The Spine  (section 3)

General (For Trauma See Section 11)

CLINICAL PROBLEM

INVESTIGATION

RECOMMENDATION
{GRADE}

COMMENT
General (For Trauma See Section 11)
Congenital disorders

(For Children see Section 13)		 301 XR Specialised investigation [C] e.g. Full length standing radiograph for scoliosis.  (M10).
MRI Indicated [B] MRI defines all spinal malformations and excludes associated thecal abnormality. CT may be required to delineate bony detail. Sedation or GA may be required for infants and younger children.

(for congenital disorders in children see 1301, 1302)
Myelopathy: tumours, inflammation, infection, infarction, etc. 302 MRI Indicated [B] MRI is the initial investigation for all spinal cord lesions & to evaluate cord compression and to give an indication of post-operative prognosis
CT/CTM Specialised Investigation [B] CT may be needed if better bony detail is required. CT myelography (CTM) only if MRI is unavailable or impossible.
NM Specialised investigation [B] NM is still widely used to screen for metasteses and to identify focal skeletal lesions (such as osteoid osteoma).
Cervical Spine
Possible atlanto-axial subluxation 303 XR Indicated [B] A single lateral cervical spine XR with the patient in supervised comfortable flexion should reveal any significant subluxation in patients with rheumatoid arthritis, Down's Syndrome, etc.
MRI Specialised Investigation [B] MRI in flexion/extension shoes effect on cord when XR is positive or neurological signs are present.
Neck pain, Brachalgia,
?degenerative change 		304 XR
 Indicated only in specific circumstances [B] Neck pain generally improves or resolves with conservative treatment. Degenerative changes begin in early middle age and are often unrelated to symptoms
MRI Specialised investigation [B] Consider MRI and specialist referral when pain affecting lifestyle or when there are neurological signs. CT Myelography may occasionally be required to provide further delineation or when MRI is unavailable or impossible.
Thoracic Spine
Pain without trauma: ?degenerative change 305 XR Indicated only in specific circumstances [C] Degenerative changes are invariable from middle-age onwards. Examination rarely useful in the absence of neurological signs or pointers to metastases or infection. Consider more urgent referral in elderly patients with sudden pain to show osteoporotic collapse or other forms of bone destruction. Consider NM for possible metastatic lesions.
MRI Specialised investigation [C] MRI may be indicated if local pain persists or is difficult to manage, or if there are long tract signs.
Lumbar Spine
Chronic back pain with no pointers to infection or neoplasm 306 XR Indicated only in specific circumstances [C] Degenerative changes are common and non-specific. Main value in younger patients (e.g. less than 20, spondylolisthesis, ankylosing spondylitis, etc.) or in older patients e.g. >55. In cases where management is difficult, negative findings may be helpful.
    MRI Specialised investigation [C] When symptoms persist or are severe or where management is difficult, MRI is considered the first-choice investigation. Imaging findings need to be interpreted with caution because many imaging 'abnormalities' occur with high frequency in asymptomatic individuals and therefore have an uncertain relationship with back pain. The significance of imaging findings depends upon correlation with clinical signs. Negative findings may be helpful.

    Back pain with possible serious features such as:

  • Onset <20,
    >55 yrs
  • Sphincter or gait disturbance
  • Saddle anaesthesia
  • Severe or progressive motor loss
  • Widespread neurological deficit
  • Previous carcinoma
  • Systematically unwell
  • HIV
  • Weight loss
  • Intravenous drug abuse
  • Steroids
  • Structural deformity
  • Non-mechanical pain            (for children see section M)
 307 MRI Indicated [C] Together with urgent specialist referral; MRI is usually the best investigation. Imaging should not delay specialist referral.

 

(For back pain in Children see Section 1311)
NM Indicated [B] NM is also widely used for possible bone destruction due to metasteses, where infection is suspected, or in some cases of chronic pain.

('NORMAL' PLAIN XR MAY BE FALSELY REASSURING).

Acute back pain:
?disk herniation; sciatica with no adverse features


 (for children see section M)

 308 XR Indicated only in specific circumstances [C] Acute back pain is usually due to conditions which cannot be diagnosed on plain XR (osteoporotic collapse an exception). 'Normal' plain XRs may be falsely reassuring.

(For acute back pain in Children see Section 1311)

 
MRI or CT Specialised Investigation [B] Demonstration of disk herniation requires MRI or CT and should be considered immediately after failed conservative management. MRI generally preferred (wider field of view, conus, post-operative changes etc.) and avoids x-irradiation. Clinico-radiological correlation is important as a significant number of disk herniations are asymptomatic.

(For acute back pain in Children see Section 1311)

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