Imaging of the Spine - Croydon Health Services NHS Trust

Imaging of the Spine - Croydon Health Services NHS Trust

Imaging of the Spine

Dr Nicola Bees

Consultant Radiologist

Imaging of the Spine

• Types of Imaging available

• Value of Imaging in back pain

• With red flags

• Without red flags

Imaging Guidelines

• Terminology

Which investigation?

• Xray


• CT is not useful as a first line except for trauma and should not be

requested from primary care.

• Isotope bone scan – not available at CUH but not usually a first line


Source of Exposure

Dental X-ray

135g bag of Brazil nuts

Chest X-ray

Lumbar Spine X-ray

CT scan of the head

UK annual average radon dose

USA average annual radiation dose

CT scan of the chest

Average annual radon dose to people in


Whole body CT scan


0.005 mSv

0.005 mSv

0.02 mSv


1.4 mSv

1.3 mSv

6.2 mSv

6.6 mSv

7.8 mSv

10 mSv

Level at which changes in blood cells can be 100 mSv

readily observed

Acute radiation effects including nausea and 1000 mSv

a reduction in white blood cell count

Comparative Radiation Doses





Red Flags


•Sphincter or gait disturbance

•Severe/progressive motor loss

•Widespread neurological deficit

•(Single level nerve deficit)


Onset of pain < 20yrs or >55 yrs

Previous or current malignancy

Systemically unwell

Raised CRP


Weight loss

IV drug abuse


Structural deformity

Non-mechanical back pain (no relief with bed



Thoracic pain




Cauda Equina


Low Back Pain with no red flags

• No imaging required.

• No imaging that will alter management.

• Can refer to MCATS guidelines for advice on management

• Can refer to MCATS for triage, assessment and conservative treatment

Reasons for not imaging




% pts with

findings at at

least one

disc level









20-39 40-59 60-80

Age (years)

Incidence of HNP, spinal stenosis, bulging disc, degenerate disc on MRI of 67 asymptomatic


Boden et al J. Bone Joint Surg. Am. 72:403-408, 1990.

Lumbar Degenerative Disk Disease

Michael T. Modic, MD and Jeffrey S. Ross, MD

Radiology 2007;245:43-61

• The etiology of pain in degenerative disease is more complex than a simple

mechanical explanation.

• The prognostic value of imaging is confounded by the high prevalence of

morphologic changes in the asymptomatic population.

• In patients with uncomplicated low back pain or radiculopathy, MR imaging

may not have an additive value over clinical assessment.

• 20-28% of asymptomatic patients have disk herniations

• DG Borenstein et al J Bone Joint Surg Am 2001;83-A:1306–1311.

• Prevalence of disk herniation in symptomatic patients with

• Low back pain 57%

• Radiculopathy 65%

• Disk herniations esp large ones can dramatically reduce with conservative


• One third of patients with disk herniation at presentation had significant

resolution or disappearance at 6 weeks, two thirds at 6 months

• Type, size, location of herniation and presentation did not correlate with


• In fact presence of herniation on MRI was a positive prognosticator

• Modic MT, Obuchowski NA, Ross JS, et al. Radiology 2005;237:597–604

Barzouhi et al N Engl J Med 2013;368:999-1007.

• The natural history of sciatica is favorable, with spontaneous resolution of

leg pain within 8 weeks in the majority of patients.

• During longer follow-up at least 15 to 20% of patients report recurring or

persistent symptoms after a first episode of sciatica, regardless of whether

they underwent surgery.

• Even after disk surgery, MRI studies have shown disk herniation in up to

53% of asymptomatic persons.

Barzouhi et al N Engl J Med 2013;368:999-1007.

• In patients with symptomatic lumbar disk herniation at baseline who were

treated with either surgery or conservative treatment and followed for 1

year, the presence of disk herniation on MRI at 1-year follow-up did not

distinguish patients with a favorable clinical outcome from those with an

unfavorable outcome.

• Patients asking for reimaging because of persistent or recurrent symptoms

should be informed about the difficulty in MRI interpretation after a first

episode of acute sciatica.

Acute Low Back Pain and Radiculopathy: MR Imaging Findings and Their

Prognostic Role and Effect on Outcome. Modic et al.

Radiology 2005; 237:597–604

• In typical patients with LBP or radiculopathy, MR imaging does not appear

to have measurable value in terms of planning conservative care.

• Patient knowledge of imaging findings does not alter outcome and is

associated with a lesser sense of well-being.


• 1.1.2 Do not offer X-ray of the lumbar spine for the management of nonspecific

low back pain.

• 1.1.3 Consider MRI (magnetic resonance imaging) when a diagnosis of

spinal malignancy, infection, fracture, cauda equina syndrome or ankylosing

spondylitis or another inflammatory disorder is suspected.

• 1.1.4 Only offer an MRI scan for non-specific low back pain within the

context of a referral for an opinion on spinal fusion.

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Any queries should be directed to

Lumbar Spine

Imaging technique

Pain and suspected

• osteoporotic collapse

• spondyloarthropathy in younger



Sciatica: less than 6 weeks with no

red flags*

Sciatica with no red flags*, not

responding to conservative

management after 6-8 weeks

Pain with red flags* (including foot


Imaging not usually indicated


MRI (Urgent) and refer for urgent Orthopaedic


Back Pain in Children/Adolescents

Refer to secondary care prior to imaging (usually


Nice guidelines for Ultrasound of Soft tissue


In patients presenting with a palpable lump, an urgent referral for suspicion of

soft tissue sarcoma should be made if the lump is:

• greater than about 5 cm in diameter

• deep to fascia, fixed or immobile

• painful

• increasing in size

• a recurrence after previous excision.

If there is any doubt about the need for referral, discussion with a local specialist

should be undertaken.

Reporting terms

• Segmentation anomaly/Transition Vertebra/Lumbarisation of

S1/Sacralisation of L5

• Bulge/Herniation/Protrusion/Extrusion/Prolapse

• Spondylolisthesis – Degenerative/Spondyloytic

• Degenerate/Dehydrated/Reduced Signal in Disc

• Schmorl’s nodes/Intravertebral disc herniation

• Haemangioma

• Narrow spinal canal/Spinal canal stenosis

Nomenclature and Classification of Lumbar Disc Pathology

Recommendations of the Combined Task Forces of the North American Spine

Society, American Society.

SPINE Volume 26, Number 5, pp E93–E113



Vertebra/Lumbarisation of

S1/Sacralisation of L5


Signal in Disc



Disc herniation

Left central to subarticular focal disc extrusion

Schmorl’s nodes


Image before referral/Refer without imaging

• Refer to MCATS – no need to image first

• Direct referral to Orthopaedics – Request MRI plus bloods (FBC ESR CRP

U+Es Cr)

• Patients with red flags

• Patients with back pain and specific/single level nerve root symptoms

and signs


• Beware that in the lumbar spine MRI can correlate poorly with clinical

symptoms and can be misleading therefore only image according to the


• Rely on clinical assessment to guide imaging and referral

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