvataneni HK, Cammisa FP Jr, Girardi FP, Ghelman B. Association between findings of provocative discography and vertebral endplate signal changes as seen on MRI. J Spinal Disord. 2000;13:438-43. [PMID: 11052355]
74.
Rankine JJ, Gill KP, Hutchinson CE, Ross ER, Williamson JB. The clinical significance of the high-intensity zone on lumbar spine magnetic resonance imaging. Spine. 1999; 24:1913-9; discussion 1920. [ 10515016]
75.
Subramanian G, McAfee JG. A new complex of 99mTc for skeletal imaging. Radiology. 1971;99:192-6. [PMID: 5548678]
76.
Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology. 1991;180:509-12. [PMID: 1829845]
77.
Collier BD, Johnson RP, Carrera GF, Meyer GA, Schwab JP, Flatley TJ, et al . Painful spondylolysis or spondylolisthesis studied by radiography and single-photon emission computed tomography. Radiology. 1985;154:207-11. [PMID: 3155479]
78.
Peh WC, Ho WY, Luk KD. Applications of bone scintigraphy in ankylosing spondylitis. Clin Imaging. 1997;21:54-62. [PMID: 9117933]
79.
Jacobsson H, Larsson SA, Vestersköld L, Lindvall N. The application of single photon emission computed tomography to the diagnosis of ankylosing spondylitis of the spine. Br J Radiol. 1984;57:133-40. [PMID: 6229308]
80.
Swanson D, Blecker I, Gahbauer H, Caride VJ. Diagnosis of discitis by SPECT technetium-99m MDP scintigram. A case report. Clin Nucl Med. 1987;12:210-1. [PMID: 3493875]
81.
Han LJ, Au-Yong TK, Tong WC, Chu KS, Szeto LT, Wong CP. Comparison of bone single-photon emission tomography and planar imaging in the detection of vertebral metastases in patients with back pain. Eur J Nucl Med. 1998;25:635-8. [PMID: 9618579]
82.
McDougall IR, Kriss JP. Screening for bone metastases. Are only scans necessary? JAMA. 1975;231:46-50. [PMID: 1243567]
83.
Corcoran RJ, Thrall JH, Kyle RW, Kaminski RJ, Johnson MC. Solitary abnormalities in bone scans of patients with extraosseous malignancies. Radiology. 1976;121:663-7. [PMID: 981663]
84.
Savelli G, Chiti A, Grasselli G, Maccauro M, Rodari M, Bombardieri E. The role of bone SPET study in diagnosis of single vertebral metastases. Anticancer Res. 2000;20:1115-20. [PMID: 10810405]
85.
Petrén-Mallmin M. Clinical and experimental imaging of breast cancer metastases in the spine. Acta Radiol Suppl. 1994;391:1-23. [PMID: 8172006]
86.
McNeil BJ. Rationale for the use of bone scans in selected metastatic and primary bone tumors. Semin Nucl Med. 1978;8:336-45. [PMID: 112684]
87.
Jacobson AF. Musculoskeletal pain as an indicator of occult malignancy. Yield of bone scintigraphy. Arch Intern Med. 1997;157:105-9. [PMID: 8996047]
88.
Even-Sapir E, Martin RH, Barnes DC, Pringle CR, Iles SE, Mitchell MJ. Role of SPECT in differentiating malignant from benign lesions in the lower thoracic and lumbar vertebrae. Radiology. 1993;187:193-8. [PMID: 8451412]
89.
Hanly JG, Barnes DC, Mitchell MJ, MacMillan L, Docherty P. Single photon emission computed tomography in the diagnosis of inflammatory spondyloarthropathies. J Rheumatol. 1993;20:2062-8. [PMID: 8014934]
90.
Joines JD, McNutt RA, Carey TS, Deyo RA, Rouhani R. Finding cancer in primary care outpatients with low back pain: a comparison of diagnostic strategies. J Gen Intern Med. 2001;16:14-23. [PMID: 11251746]
91.
Liang M, Komaroff AL. Roentgenograms in primary care patients with acute low back pain: a cost-effectiveness analysis. Arch Intern Med. 1982;142:1108-12. [PMID: 6212032]
92.
Albeck MJ, Danneskiold-Samsoe B. Patient attitudes to myelography, computed tomography and magnetic resonance imaging when examined for suspected lumbar disc herniation. Acta Neurochir Wien. 1995;133:3-6. [PMID: 8561032]
93.
Albeck MJ, Hilden J, Kjaer L, Holtås S, Praestholm J, Henriksen O, et al . A controlled comparison of myelography, computed tomography, and magnetic resonance imaging in clinically suspected lumbar disc herniation. Spine. 1995;20:443-8. [PMID: 7747227]
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Annals of Internal Medicine
Volume 137 • Number 7 • 1 October 2002
Pages: 586 - 597
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Published online: 1 October 2002
Published in issue: 1 October 2002
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© 2002 American College of Physicians.
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Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann Intern Med.2002;137:586-597. [Epub 1 October 2002]. doi:10.7326/0003-4819-137-7-200210010-00010
Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann Intern Med.2002;137:586-597. [Epub 1 October 2002]. doi:10.7326/0003-4819-137-7-200210010-00010
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