Evidence against the use of lumbar spine radiography for low back pain

Red flags to screen for vertebral fracture in patients presenting with low-back pain

EDITORIAL NOTE

See https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD014461.pub2/full for a more recent review that covers this topic and has superseded this review.

BACKGROUND

Low-back pain (LBP) is a common condition seen in primary care. A principal aim during a clinical examination is to identify patients with a higher likelihood of underlying serious pathology, such as vertebral fracture, who may require additional investigation and specific treatment. All 'evidence-based' clinical practice guidelines recommend the use of red flags to screen for serious causes of back pain. However, it remains unclear if the diagnostic accuracy of red flags is sufficient to support this recommendation.

OBJECTIVES

To assess the diagnostic accuracy of red flags obtained in a clinical history or physical examination to screen for vertebral fracture in patients presenting with LBP.

SEARCH METHODS

Electronic databases were searched for primary studies between the earliest date and 7 March 2012. Forward and backward citation searching of eligible studies was also conducted.

SELECTION CRITERIA

Studies were considered if they compared the results of any aspect of the history or test conducted in the physical examination of patients presenting for LBP or examination of the lumbar spine, with a reference standard (diagnostic imaging). The selection criteria were independently applied by two review authors.

DATA COLLECTION AND ANALYSIS

Three review authors independently conducted 'Risk of bias' assessment and data extraction. Risk of bias was assessed using the 11-item QUADAS tool. Characteristics of studies, patients, index tests and reference standards were extracted. Where available, raw data were used to calculate sensitivity and specificity with 95% confidence intervals (CI). Due to the heterogeneity of studies and tests, statistical pooling was not appropriate and the analysis for the review was descriptive only. Likelihood ratios for each test were calculated and used as an indication of clinical usefulness.

MAIN RESULTS

Eight studies set in primary (four), secondary (one) and tertiary care (accident and emergency = three) were included in the review. Overall, the risk of bias of studies was moderate with high risk of selection and verification bias the predominant flaws. Reporting of index and reference tests was poor. The prevalence of vertebral fracture in accident and emergency settings ranged from 6.5% to 11% and in primary care from 0.7% to 4.5%. There were 29 groups of index tests investigated however, only two featured in more than two studies. Descriptive analyses revealed that three red flags in primary care were potentially useful with meaningful positive likelihood ratios (LR+) but mostly imprecise estimates (significant trauma, older age, corticosteroid use; LR+ point estimate ranging 3.42 to 12.85, 3.69 to 9.39, 3.97 to 48.50 respectively). One red flag in tertiary care appeared informative (contusion/abrasion; LR+ 31.09, 95% CI 18.25 to 52.96). The results of combined tests appeared more informative than individual red flags with LR+ estimates generally greater in magnitude and precision.

AUTHORS' CONCLUSIONS

The available evidence does not support the use of many red flags to specifically screen for vertebral fracture in patients presenting for LBP. Based on evidence from single studies, few individual red flags appear informative as most have poor diagnostic accuracy as indicated by imprecise estimates of likelihood ratios. When combinations of red flags were used the performance appeared to improve. From the limited evidence, the findings give rise to a weak recommendation that a combination of a small subset of red flags may be useful to screen for vertebral fracture. It should also be noted that many red flags have high false positive rates; and if acted upon uncritically there would be consequences for the cost of management and outcomes of patients with LBP. Further research should focus on appropriate sets of red flags and adequate reporting of both index and reference tests.

The effect of clinical guidelines on the utilisation of radiographs in chiropractic clinics in Denmark - an interrupted time series analysis

BACKGROUND

In Denmark, chiropractors have a statutory right to use radiography and the government-funded national Health Insurance provides partial reimbursement. Danish National Clinical Guidelines recommends against routine use of imaging for uncomplicated spinal pain; however, it is not clear if clinical imaging guidelines recommendations have had an effect on the utilisation of spinal radiography. This study aimed to describe the utilisation rate of radiographs in Danish chiropractic clinics in the period from 2010 to 2020 and to assess the impact of clinical guidelines and policy changes on the utilisation of radiographs in Danish chiropractic clinics.

METHODS

Anonymised data from January 1st, 2010, to December 31st, 2020, were extracted from the Danish Regions register on health contacts in primary care. Data consisted of the total number of patients consulting one of 254 chiropractic clinics and the total number of patients having or being referred for radiography. Data were used to investigate the radiography utilisation per month from 2010 to 2020. An 'interrupted time series' analysis was conducted to determine if two interventions, the dissemination of 1) Danish clinical imaging guidelines recommendations and policy changes related to referral for advanced imaging for chiropractors in 2013 and 2) four Danish clinical guidelines recommendations in 2016, were associated with an immediate change in the level and/or slope of radiography utilisation.

RESULTS

In total, 336,128 unique patients consulted a chiropractor in 2010 of which 55,449 (15.4%) had radiography. In 2020, the number of patients consulting a chiropractor had increased to 366,732 of which 29,244 (8.0%) had radiography. The pre-intervention utilisation decreased by two radiographs per 10,000 patients per month. Little absolute change, but still statistically significant for Intervention 1, in the utilisation was found after the dissemination of the clinical guidelines and policy changes in 2013 or 2016.

CONCLUSIONS

The proportion of Danish chiropractic patients undergoing radiography was halved in the period from 2010 to 2020. However, the dissemination of clinical imaging guidelines recommendations and policy changes related to referrals for advanced imaging showed little meaningful change in the monthly utilisation of radiographs in the same period.

Red flags to screen for vertebral fracture in people presenting with low back pain

BACKGROUND

Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture.

OBJECTIVES

To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture).

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022.

SELECTION CRITERIA

We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool.

MAIN RESULTS

This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96).

AUTHORS' CONCLUSIONS

The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.

Diagnosis Value of Patient Evaluation Components Applicable in Primary Care Settings for the Diagnosis of Low Back Pain: A Scoping Review of Systematic Reviews

Low back pain ranks as the leading cause of years lived with disability worldwide. Although best practice guidelines share a consistent diagnostic approach for the evaluation of patients with low back pain, confusion remains as to what extent patient history and physical examination findings can inform management strategies. The aim of this study was to summarize evidence investigating the diagnostic value of patient evaluation components applicable in primary care settings for the diagnosis of low back pain. To this end, peer-reviewed systematic reviews were searched in MEDLINE, CINAHL, PsycINFO and Cochrane databases from 1 January 2000 to 10 April 2023. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data. Of the 2077 articles identified, 27 met the inclusion criteria, focusing on the diagnosis of lumbar spinal stenosis, radicular syndrome, non- specific low back pain and specific low back pain. Most patient evaluation components lack diagnostic accuracy for the diagnosis of low back pain when considered in isolation. Further research is needed to develop evidence-based and standardized evaluation procedures, especially for primary care settings where evidence is still scarce.

Structural, Functional and Neurochemical Cortical Brain Changes Associated with Chronic Low Back Pain

Chronic low back pain (CLBP) is one of the most prevalent musculoskeletal disorders, being one of the leading contributors to disability worldwide and involving an important economic and social burden. Up to 90% of CLBP is non-specific (not associated with specific injuries), with a chronicity expectation estimated at 10%. Currently, motivational and emotional central circuits are being investigated due to their role in CLBP persistency and chronification. Therefore, this narrative review aimed to summarize the evidence regarding the cortical brain changes described for proposing novel multidisciplinary approaches. Novel advances in neuroimaging techniques demonstrated structural (e.g., decrease in the grey matter located at the dorsolateral prefrontal cortex), functional (e.g., connectivity impairments in those areas involved in pain processing), and neurochemical changes (e.g., decrease in cerebral metabolites). In addition, significant changes were found in the primary somatosensory and motor cortex, contributing to the alteration of low back muscles activation and function.

Combining Psychophysical and EEG Biomarkers for Improved Observation of Altered Nociceptive Processing in Failed Back Surgery Syndrome

Diagnosis and stratification of chronic pain patients is difficult due to a lack of sensitive biomarkers for altered nociceptive and pain processing. Recent developments enabled to preferentially stimulate epidermal nerve fibers and simultaneously quantify the psychophysical detection probability and neurophysiological EEG responses. In this work, we study whether using one or a combination of both outcome measures could aid in the observation of altered nociceptive processing in chronic pain. A set of features was extracted from data from a total of 66 measurements on 16 failed back surgery syndrome patients and 17 healthy controls. We assessed how well each feature discriminates both groups. Subsequently, we used a random forest classifier to study whether psychophysical features, EEG features or a combination can improve the classification accuracy. It was found that a classification accuracy of 0.77 can be achieved with psychophysical features, while a classification accuracy of 0.65 was achieved using only EEG features.Clinical Relevance-This study shows which combined features of nociceptive detection behavior and evoked EEG responses are most sensitive and specific to altered nociception in failed back surgery syndrome.

The diagnostic value of Red Flags in thoracolumbar pain: a systematic review

PURPOSE

Red Flags (RFs) are signs and symptoms related to the screening of serious underlying pathologies mimicking a musculoskeletal pain. The current literature wonders about the usefulness of RFs, due to high false-positive rates and low diagnostic accuracy. The aims of this systematic review are: (a) to identify and (b) to evaluate the most important RFs that could be found by a health care professional during the assessment of patients with low and upper back pain (named as thoracolumbar pain (TLP)) to screen serious pathologies.

MATERIALS AND METHODS

A systematic review of the literature was conducted. Searches were performed on seven databases (Pubmed, Web of Science, Cochrane Library, Pedro, Scielo, CINAHL, and Google Scholar) between March 2019 and June 2020, using a search string which included synonyms of low back pain (LBP), chest pain (CP), differential diagnosis, RF, and serious disease. Only observational studies enrolling patients with LBP or CP were included. Risk of bias was assessed with the Newcastle Ottawa Scale and inter-rater agreement between authors for full-text selection was evaluated with Cohen's Kappa. Where possible the diagnostic accuracy was recorded for sensitivity (Sn), specificity (Sp), and positive/negative likelihood ratio (LR+/LR-).

RESULTS

Forty full-texts were included. Most of the included observational studies were judged as low risk of bias, and Cohen's Kappa was good (=0.78). The identified RFs were: advanced age; neurological signs; history of trauma; malignancy; female gender; corticosteroids use; night pain; unintentional weight loss; bladder or bowel dysfunction; loss of anal sphincter tone; saddle anaesthesia; constant pain; recent infection; family or personal history of heart or pulmonary diseases; dyspnoea; fever; postprandial CP; typical reflux symptoms; haemoptysis; sweating; pain radiated to upper limbs; hypotension; retrosternal pain; exertional pain; diaphoresis; and tachycardia. The diagnostic accuracy of RFs as self-contained screening tool was low, while the combination of multiple RFs showed to increase the probability to identify serious pathologies.

CONCLUSIONS

Despite the use of single RF should not be recommended for the screening process in clinical practice, the combination of multiple RFs to enhance diagnostic accuracy is promising. Moreover, the identified RFs could be a baseline to develop a screening tool for patients with TLP.Implications for rehabilitationDifferential diagnosis and screening for referral are mandatory skills for each healthcare professional in direct access clinical settings, and should be the primary step for an appropriate management of a patient with signs and symptoms mimicking serious pathologies in thoracolumbar region.Clinical reasoning and decision-making processes are essential throughout all phases of a patient's pathway of care. By which, the use of single Red Flag (RF) as a self-contained screening tool should not be recommended. The combination of multiple RFs promises to increase diagnostic accuracy and could grow into an excellent screening tool for thoracolumbar pain.

International Framework for Red Flags for Potential Serious Spinal Pathologies

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) led the development of a framework to help clinicians assess and manage people who may have serious spinal pathology. While rare, serious spinal pathology can have devastating and life-changing or life-limiting consequences, and must be identified early and managed appropriately. Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. This framework is intended to provide a clinical-reasoning pathway to clarify the role of red flags. J Orthop Sports Phys Ther 2020;50(7):350-372. Epub 21 May 2020. doi:10.2519/jospt.2020.9971.

Patient Preferences for Plain Radiographs in the Setting of Atraumatic Shoulder Pain: Which Factors Influence Their Decision?

INTRODUCTION

Plain radiographs of the shoulder are routinely obtained for patients presenting with atraumatic shoulder pain, although the diagnostic utility of this imaging modality is unclear. Despite this, patients often prefer to obtain radiographs and may associate them with a more satisfactory visit.

METHODS

New patients presenting with atraumatic shoulder pain were provided with information regarding the potential advantages and disadvantages of plain radiographs as part of their visit. Patients then decided whether to receive radiographs and baseline patient demographics were collected. A detailed physical examination and history was performed by a fellowship-trained provider, and a preliminary diagnosis and tentative treatment plan was formulated. The radiographs were then reviewed to determine whether the diagnosis and treatment plan was altered by addition of the radiographs. Patients who opted for radiographs then reported whether they felt the radiographs aided in diagnosis and treatment and whether the addition of the radiograph influenced their visit satisfaction.

RESULTS

A total of 220 patients met the inclusion criteria. Overall, 121 patients (55%) requested a radiograph. The mean age was 57.1 ± 16.1 years (range, 18 to 91 years). Lack of bachelor's degree (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.2 to 6.2; P = 0.01), lack of previous contralateral shoulder pain (OR, 4.0; 95% CI, 2.0 to 8.2; P = 0.0001), and lack of a previous shoulder radiograph (OR, 8.4; 95% CI, 4.1 to 16.9; P < 0.0001) or MRI within the last 6 months (OR, 6.2; 95% CI, 1.4 to 26.8; P = 0.01) were independently associated with patient preference to obtain radiographs for atraumatic shoulder pain. Of the 121 patients who requested radiographs, 117 (96.7%) felt that radiographs improved their satisfaction.

DISCUSSION

Patients who obtained radiographs overwhelmingly reported its importance in improving visit satisfaction and diagnostic accuracy. Given the increasing emphasis on shared decision making, further study of patient factors influencing the decision to obtain routine radiographs will lead to more efficient practice management and potentially improved patient satisfaction.

LEVEL OF EVIDENCE

Level II (Diagnostic).

Clinical prevalence and population incidence of serious pathologies among patients undergoing magnetic resonance imaging for low back pain

BACKGROUND

In rare cases low back pain may be caused by underlying serious pathology such as fracture, malignancy, cauda equina syndrome, or spinal infection. The lack of evidence regarding either the clinical prevalence or population incidence of serious pathologies in the lumbar spine makes it difficult for clinicians to adequately assess a patient's risk of serious pathology.

PURPOSE

To determine the prevalence of serious pathologies in patients with low back pain who have been referred for a lumbar magnetic resonance imaging (MRI) by a specialist in a private secondary care or public tertiary care setting. The incidence of these serious pathologies in the geographic region of South Auckland, New Zealand was also investigated.

STUDY DESIGN

Retrospective, observational cohort study.

PATIENT SAMPLE

Consecutive patients referred for lumbar MRI over a 10-month period (1st of October 2013-31st of July 2014).

METHOD

Data from all eligible MRI reports was analyzed and any serious pathologies were identified and recorded. Prevalence (along with 95% confidence intervals) was calculated as a percentage of the study population. Prevalence specific to private secondary care and public tertiary care settings was also calculated and prevalence rate ratios were determined to allow comparison between settings. Incidence in the geographic region of South Auckland, New Zealand, was determined using data collected from participants recruited from the regional public hospital. Population incidence with respect to age, gender, and ethnicity for each target condition was calculated and incidence rate ratios were computed to compare groups.

RESULTS

A total of 2,383 participants referred for lumbar MRI scans were included in this study. Prevalence was significantly higher in the public tertiary care setting than in the private secondary care setting for all pathologies investigated in this study. Pathology specific prevalence in secondary care vs tertiary care settings was: malignancy, 0.3%, 4.4% (p<.001); fracture 2.2%, 6.7% (p<.001); cauda equina compression 0.6%, 2.3% (p=.001); infection 0.1%, 3.4% (p<.001). The combined prevalence in secondary care was 3.2% and in tertiary care 14.8% (p<.001). Pathology specific total incidence was: fracture, 13 per 100,000 person-years (p-y); malignancy 8.5 per 100,000 p-y; cauda equina compression 4.4 per 100,000 p-y; spinal infection 6.6 per 100,000 p-y.

CONCLUSIONS

The prevalence of serious pathologies was significantly higher in tertiary care (public health) than in private secondary care settings. One in every 6.5 patients referred for MRI in tertiary care demonstrated structural abnormalities associated with serious pathology, which raises the question of whether access to MRI should be re-evaluated.

Does the awareness of having a lumbar spondylolisthesis influence self-efficacy and kinesiophobia? A retrospective analysis

Background

High pain self-efficacy and low kinesiophobia seem related to a better prognosis in patients complaining of low back pain (LBP). The literature stresses the potential negative effects of anatomical defect diagnosis (e.g. lumbar spondylolisthesis) on the psychological profile. The aim of this study is to investigate the relationships between awareness of having a spondylolisthesis, pain self-efficacy and kinesiophobia.

Methods

A secondary retrospective analysis was done. Ninety-eight subjects with subacute and chronic LBP were included: 49 subjects with diagnosed symptomatic lumbar spondylolisthesis and 49 subjects with diagnosed non-specific LBP. The pain self-efficacy measured with the Pain Self-Efficacy Questionnaire and the fear of movement measured with the Tampa Scale of Kinesiophobia were considered variables to investigate, whereas diagnosis and demographic/clinical variables were considered predictors or potential confounders.

Results

By comparing the two groups, the awareness of having a spondylolisthesis did not significantly influence neither pain self-efficacy (p = 0.82), nor kinesiophobia (p = 0.75). Higher perceived pain reduces pain self-efficacy and increases kinesiophobia in both groups (p = 0.002 and p = 0,031 respectively).

Conclusions

It seems that the awareness of an anatomical defect as spondylolisthesis does not significantly affect the beliefs of carry out activities and movements despite the pain. Other studies with wider samples are required, to confirm these preliminary results.

A Clinical Case Demonstrating the Effectiveness of an Individualized Multimodal Intervention for Chronic Pain and Cognitive Sequelae Secondary to Traumatic Brain Injury

Chronic pain and cognitive difficulties are common secondary to traumatic brain injury (TBI); however, given the vast heterogeneity in TBI presentation, no empirically supported treatments specific to TBI exist. This case demonstrates the effectiveness of an empirically informed multimodal treatment, in which treatment components were selected based on the patient’s individual symptoms and delivered in a manner cognizant of the patient’s cognitive profile. Treatment incorporated components of cognitive behavioral therapy, physical intervention, mindfulness, sleep hygiene, distress tolerance, and cognitive rehabilitation. Pain, sleep, and therapy-related activities were logged daily. Treatment progress was further measured with the Beck Depression Inventory–II, Beck Anxiety Inventory, Satisfaction With Life Scale, and Insomnia Severity Index. The patient reported a significant reduction in pain (average pain rating reduced from 8.5-9 to 6.90 on the numerical rating scale [NRS]) and reported experiencing his least painful day in “years” (i.e., pain rating of 3). The patient reported improvements in mood and sleep, increased engagement in physical/other pleasant activities, and improved academic performance. The patient is currently not pursuing opioids or surgical intervention for pain. This case demonstrates the importance of utilization of neuropsychological data in the identification of treatment goals, appropriate treatment selection, and implementation of suitable techniques. This approach can provide neurologically atypical individuals with interventions that better address their symptom presentation and maximize prognosis.

Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review

Clinicians do not want to miss underlying serious pathology, but it is still unclear which red flags are relevant. We aimed to evaluate the origin and evidence on diagnostic accuracy of red flags for malignancy for management of low back pain (LBP) in primary care. We performed a comprehensive overview and searched the literature using snowballing techniques and reference checking for evidence on red flags endorsed in clinical guidelines for identifying patients with higher likelihood of malignancy. We selected studies including people with LBP without any restriction on study design. We extracted data on prevalence and diagnostic accuracy. Furthermore, we assessed the methodological quality of studies evaluating diagnostic accuracy. We identified 13 red flags endorsed in a total of 16 guidelines and 2 extra red flags not endorsed in any guideline. We included 33 publications varying from systematic reviews to case reports. The origin of many red flags was unclear or was sourced from case reports. The incidence of malignancy in patients presenting with LBP in primary care varied between 0% and 0.7%. Seven studies provided diagnostic accuracy data on red flags. We found 5 red flags with accuracy data from 2 or more studies, with 2 ("history of malignancy" and "strong clinical suspicion") considered informative. In conclusion, the origin and diagnostic accuracy of many red flags endorsed in guidelines are unclear. A "history of malignancy" and "strong clinical suspicion" are the only red flags with empirical evidence of acceptably high diagnostic accuracy.

Acute Low Back Pain: Differential Somatosensory Function and Gene Expression Compared With Healthy No-Pain Controls

OBJECTIVES

Low back pain (LBP) is the second most frequently diagnosed pain condition in the United States, and although a majority of individuals have resolution of pain during the acute period, an estimated 40% of individuals will experience persistent pain. Given the heterogenous nature of LBP, this study sought to describe and compare somatosensory and molecular (gene expression) profiles between individuals with acute LBP and healthy no-pain controls.

METHODS

Using a previously established protocol, we comprehensively assessed somatosensory parameters among 31 no-pain control participants and 31 participants with acute LBP. Samples of whole blood were drawn to examine mRNA expression of candidate genes involved in the transduction, maintenance, and modulation of pain.

RESULTS

The acute LBP group exhibited increased pain sensitivity to cold stimuli, mechanical stimuli, including mechanical temporal summation at both the painful back area and remote location suggesting a mechanism of enhanced central nervous system excitability. In addition, deep tissue-specific peripheral sensitization was suggested due to significant differences in pressure pain threshold of the painful back area, but not the remote body site. Several genes that were differentially expressed were significantly associated with somatosensory alterations identified in the acute LBP group.

DISCUSSION

Acute LBP participants showed selective pain sensitivity enhancement and differential gene expression profiles compared with pain-free controls. Further research to characterize pain-associated somatosensory changes in the context of altered mRNA expression levels may provide insight on the molecular underpinnings of maladaptive chronic pain.

Lumbar Spine X-Ray as a Standard Investigation for all Low back Pain in Ghana: Is It Evidence Based?

BACKGROUND

Low back pain (LBP) has a prevalence of 84% in Africa. The commonest form of imaging is plain lumbar spine x-ray. It gives a radiation dose equivalent to 65 times a chest x-ray dose and sends one of the highest doses to the human reproductive organs. The commonest cause of LBP in Africa is degenerative disease. X-ray findings do not change mode of treatment yet most physicians still routinely request for x-rays.

METHODS

This is a systematic review of databases including The Cochrane, CINAHL plus, AMED, and MEDLINE. Key evidence was clinical guidelines on x-ray use for low back pain. Key search terms included low back pain, x-rays, guidelines, Ghana.

RESULTS

Four clinical guidelines on LBP emerged from two Systematic Reviews rated excellent and four good Randomized Controlled Trials: The European guidelines for acute and sub-acute non-specific Low Back Pain, The American College of Physicians and the American Pain Society guideline for diagnostic imaging for Low Back Pain, The NICE guidelines for persistent non-specific Low Back Pain and the Ghana Standard Treatment Guidelines (GSTG). All the guidelines agree that a good history and clinical examination for all LBP patients helps in diagnosing. Only GSTG recommends routine plain spinal x-rays.

CONCLUSION

There is strong evidence indicating very little benefit from routine lumbar spine x-rays for all LBP. The GSTG needs to be revised considering the increased risks of radiation exposure and the x-ray costs.

FUNDING

None declared.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews

Background

Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.

Methods

A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR.

Results

Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.

Conclusions

This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1549-6) contains supplementary material, which is available to authorized users.

Central sensitization in chronic low back pain: A narrative review

Low back pain is one of the four most common disorders in all regions, and the greatest contributor to disability worldwide, adding 10.7% of total years lost due to this health state. The etiology of chronic low back pain is, in most of the cases (up to 85%), unknown or nonspecific, while the specific causes (specific spinal pathology and neuropathic/radicular disorders) are uncommon. Central sensitization has been recently recognized as a potential pathophysiological mechanism underlying a group of chronic pain conditions, and may be a contributory factor for a sub-group of patients with chronic low back pain. The purposes of this narrative review are twofold. First, to describe central sensitization and its symptoms and signs in patients with chronic pain disorders in order to allow its recognition in patients with nonspecific low back pain. Second, to provide general treatment principles of chronic low back pain with particular emphasis on pharmacotherapy targeting central sensitization.

The influence of patient position on withdrawal force of lumbar epidural catheters after total knee arthroplasty: A randomized trial

STUDY OBJECTIVE

Elderly patients with degenerative knee disease may have accompanying degenerative spine conditions. There are no studies on lumbar epidural catheter withdrawal forces in these patients. The aim of this study was to investigate withdrawal forces and possible associated risk factors in patients undergoing total knee arthroplasty (TKA).

DESIGN

Prospective randomized trial.

SETTING

Operating room and ward in a university hospital.

PATIENTS

Seventy-eight patients aged 65 to 80years who were undergoing TKA and combined spinal epidural anesthesia were enrolled.

INTERVENTIONS

Lumbar epidural catheterization was performed in a lateral position before surgery and the patients were randomly allocated to one of 3 positions for removal: flexed lateral (L), prone (P), and sitting (S). On the third postoperative day, the lumbar epidural catheters were removed by a single investigator with the patient in the assigned position.

MEASUREMENTS

We measured the peak tension during catheter withdrawal and evaluated the factors affecting peak tension.

MAIN RESULTS

The forces required to remove the catheters were considerably greater in the sitting and prone than in the flexed lateral position: group P (3.9N [0.28-10.36]), group S (4.1N [0.04-11.57]), and group L (1.3N [0.07-3.65]) (P<.001). There was a positive correlation between the length of catheter in the epidural space and peak tension (P=.0026, β coefficient=.223).

CONCLUSIONS

For ease of removal of catheters from the lumbar epidural space, the flexed lateral position is recommended for elderly patients undergoing TKA. When placing the epidural catheter, the physician should be careful not to insert a catheter that is excessively long.

Increased low back pain prevalence in females than in males after menopause age: evidences based on synthetic literature review

Female sex hormones play an important role in the etiology and pathophysiology of a variety of musculoskeletal degenerative diseases. Postmenopausal women show accelerated disc degeneration due to relative estrogen deficiency. This literature review aims to validate or falsify this hypothesis, i.e., while overall females have higher prevalence of low back pain (LBP) across all age groups, this male vs. female difference in LBP prevalence further increases after female menopause age. The literature search was performed on PubMed on January 2, 2016. The search word combination was (low back pain) AND prevalence AND [(males OR men) AND (females OR women)]. The following criteria were taken to include the papers for synthetic analysis: (I) only English primary literatures on nonspecific pain; (II) only prospective studies on general population, but not population with occupational LBP causes, of both males and female subjects studied using the same LBP criterion, ages-specific information available, and males and female subjects were age-matched; (III) studies without major quality flaws. In total 98 studies with 772,927 subjects were analyzed. According to the information in the literature, participant subjects were divided into four age groups: (I) school age children group: 6-19 years; (II) young and middle aged group: 20-50 years; (III) mixed age group: data from studies did not differentiate age groups; (IV) elderly group: ≥50 years old. When individual studies were not weighted by participant number and each individual study is represented as one entry regardless of their sample size, the median LBP prevalence ratio of female vs. males was 1.310, 1.140, 1.220, and 1.270 respectively for the four age groups. When individual studies were weighted by participant number, the LBP prevalence ratio of female vs. males was 1.360, 1.127, 1.185, and 1.280 respectively for the four groups. The higher LBP prevalence in school age girls than in school age boys is likely due to psychological factors, female hormone fluctuation, and menstruation. Compared with young and middle aged subjects, a further increased LBP prevalence in females than in males was noted after menopause age.

Prevalence and "Red Flags" Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice

BACKGROUND

In a small proportion of patients experiencing unspecified back pain, a specified underlying pathology is present.

OBJECTIVE

The purposes of this study were: (1) to identify the prevalence of physician-specified causes of back pain and (2) to assess associations between "red flags" and vertebral fractures, as diagnosed by the patients' general practitioner (GP), in older adults with back pain.

METHODS

The Back Complaints in the Elders (BACE) study is a prospective cohort study. Patients (aged >55 years) with back pain were included when consulting their GP. A questionnaire was administered and a physical examination and heel bone densitometry were performed, and the results determined back pain and patient characteristics, including red flags. Participants received a radiograph, and reports were sent to their GP. The final diagnoses established at 1 year were collected from the GP's patient registry.

RESULTS

Of the 669 participants included, 6% were diagnosed with a serious underlying pathology during the 1-year follow-up. Most of these participants (n=33, 5%) were diagnosed with a vertebral fracture. Multivariable regression analysis showed that age of ≥75 years, trauma, osteoporosis, a back pain intensity score of ≥7, and thoracic pain were associated with a higher chance of getting the diagnosis of a vertebral fracture. Of these variables, trauma showed the highest positive predictive value for vertebral fracture of 0.25 (95% confidence interval=0.09, 0.41) and a positive likelihood ratio of 6.2 (95% confidence interval=2.8, 13.5). A diagnostic prediction model including the 5 red flags did not increase these values.

LIMITATIONS

Low prevalence of vertebral fractures could have led to findings by chance.

CONCLUSIONS

In these older adults with back pain presenting in general practice, 6% were diagnosed with serious pathology, mainly a vertebral fracture (5%). Four red flags were associated with the presence of vertebral fracture.

[Formalized consensus: clinical practice recommendations for the management of acute low back pain of the African patient]

La lombalgie aiguë est la pathologie rhumatismale la plus fréquente en Afrique. L’épidémiologie et la présentation clinique ne diffèrent pas de celles observées sur les autres continents. En revanche, les aspects psycho-sociaux, la disponibilité des traitements, l'accès aux soins et le poids culturel des médecines traditionnelles sont autant de spécificités qui ont conduit à la réalisation du 1er consensus d'experts en rhumatologie pour la prise en charge du patient africain. Destiné aux praticiens, ce travail collaboratif multinational a pour objectif de fournir 11 recommandations de pratiques cliniques simples, fondées sur les preuves, et adaptées aux conditions de l'exercice médical en Afrique. Leur ambition est d'améliorer la prise en charge de la lombalgie aigue par une évaluation initiale clinique pertinente, une diminution des examens radiologiques inutiles, une prescription médicamenteuse adéquate et l'abandon de procédures invasives inappropriées.

Dose Optimization in Lumbar Spine Radiographic Examination by Air Gap Method at CR and DR Systems: A Phantom Study

OBJECTIVE

This study aims at investigating the feasibility of replacing an antiscatter grid with an air gap to achieve dose reduction for lumbar spine radiography while retaining image quality at an acceptable diagnostic level.

METHODS

Frontal and lateral projections of lumbar spine radiographic examinations were performed on an anthropomorphic phantom. Nongrid images of both the computed radiography (CR) and digital radiography (DR) systems with air gap thickness ranging from 0 to 25 cm were produced and compared with their corresponding grid images. Dose measurements using thermoluminescent dosimeters at the ovary and testes regions of the phantom were conducted. The image quality of all the images was evaluated by five radiographers using image quality score and visual grading analysis tests. Data on dose measurements and image quality tests were input for statistical analysis. The dose area product (DAP) of all the examinations was recorded and input for the computation of effective doses using a PC-based Monte Carlo program (PCXMC 2.0; STUK, Helsinki, Finland).

RESULTS

Significant dose reduction effects on the ovaries of 60.2%-74.1% and 55.1%-73.3% were found, respectively, at the frontal and lateral projections of nongrid lumbar spine examinations compared with their corresponding grid ones in both the CR and DR systems. Results on the image quality score and visual grading analysis tests showed that nongrid images with 10-cm and 5-cm of air gap thicknesses respective to the frontal and lateral images of the lumbar spine were rated with the highest scores. In general, a dose reduction effect using the air gap method was found to be more pronounced in the CR system compared with the DR system. Nevertheless, the CR system delivered a 2.4-4.5 times higher ovary dose respective to the frontal and lateral projections of lumbar spine examinations compared with the DR system.

CONCLUSIONS

Ten and 5 centimeters were found to be the optimal air gap thicknesses respective to the frontal and lateral lumbar spine radiographic examinations of the tested Rando phantom (Alderson Laboratories, Stamford, CT) in both the CR and DR systems. Significant dose reduction effects on both the ovary and testes regions of the nongrid examinations were shown. The effective dose computed from PCMCX 2.0 reflected that the risk of cancer induction was halved when an antiscatter grid was replaced by the nongrid method with an optimal air gap thickness in the tested examinations. Further reduction on cancer risk could be achieved by using DR instead of the CR system.

Smoking increases risk of pain chronification through shared corticostriatal circuitry

Smoking is associated with increased incidence of chronic pain. However, the evidence is cross-sectional in nature, and underlying mechanisms remain unclear. In a longitudinal observational study, we examined the relationship between smoking, transition to chronic pain, and brain physiology. In 160 subjects with subacute back pain (SBP: back pain lasting 4-12 weeks, and no prior back pain [BP] for at least 1 year) pain characteristics, smoking status, and brain functional properties were measured repeatedly over 1 year. Sixty-eight completed the study, subdivided into recovering (SBPr, n = 31) and persisting (SBPp, n = 37), based on >20% decrease in BP over the year. Thirty-two chronic back pain (CBP: duration > 5 years) and 35 healthy controls were similarly monitored. Smoking prevalence was higher in SBP and CBP but not related to intensity of BP. In SBP, smoking status at baseline was predictive of persistence of BP 1 year from symptom onset (differentiating SBPp and SBPr with 0.62 accuracy). Smoking status combined with affective properties of pain and medication use improved prediction accuracy (0.82). Mediation analysis indicated the prediction of BP persistence by smoking was largely due to synchrony of fMRI activity between two brain areas (nucleus accumbens and medial prefrontal cortex, NAc-mPFC). In SBP or CBP who ceased smoking strength of NAc-mPFC decreased from precessation to postcessation of smoking. We conclude that smoking increases risk of transitioning to CBP, an effect mediated by corticostriatal circuitry involved in addictive behavior and motivated learning.

Predicting transition to chronic pain

PURPOSE OF REVIEW

Most individuals who develop pain following an inciting event will return to a healthy state as the injury heals. However, a small percentage continue to suffer, that is, transition to chronic pain. Chronic pain may persist for years and is accompanied by cognitive abnormalities, as well as diminished quality of life. In animals, persistent pain is characterized by peripheral and spinal cord reorganization, and recent evidence in humans also indicates cortical reorganization. Yet, despite more than 30 years of research, there is little agreement on the neural mechanisms that mediate the transition from acute to chronic pain.

RECENT FINDINGS

In a longitudinal brain-imaging study, individuals who developed an intense back pain episode were followed over a 1-year period, during which pain and brain parameters were collected repeatedly. A smaller number of healthy individuals and chronic back pain patients were also studied concomitantly, as positive and negative controls. At the time of entry into the study, strength of synchrony between the medial prefrontal cortex and nucleus accumbens (i.e. functional connectivity) was predictive (>80% accuracy) of individuals who subsequently transition to chronicity 1 year later.

SUMMARY

Properties of the brain's emotional learning circuitry predict the transition to chronic pain. The involvement of this circuitry in pain remains mostly unexplored. Future human and animal model studies are necessary to unravel underlying mechanisms driving pain chronicity, with the potential of advancing novel therapeutics for preventing pain chronification.

Red flags to screen for malignancy and fracture in patients with low back pain: systematic review

OBJECTIVE

To review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary, or tertiary care.

DESIGN

Systematic review.

DATA SOURCES

Medline, OldMedline, Embase, and CINAHL from earliest available up to 1 October 2013.

INCLUSION CRITERIA

Primary diagnostic studies comparing red flags for fracture or malignancy to an acceptable reference standard, published in any language.

REVIEW METHODS

Assessment of study quality and extraction of data was conducted by three independent assessors. Diagnostic accuracy statistics and post-test probabilities were generated for each red flag.

RESULTS

We included 14 studies (eight from primary care, two from secondary care, four from tertiary care) evaluating 53 red flags; only five studies evaluated combinations of red flags. Pooling of data was not possible because of index test heterogeneity. Many red flags in current guidelines provide virtually no change in probability of fracture or malignancy or have untested diagnostic accuracy. The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%).

CONCLUSIONS

While several red flags are endorsed in guidelines to screen for fracture or malignancy, only a small subset of these have evidence that they are indeed informative. These findings suggest a need for revision of many current guidelines.

Red flags to screen for vertebral fracture in patients presenting with low-back pain

BACKGROUND

Low-back pain (LBP) is a common condition seen in primary care. A principal aim during a clinical examination is to identify patients with a higher likelihood of underlying serious pathology, such as vertebral fracture, who may require additional investigation and specific treatment. All 'evidence-based' clinical practice guidelines recommend the use of red flags to screen for serious causes of back pain. However, it remains unclear if the diagnostic accuracy of red flags is sufficient to support this recommendation.

OBJECTIVES

To assess the diagnostic accuracy of red flags obtained in a clinical history or physical examination to screen for vertebral fracture in patients presenting with LBP.

SEARCH METHODS

Electronic databases were searched for primary studies between the earliest date and 7 March 2012. Forward and backward citation searching of eligible studies was also conducted.

SELECTION CRITERIA

Studies were considered if they compared the results of any aspect of the history or test conducted in the physical examination of patients presenting for LBP or examination of the lumbar spine, with a reference standard (diagnostic imaging). The selection criteria were independently applied by two review authors.

DATA COLLECTION AND ANALYSIS

Three review authors independently conducted 'Risk of bias' assessment and data extraction. Risk of bias was assessed using the 11-item QUADAS tool. Characteristics of studies, patients, index tests and reference standards were extracted. Where available, raw data were used to calculate sensitivity and specificity with 95% confidence intervals (CI). Due to the heterogeneity of studies and tests, statistical pooling was not appropriate and the analysis for the review was descriptive only. Likelihood ratios for each test were calculated and used as an indication of clinical usefulness.

MAIN RESULTS

Eight studies set in primary (four), secondary (one) and tertiary care (accident and emergency = three) were included in the review. Overall, the risk of bias of studies was moderate with high risk of selection and verification bias the predominant flaws. Reporting of index and reference tests was poor. The prevalence of vertebral fracture in accident and emergency settings ranged from 6.5% to 11% and in primary care from 0.7% to 4.5%. There were 29 groups of index tests investigated however, only two featured in more than two studies. Descriptive analyses revealed that three red flags in primary care were potentially useful with meaningful positive likelihood ratios (LR+) but mostly imprecise estimates (significant trauma, older age, corticosteroid use; LR+ point estimate ranging 3.42 to 12.85, 3.69 to 9.39, 3.97 to 48.50 respectively). One red flag in tertiary care appeared informative (contusion/abrasion; LR+ 31.09, 95% CI 18.25 to 52.96). The results of combined tests appeared more informative than individual red flags with LR+ estimates generally greater in magnitude and precision.

AUTHORS' CONCLUSIONS

The available evidence does not support the use of many red flags to specifically screen for vertebral fracture in patients presenting for LBP. Based on evidence from single studies, few individual red flags appear informative as most have poor diagnostic accuracy as indicated by imprecise estimates of likelihood ratios. When combinations of red flags were used the performance appeared to improve. From the limited evidence, the findings give rise to a weak recommendation that a combination of a small subset of red flags may be useful to screen for vertebral fracture. It should also be noted that many red flags have high false positive rates; and if acted upon uncritically there would be consequences for the cost of management and outcomes of patients with LBP. Further research should focus on appropriate sets of red flags and adequate reporting of both index and reference tests.

Multivariate classification of structural MRI data detects chronic low back pain

Chronic low back pain (cLBP) has a tremendous personal and socioeconomic impact, yet the underlying pathology remains a mystery in the majority of cases. An objective measure of this condition, that augments self-report of pain, could have profound implications for diagnostic characterization and therapeutic development. Contemporary research indicates that cLBP is associated with abnormal brain structure and function. Multivariate analyses have shown potential to detect a number of neurological diseases based on structural neuroimaging. Therefore, we aimed to empirically evaluate such an approach in the detection of cLBP, with a goal to also explore the relevant neuroanatomy. We extracted brain gray matter (GM) density from magnetic resonance imaging scans of 47 patients with cLBP and 47 healthy controls. cLBP was classified with an accuracy of 76% by support vector machine analysis. Primary drivers of the classification included areas of the somatosensory, motor, and prefrontal cortices--all areas implicated in the pain experience. Differences in areas of the temporal lobe, including bordering the amygdala, medial orbital gyrus, cerebellum, and visual cortex, were also useful for the classification. Our findings suggest that cLBP is characterized by a pattern of GM changes that can have discriminative power and reflect relevant pathological brain morphology.

Diagnostic imaging for spinal disorders in the elderly: a narrative review

The high prevalence of neck and low back pain in the rapidly aging population is associated with significant increases in health care expenditure. While spinal imaging can be useful to identify less common causes of neck and back pain, overuse and misuse of imaging services has been widely reported. This narrative review aims to provide primary care providers with an overview of available imaging studies with associated potential benefits, adverse effects, and costs for the evaluation of neck and back pain disorders in the elderly population. While the prevalence of arthritis and degenerative disc disease increase with age, fracture, infection, and tumor remain uncommon. Prevalence of other conditions such as spinal stenosis and abdominal aortic aneurysm (AAA) also increase with age and demand special considerations. Radiography of the lumbar spine is not recommended for the early management of non-specific low back pain in adults under the age of 65. Aside from conventional radiography for suspected fracture or arthritis, magnetic resonance imaging (MRI) and computed tomography (CT) offer better characterization of most musculoskeletal diseases. If available, MRI is usually preferred over CT because it involves less radiation exposure and has better soft-tissue visualization. Use of subspecialty radiologists to interpret diagnostic imaging studies is recommended.

Estimated number of korean adults with back pain and population-based associated factors of back pain : data from the fourth Korea national health and nutrition examination survey

OBJECTIVE

We estimated the number of Korean adults with back pain and evaluated population-based associated factors of back pain from a representative sample data from the Fourth Korea National Health and Nutrition Examination Survey.

METHODS

The number of Korean adults who experienced back pain (experienced patients), those who experienced back pain lasting for three or more months during the past year (chronic patients), and those who were currently suffering from back pain (current patients) were estimated by analyzing the data from the fourth Korea National Health and Nutrition Examination Survey conducted in 2007 using surveyfreq procedure of the SAS statistical package. Population-based odds ratios for being experienced, chronic, and current patient according to demographic (age and gender), socioeconomic (education and occupation), and lifestyle factors (smoking, drinking, and exercise) were estimated using surveylogistic procedure.

RESULTS

It was estimated that there were 5,554,256 (proportion, 15.4%; 95% CI, 4,809,466 - 6,299,046) experienced patients, 2,060,829 (5.7%; 1,557,413-2,564,246) chronic patients, and 3,084,188 (8.5%; 2,600,197 - 3,568,179) current patients among 36,107,225 Korean adults aged 20-89 years in 2007. Each of explanatory variables was significantly associated with at least one of the response variables for back pain.

CONCLUSION

Based on our study results, further efforts to investigate epidemiology of back pain, to evaluate associated factors, and to improve treatment outcomes are needed.

Software-assisted spine registered nurse care coordination and patient triage--one organization's approach

Back disorders encompass a spectrum of conditions, from those of acute onset and short duration to lifelong disorders. The use of a traditional spine center model of patient flow, in which the patient is scheduled the first available appointment without an initial assessment of spine-related symptoms at West Virginia University Spine Center, Morgantown, West Virginia, resulted in frustration and delays for the spine patient and referring physician dissatisfaction. Today, the use of a software-assisted spine patient triage and registered nurse care coordinator patient navigation system in this multidiscipline, multimodality comprehensive spine program provides quick and efficient patient triage to the appropriate level of spine care (surgeon vs. nonsurgeon). The model consists of five major steps, which are explored in this article: medical history intake; films or studies retrieval; rapid review of the patient's medical condition and diagnostics by a spine specialist preappointment and subsequent triage to the appropriate level of spine care; registered nurse care coordinator patient education and guided navigation through the patient's preferred treatment plan; and last, diagnostic study, pain injection, and provider scheduling. Patient satisfaction scores, referring physician satisfaction scores, and resultant impact on referral volumes, ancillary utilization, workload productivity, and surgical yield demonstrate that this new approach to patient triage has made significant improvements in efficiency, productivity, and service.

Estudo da validade e confiabilidade intra e interobservador da versão modificada do teste de Schöber modificado em indivíduos com lombalgia

Em pacientes com lombalgia, mensura-se a amplitude de movimento (ADM) da coluna lombar por meio da versão modificada do teste de Schöber modificado (MTSM), mas suas propriedades psicométricas não são comprovadas para uso clínico. Este estudo verificou a validade e confiabilidade intra e interobservador do MTSM em indivíduos com lombalgia, comparando as medidas da ADM com as obtidas por meio de radiografia, método considerado padrão-ouro. Participaram 20 voluntários com lombalgia, de ambos os sexos, funcionários de um Hospital Universitário. O MTSM foi aplicado duas vezes por dois avaliadores. As medidas obtidas pelo teste e por radiografia foram comparadas usando o coeficiente de correlação de Pearson, obtendo-se r=0,14, ou seja, correlação fraca. O coeficiente de correlação intraclasse (CCI) dos MTSM intra-observador foi 0,96 (IC 95% 0,91;0,98) e interobservador 0,93 (IC 95% 0,84;0,97), indicando alta confiabilidade; o teste de Bland & Altman mostrou alta concordância intra e interobservador, com valores de -0,21 e -0,28, respectivamente. Embora tenha sido encontrada alta confiabilidade intra e interobservador na aplicação da versão modificada do teste de Schöber modificado, este apresentou baixa validade para medir a ADM da coluna lombar, quando comparado ao padrão-ouro.

Towards a theory of chronic pain

In this review, we integrate recent human and animal studies from the viewpoint of chronic pain. First, we briefly review the impact of chronic pain on society and address current pitfalls of its definition and clinical management. Second, we examine pain mechanisms via nociceptive information transmission cephalad and its impact and interaction with the cortex. Third, we present recent discoveries on the active role of the cortex in chronic pain, with findings indicating that the human cortex continuously reorganizes as it lives in chronic pain. We also introduce data emphasizing that distinct chronic pain conditions impact on the cortex in unique patterns. Fourth, animal studies regarding nociceptive transmission, recent evidence for supraspinal reorganization during pain, the necessity of descending modulation for maintenance of neuropathic behavior, and the impact of cortical manipulations on neuropathic pain is also reviewed. We further expound on the notion that chronic pain can be reformulated within the context of learning and memory, and demonstrate the relevance of the idea in the design of novel pharmacotherapies. Lastly, we integrate the human and animal data into a unified working model outlining the mechanism by which acute pain transitions into a chronic state. It incorporates knowledge of underlying brain structures and their reorganization, and also includes specific variations as a function of pain persistence and injury type, thereby providing mechanistic descriptions of several unique chronic pain conditions within a single model.

[Imaging in rheumatology. Degenerative diseases of the spine]

Degeneration of the spine is a common reason for pain in the musculoskeletal system. Radiography is an important tool for diagnosis and differential diagnosis. Cost efficacy and economy of time are advantages in using conventional x-rays. Although narrowing of intervertebral disc spaces, irregular ossification of the vertebral end-plate as well as osteophytes, facet joint osteoarthritis and spondylolisthesis can be observed, early changes in the discs or the subdiscal bone can not be detected by x-rays. Moreover, 3-dimensional imaging is not possible. Computer tomography (CT) and magnetic resonance imaging (MRI) are reliable for identifying disorders of the spine and soft-tissue. Differentiation between inflammation, trauma and tumor is possible. There is still a problem with the relationship between the information obtained by x-rays or MRI and clinical symptoms. Therefore, interpretation of radiological examinations assumes a knowledge of clinical symptoms and the different kinds of diseases which are possible.

Improvement of lower extremity electrodiagnostic findings following a trial of spinal manipulation and motion-based therapy

BACKGROUND

Lumbar disc herniation is a problem frequently encountered in manual medicine. While manual therapy has shown reasonable success in symptomatic management of these cases, little information is known how manual therapy may affect the structure and function of the lumbar disc itself. In cases where lumbar disc herniation is accompanied by radicular symptoms, electrodiagnostic testing has been used to provide objective clinical information on nerve function. This report examines the treatment rendered for a patient with lower extremity neurological deficit, as diagnosed on electrodiagnostic testing. Patient was treated using spinal manipulation and exercises performed on a Pettibon Wobble Chair, using electrodiagnostic testing as the primary outcome assessment.

CASE PRESENTATION

An elderly male patient presented to a private spine clinic with right-sided foot drop. He had been prescribed an ankle-foot orthosis for this condition. All sensory, motor, and reflex findings in the right leg and foot were absent. This was validated on prior electromyography and nerve conduction velocity testing, performed by a board certified neurologist. Patient was treated using spinal manipulation twice-weekly and wobble chair exercises three times daily for 90 days total. Following this treatment, the patient was referred for follow-up electrodiagnostic studies. Significant improvements were made in these studies as well as self-rated daily function.

CONCLUSION

Motion-based therapies, as part of a comprehensive rehabilitation program, may contribute to the restoration of daily function and the reversal of neurological insult as detected by electrodiagnostic testing. Electrodiagnostic testing may be a useful clinical tool to evaluate the progress of chiropractic patients with lumbar disc herniation and radicular pain syndromes.

Low back pain investigations and prognosis: a review

Low back pain is reviewed in terms of when investigations are useful and its clinical course. Despite the extensive evaluation of the accuracy of investigations such as radiography, magnetic resonance imaging, and myelography, there is a surprising dearth of research to inform their use in primary care. There is no clear evidence on which to base judgments for selection of appropriate tests to confirm or exclude low back pain pathology. It appears that investigations are rarely necessary for low back pain. Specific investigations should be ordered to identify a particular pathology but should not be ordered routinely for general screening. In the absence of pathology, low back pain and its associated disability improve rapidly in the first weeks after onset, but, in contradiction to all guidelines, both commonly persist and the best evidence suggests that recurrences are common.

[Conventional X-rays and conventional tomography in orthopaedics. Current status]

Although sonography, computed tomography (CT) and magnetic resonance imaging (MRI) are common tools in radiology, conventional X-rays still have a place in orthopaedic diagnostic investigation. The advantages of radiographic imaging are high local resolution concerning bone, economy of time besides relatively low costs and worldwide experience. The conventional X-ray is indispensable for planning surgical procedures and clinical monitoring. For several pathological processes an X-ray is sufficient for diagnosis and therapy (i.e. degeneration, fracture). Early changes of the bone (i.e. osteonecrosis) cannot be detected by X-ray. CT and MRI have closed the diagnostic gap. Indications for conventional tomography are rare.

Misleading history of pain location in 51 patients with osteoporotic vertebral fractures

The aim of this study was to investigate associations between the location of osteoporotic vertebral fractures and the patient's localization of pain. Fifty-one consecutive patients (m 6, f 45; average age 74.8 years) with diagnosed osteoporotic vertebral fractures between T8 and L2 were included in the study. Exclusion criteria were fractures above T8 and below L2, spondylolisthesis, disc herniations, tumors, infections, and instability. Pain location was assessed by pain drawing, subdivided into thoracic, lumbar, and thoracic plus lumbar pain areas, and pain intensity using a 101 numeric rating scale. Furthermore, the onset of back pain and the lack or the indication of a trigger event at the onset of pain were documented. Only four of 20 patients with thoracic fractures reported thoracic pain, while the other 16 (80%) reported only lumbar pain. The location of the fracture and the patient's pain report were not related (Cohens Kappa=0.046; P=0.438). Patients with thoracic or lumbar osteoporotic fractures report pain mainly in the lumbosacrogluteal area. Therefore, the complaint of low back pain (LBP) in persons at risk for osteoporotic fractures may require both thoracic and lumbar X-rays. LBP patients with a suspect history of an osteoporotic vertebral fracture should also be given an X-ray of the thoracic and lumbar spine. Patients with a thoracic vertebral fracture had more severe pain than patients with a lumbar vertebral fracture. Onset not related to a fall or a false movement related to a significantly longer pain duration.

Minimally invasive procedures for the treatment of failed back surgery syndrome

Failed back surgery syndrome has become unfortunately a common clinical entity. FBSS does not have one specific treatment because it does not have one specific cause. Some features are shared with chronic low back pain (CLBP) and some pathological processes are specific. Both pathologies are leading causes of disability in the industrialized world and costly medical and surgical treatments are continuously used despite their limited efficacy. Nonetheless, evidence based practice guidelines are systematically developed. In this chapter we cautiously review the vast, complex and at times contradictory literature regarding the treatment of FBSS. Interventional Pain literature suggests that there is moderate evidence (small randomized or non randomized or single group or matched case controlled studies) for medial branch neurotomy and limited evidence (non experimental one or more center studies) for intra-discal treatments in mechanical low back pain. There is moderate evidence for the use of transforaminal epidural steroid injections, lumbar percutaneous adhesiolysis and spinal endoscopy for painful lumbar radiculopathy and spinal cord stimulation and intrathecal pumps mostly after spinal surgery. In reality there is no gold standard for the treatment of FBSS but, these results seem promising.

The use and diagnostic yield of radiology in subjects with longstanding musculoskeletal pain--an eight year follow up

BACKGROUND

Longstanding musculoskeletal pain is common in the general population and associated with frequent use of health care. Plain radiography is a common diagnostic approach in these patients despite knowledge that the use in the investigation of musculoskeletal pain is associated with low diagnostic yield, substantial costs and high radiation exposure. The aim of this study was to assess the use of diagnostic imaging and the proportion of pathological findings with regard to duration and distribution of pain in a cohort from the general population.

METHODS

An eight-year longitudinal study based on questionnaires at three occasions and medical records on radiological examinations done in medical care. Thirty subjects were selected from an established population based cohort of 2425 subjects that in 1995 answered a postal survey on pain experience. At baseline there were ten subjects from each of three pain groups; No chronic pain, Chronic regional pain, and Chronic widespread pain (CWP). Those who presented with CWP at two or all three occasions were considered to have a longstanding or re-occurring CWP. In total the thirty subjects underwent 102 radiological examinations during the eight year follow up.

RESULTS

There was a non-significant (p = 0.10) finding indicating that subjects with chronic pain at baseline (regional or widespread) were examined three times more often than those with no chronic pain. When the indication for the examination was pain, there was a low proportion of positive findings in subjects with longstanding CWP, compared to all others (5.3% vs 28.9%; p = 0.045). On the other hand, in examinations on other indications than pain the proportion of positive findings was high in the CWP group (62.5% vs 14.8%; p = 0.001).

CONCLUSION

Radiological examinations had a low diagnostic yield in evaluation of pain in subjects with longstanding/reoccurring CWP. These subjects had on the other hand more often positive findings when examined on other indications than pain. This may indicate that subjects with longstanding/reoccurring CWP are more prone to other diseases. It is a challenge for caregivers, often primary care physicians, to use radiological examinations to the best for their patients.

Epidemiology of back disorders: prevalence, risk factors, and prognosis

PURPOSE OF REVIEW

This article reviews some of the advances that have taken place in understanding back disorders, with a particular emphasis on low back pain, as this area has been most represented in the literature in the preceding year (September 2003 to September 2004).

RECENT FINDINGS

Epidemiological studies continue to provide insights into the prevalence of back pain and have identified many individual, psychosocial, and occupational risk factors for its onset. Psychological factors have an important role in the transition from acute to chronic pain and related disability. Recent advances show that there is a significant genetic effect on severe low back pain in the community. Data emerging from candidate gene studies show an association between lumbar disc disease and mutations of genes encoding the alpha-2 and alpha-3 subunits of collagen IX.

SUMMARY

Back pain is among the most common conditions for which patients seek medical care. Interventions based on behavioral and cognitive principles and exercise programs are effective in improving disability in chronic back pain. Although progress has been made in understanding the role of genetic mutations in disorders such as lumbar disc disease, further investigation of the interaction between genetic and environmental factors such as physical stress is needed.