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Bab Ii HNP
Bab Ii HNP
Best Practices
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A
42-year-old woman with a histo- current medications include fluoxetine 60
ry of chronic back pain reported mg by mouth (po) daily, morphine sulfate
that she has had this pain for 20 extended-release 60 mg po twice per day,
years, initially occurring due to morphine sulfate immediate-release 15 mg
training for her work as a law enforcement of- four times daily as needed, cyclobenzaprine
ficer. She stated that the pain is largely lower 20 mg po three times per day, and ibuprofen
lumbar and radiates to her legs bilaterally on 800 mg po three times daily as needed.
the left side down to the calf and the right in Her relevant social history includes cur-
Keywords: disk herniation, low back pain, MRI, spinal
the upper thigh only. The pain has gotten rently working 6 hours per week as a massage
stenosis, spine metastasis
progressively worse over the years. She not- therapist. She cannot work anymore than this
DOI:10.2214/AJR.10.4367 ed some bladder and bowel incontinence for because of her back pain. She has been told
the past several months. The bowel inconti- to stop working altogether and apply for dis-
Received January 28, 2010; accepted after revision nence manifests by her noting her underwear ability but prefers to continue working.
April 19, 2010.
to be soiled. She has seen an orthopedic sur- The relevant portions of the physical ex-
1
Department of Radiology, School of Medicine, University geon and has had at least five epidural steroid amination were as follows: There was marked
of Washington, Seattle, WA. injections with minimal improvement. She tenderness to palpation throughout cervical,
has been on morphine sulfate controlled-re- midthoracic, and lower lumbar spine. The
2
Comparative Effectiveness, Cost and Outcomes lease tablets (MS Contin, Purdue Pharma) as straight leg raising test was negative bilater-
Research Center, University of Washington, Seattle, WA.
well as short-acting morphine for many ally. There was pain with all movements. Her
3
Department of Neurological Surgery, School of years, and that keeps her pain at a 4 of 10. lower extremity strength was limited by pain
Medicine, University of Washington, Seattle, WA. She stated that it quickly goes to 10 of 10 but otherwise appeared normal bilaterally.
4
with any sort of activity. She has tried metha- There was no sensory loss in either the upper
Department of Health Services, School of Public Health,
done in the past without success. She has or lower extremities bilaterally. Her reflexes
University of Washington, Box 359728, 325 Ninth Ave.,
Seattle, WA 98104-2499. Address correspondence to also tried oxycodone (OxyContin, Purdue were brisk but symmetric throughout upper
J. G. Jarvik ([email protected]). Pharma), which has stopped working. and lower extremities. Her toes were down-
Her medical history is notable for chron- going bilaterally. Her gait was slowed but
AJR 2010; 195:550–559
ic neck pain, chronic knee pain, depression, normal. Rectal examination revealed normal
0361–803X/10/1953–550 temporomandibular joint (TMJ) syndrome, rectal tone. MRI revealed a disk extrusion
and carpal tunnel syndrome. Her past surgi- at L2–L3 with moderate central canal com-
© American Roentgen Ray Society cal history is notable for TMJ surgery. Her pression and nerve root crowding (Fig. 1).
A B C
Background and Importance management. The focus of this article is to lignancies among patients seen in a primary
Low back pain (LBP) is one of the most further explore the appropriate use of MRI in care clinic. They reported that MRI cost 10
common causes of physician visits in the the management of patients with LBP. times as much as the conventional strategy
United States [1], with a huge socioeconomic ($50,000 vs $5,000), and the cost of finding
burden. In 2005, just the direct medical costs The Imaging Question each extra patient with a spine malignancy in
of care for LBP exceeded $86 billion [2]. Be- Why is MRI not used as the routine ini- MRI group exceeded $625,000 [19].
cause of this burden, numerous studies have tial test for patients with LBP? Related ques- Another problem with MRI is the high
focused on the diagnosis and management tions concern which patients should get MRI prevalence of abnormal findings among in-
of LBP. New technologies have been quick- without radiography and the importance of dividuals without LBP [20–34]. This high
ly adopted with the hope that they will im- the spinal stenosis and disk protrusion iden- prevalence makes it difficult, or possibly
prove our understanding of the physiopathol- tified on the MRI. With its high contrast and even perilous, to attribute a patient’s symp-
ogy of the disease and assist us in managing spatial resolution and lack of ionizing radia- toms to certain imaging findings. Moreover,
patients’ pain and discomfort. Unfortunately, tion, MRI is considered by many to be the irrelevant findings can result in emotion-
previous studies have not been able to show best imaging technique for the investigation al stress, utilization of unnecessary down-
that higher utilization of advanced imaging of LBP [7]. Yet MRI also has limitations and stream resources and even unnecessary
technology is associated with improvements drawbacks. We review these next. interventions, such as surgery. Deyo and col-
in patient outcome [3, 4]. Several randomized clinical trials have leagues [35] showed a higher rate of spinal
The rationale for advanced imaging is shown that among patients without red surgeries for LBP in states with a higher uti-
frequently to identify rare but high-conse- flags—clinical signs and symptoms indicat- lization rate of advanced imaging technolo-
quence conditions, such as metastases or in- ing serious underlying conditions (Tables gy. However, this higher utilization rate was
fection. However, in the primary care popu- 1 and 2)—early imaging (vs conservative not associated with better patient outcome in
lation, fewer than 1% of all LBP patients have treatment without imaging) does not im- these states [35].
these conditions [5]. Therefore, the question prove patient outcomes [3, 8, 11–18].
remains how best to balance the high cost of MRI is expensive. A frequent motivation Synopsis and Synthesis of Evidence
procedures such as CT and MRI with their for obtaining imaging in the primary care We have summarized the value of MRI for
limited value in diagnosis and treatment of setting is to exclude an underlying malig- patients with LBP with various spine conditions.
LBP patients. nancy as the cause of LBP. Joines and col-
Figure 2 summarizes the results of the leagues [19] compared the cost-effectiveness Nonspecific or Idiopathic LBP
most recent evidence-based LBP guidelines of MRI compared with a conventional can- Approximately 70% of acute LBP patients
[6–10]. Without red flags in the history or cer screening program using history, physi- can attribute their pain to spinal muscle strain or
physical examination, conservative care cal examination, erythrocyte sedimentation sprain [5]. These patients are, in general, young-
with patient education is the first step in pain rate, and radiography for detecting spine ma- er and have no clinical red flags. Under these
(No red flag) spinal stenosis (Suspicion for serious spine problems)
No Yes
No improvement, signs
No improvement, no signs
and symptoms of severe
Improvement in or symptoms of
radiculopathy or spinal
patient pain radiculopathy Treat
stenosis (back or leg pain
or spinal stenosis accordingly
relieved by sitting)
Fig. 2—Flowchart shows clinical practice guideline for management of low back pain [7].
circumstances, MRI should not be performed edges of the base in the same plane.” If in T2-weighted images show good contrast be-
within the first 4–8 weeks of symptoms. any plane the greatest distance between the tween the outer part of the annulus, which
edges of the disk goes beyond the distance is more fibrous tissue (low signal), and in-
Disk Degeneration: Herniation, Bulges, between the edges of the base, the lesion is ner part of the annulus and nucleus pulposus,
Protrusions, and Extrusions called “extrusion” [36] (Fig. 3). In practical which have more water content (high signal)
The Combined Task Forces of the North terms, if the herniated disk material has a [38]. An area of low-intensity signal may be
American Spine Society, American Society neck, it is an extrusion. visible in the middle of the nucleus pulpo-
of Spine Radiology, and American Society T1- and T2-weighted sagittal and axial sus in a nondegenerated disk [37, 38]. This
of Neuroradiology have defined herniated MR images can clearly visualize the verte- is considered a normal observation and most
disk as a “localized displacement of nucle- bral endplates and intervertebral disks [37]. commonly is visible in younger individuals.
us, cartilage, fragmented apophyseal bone,
or fragmented annular tissue beyond the in- TABLE 1: Key Features in History and Physical Examination of Patients With
tervertebral disc space” [36]. A bulging disk Low Back Pain (LBP)
is not considered a herniated disk and is de- Possible Findings in Physical
fined as the presence of disk tissue diffusely Underlying Cause Key Features in History Examination
(> 50% of the circumference) extending be- Idiopathic Usually none; sometimes attributed to Vague spinal pain with or without
yond the edges of the ring apophyses. This trauma paraspinal muscle spasm
bulging can be symmetric or asymmetric
Extruded disk Radicular pain, usually in distribution Positive straight leg raise test; problem
[36] (Fig. 3). of L4, L5, or S1 nerve root in walking on the heel (L4–L5 disk
Herniations are subdivided into protru- herniation) or on the toes (L5–S1 disk
sion and extrusions. As defined by the Com- herniation)
bined Task Forces, a “protrusion is present Spinal stenosis LBP or radicular pain that increases Numbness, vibration deficit, abnormal
if the greatest distance in any plane between with walking and improves with Romberg test
the edges of the disc material beyond the disc seating and flexion of the spine in
older individuals
space is less than the distance between the
TABLE 2: Potential Red Flags in History and Physical Examination of Patients with Low Back Pain
Underlying Cause Key Features in History Possible Findings in Physical Examination
Possible malignancy Older adults, gradual increase in pain, history of cancer, Cachectic appearance; signs and symptoms related to
unintentional weight loss, no relief with bed rest or conserva- the underlying malignancy
tive therapy, > 1 mo of pain
Possible infection History of IV drug use; recent immigration to the United States Fever, malaise, spinal tenderness to percussion
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It probably represents a higher concentration ally consisting of an expert consensus panel ported a significant association between leg
of proteoglycans causing signal loss on T2- using an amalgam of various data depending pain (not back pain) measured by a visual an-
weighted images [37, 38]. on availability, including clinical information, alog scale (VAS) and abnormal MRI findings.
Intervertebral disks likely degenerate be- other diagnostic testing such as myelography, VAS is a psychometric tool that measures sub-
cause of reduction in oxygen and nutrient sup- and surgical findings [10]. The lower specific- jective characteristics that cannot be directly
ply due to the normal aging process, trauma, ity of MRI can be attributed to the high prev- evaluated or measured [47]. In the study by
and so on [37, 39, 40]. Vertebral endplates alence of degeneration (46–93%) and protru- Porchet et al., each additional centimeter on
play a key role in providing the nutrients to in- sions (20–80%) in asymptomatic adults [45]. the VAS scale was associated with 10% low-
tervertebral disks. As a result, it is conceivable The wide range of prevalence may be partial- er odds of observing severe disk degeneration.
that changes in endplates occur at the same ly explained by differences in age groups and In spite of this, studies often were not able to
time or even before disk degeneration. Mod- definition of herniation. identify any MRI abnormality associated with
ic et al. [41] described three types of endplate Several studies have attempted to evalu- pain for most LBP patients [31].
changes. Type 1 is low signal on T1-weighted ate the correlation between MRI findings and It has been suggested that disk morphology
images and high signal on T2-weighted im- symptoms. Porchet and colleagues [46] re- is associated with symptoms and as a result
ages and likely represents endplate edema.
Type 2 is high signal on T1-weighted images
and on T2 fast spin-echo images but is dark A Disk B Disk
on fat-suppressed sequences and likely rep-
resents fat. Type 3 is low signal on both T1-
and T2-weighted sequences and represents
endplate sclerosis. These endplate changes Superior endplate Superior endplate
are commonly referred to as “Modic” chang-
es [41]. Some researchers have suggested that
type 1 endplate changes are painful [42, 43].
For example, Kuisma and colleagues [43] re- Symmetrical Bulging Disk Asymmetrical Bulging Disk
ported significant association between Modic
type 1 changes and the frequency and inten-
sity of LBP among 228 middle-age Finnish C D
workers. However, some other studies dispute
these findings. In a study by Mitra and Harlin
[44], 44 patients with 48 Modic type 1 chang- Superior endplate Superior endplate
es were followed for 12–72 months. These au-
thors were not able to detect any statistically Disk Disk
significant association between Modic type 1
changes and patients’ symptoms.
MRI is the method of choice for the evalu-
ation of disk morphology [7] because of the Protrusion Extrusion
good sensitivity (60–100%) and specificity
(43–97%) for disk herniations (both protru- Fig. 3—Schematic shows different disk morphologies [36].
sions and extrusion) [10]. In this case, a posi- A, Symmetric bulging disk.
B, Asymmetric bulging disk.
tive test was the presence of either a protrusion C, Protrusion.
or extrusion with the reference standard usu- D, Extrusion.
should influence pain management [48, 49]. MRI allows physicians to diagnose infection and facet joints might also become involved
Although bulging disks and protrusions are early before bone destruction becomes visi- [69]. Similar to other causes of inflamma-
common and poorly correlated with symp- ble on radiographs or even CT. Because MRI tion, ankylosing spondylitis leads to low-
toms, extrusions are rare in asymptomatic pa- shows the extent of the disease and soft-tis- intensity signals on T1-weighted and high-
tients (1–5% prevalence) and may be a good sue involvement, especially epidural extent, intensity signals on STIR or fat-suppressed
predictor of response to treatment and patient it is considered critical before surgical inter- T2-weighted images [67].
outcome [10]. vention [63]. MRI has also been used in evaluation of
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The vertebral inflammation and edema the response to antitumor necrosis factor
Central Canal Stenosis in early stages of the disease are identifi- therapy [67]. However, in spite of the wide-
Spinal stenosis can occur for various rea- able as low-intensity signal on T1-weight- spread use of MRI in the management of in-
sons, such as congenital spine abnormalities ed and high-intensity signal on T2-weight- flammatory spine diseases, no robust study
and disk herniation, but classically consists ed fat-suppressed images [38, 61]. In more has evaluated the value of MRI in the man-
of the triad of disk bulge with facet hypertro- advanced stages of the disease, fibrosis and agement of spondyloarthropathies [67].
phy and hypertrophy of the ligamentum fla- sclerosis lead to lower signal and fatty chang-
vum. In general, MRI is considered the best es of vertebral body and thus higher intensity Metastases
approach for the workup of spinal stenosis signal on T1-weighted images [64]. MRI is the best approach for evaluation of
[50–52]. The reported sensitivity and spec- Contrast-enhanced MRI improves detection spine metastases because its high soft-tissue
ificity of MRI for the diagnosis of spinal of intravertebral, paravertebral, and epidural contrast results in excellent sensitivity [70–
stenosis varies from 77% to 90% and 72% to abscesses [61] by enhancing the margin of the 75]. The reported sensitivity of MRI varies
100%, respectively, with the reference stan- abscess, whereas the central portion of abscess from 83% to 100% and the estimated speci-
dard in these studies consisting of either sur- remains unenhanced. This increased conspicu- ficity is 92%, using biopsy or clinical follow-
gical findings or adequate clinical follow-up ity is especially important with epidural exten- up as the index standard [71–74, 76].
[51, 53–55]. sion [65]. In spite of the anecdotal importance Spinal metastases can be intramedullary,
T1-weighted images can clearly visualize of contrast-enhanced MRI, no study has evalu- extramedullary–intradural, or extradural.
stenosis and provide valid information re- ated the value of contrast administration with T2-weighted MR images show intramedul-
garding the underlying cause of stenosis [56]. respect to patient outcomes in the diagnosis lary lesions as areas with high-intensity sig-
In the case of spondylolisthesis, spinal steno- and management of spinal infection. nals that enhance with contrast administra-
sis is better visualized on sagittal T1-weight- MRI has a few limitations in the evalua- tion [38]. T1-weighted images with contrast
ed images [38]. Long-term spinal stenosis at tion of spinal infections. First, in a fully de- administration and fat-suppression can be
the level of the conus can result in myelopa- veloped infection, two adjacent vertebrae and used to visualize extramedullary–intradural
thy. This generally results in high intramed- the intervening disk are usually involved. or extradural metastasis.
ullary signal intensity on T2-weighted imag- However, in the early stages of disease, in-
es that may enhance with gadolinium [56]. volvement of both vertebrae might not be Compression Fractures
Because pain often is worse in the loaded visible [64]. Second, surgical interventions Spinal compression fractures mostly oc-
spine or in certain positions such as flexion can distort the normal spinal anatomy, mak- cur in older women with osteoporosis, with
[57, 58], it is plausible that supine MRI would ing it difficult to interpret postsurgical im- or without any identifiable trauma. CT, espe-
be less sensitive than upright MRI. In dynam- ages [59]. Finally, there is limited evidence cially MDCT, is the method of choice in the
ic MRI, patients are usually positioned up- regarding the value of follow-up MRI of pa- evaluation of bony structures. However, MRI
right or in flexion or extension status to mimic tients with spinal infection [59]. is the best technique to investigate marrow
those circumstances in which the spinal canal In spite of successful treatment, MRI find- edema and soft tissues, including spinal cord
has the least diameter and, as a result, impose ings often lag, showing a worsening appear- and ligaments [77–80].
the most amount of pressure on spinal nerves ance for several weeks or months [65]. Prob- Sagittal T1-weighted, T2*-weighted, and
[58]. Alyas and colleagues [58] used upright ably the most valuable imaging findings to STIR sequences are usually used for diagno-
MRI and reported smaller central canal sizes monitor treatment are decreasing bone marrow sis of traumatic injuries. MRI clearly depicts
when the spine was loaded. However, no rig- edema and decreasing contrast uptake [65]. cord compression due to displaced bone or
orous study has evaluated the accuracy of up- disk. MRI also clearly shows bone marrow
right and dynamic MRI. In addition, there is Ankylosing Spondylitis edema, helping to identify which fractures
no evidence that the use of such technology Although radiography remains the initial are acute. Edema is better visible in the sag-
improves patient outcome. imaging technique for patients with ankylos- ittal plane using fat-suppressed T2-weighted
ing spondylitis, MRI is the method of choice or STIR sequences [81].
Infection for subsequent evaluations of the spine [66– Other potential findings that could indi-
MRI is the method of choice for evalua- 68], with sensitivity of 25–85% and specific- cate acute versus chronic fracture are para-
tion of spinal infections [59–61], with sen- ity of 90–100% using a combination of clini- vertebral hemorrhage and spinal cord ede-
sitivity of 96% and specificity of 92%, using cal, laboratory, and follow-up of up to 1 year ma. These can be clearly visualized on
final clinical, histologic, and microbiologic as the index standard [63]. Spinal inflamma- T2-weighted MR images [77, 79].
information as the reference standard [62]. tion is more visible at the corners of verte- Finally, MRI findings can be used to dif-
Fat suppression and gadolinium administra- bral bodies (which lead to Romanus lesions) ferentiate between malignant versus benign
tion are important techniques to use [59–61]. or endplates, although spinous processes vertebral fractures. The presence of each one
of the following findings could indicate spi- [10] revised the AHCPR guidelines and pub- cost of the imaging test (e.g., cost of MRI
nal metastasis: vertebral body expansion with lished an updated algorithm for the diagnos- without contrast administration), downstream
a convex posterior border, abnormal signal tic evaluation of LBP. Later on, the European costs related to the diagnostic test, and the
completely replacing normal marrow and ex- Commission, Research Directorate-Gener- monetary or nonmonetary value of the out-
tending into the posterior elements, and pres- al, Department of Policy, Coordination, and comes of interest (e.g., the monetary value of
ence of a paraspinal mass [77]. In contrast, Strategy [6] and most recently the American reducing the length of hospital stay).
low-signal bands in the vertebral bodies on College of Physicians and the American Pain To these methodologic challenges, we add
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T1- and T2-weighted images, normal bone Society published LBP management guide- potential problems regarding assessment of
marrow appearance, and presence of sever- lines based on the most recent publications new technologies by the Food and Drug Ad-
al compression fractures are more in support [7]. In spite of substantial advancements in ministration (FDA) [91–95]. The FDA is re-
of benign osteoporotic compression fractures technology during the past two decades, the sponsible for both safety and effectiveness of
[77, 82]. Zajick et al. [83] described the use of main conclusions of all these guidelines are new technologies, including imaging devic-
in-phase/out-of-phase imaging to distinguish practically the same. All of the guidelines es. However, conducting well-designed, con-
benign from malignant fractures. They found emphasize the importance of a focused histo- trolled trials that evaluate the effectiveness of
that benign fractures had signal suppression ry and thorough physical examination before these diagnostic interventions requires large
of at least 20% on the out-of-phase compared any imaging is ordered. In addition, all agree numbers of patients, often using multiple in-
with the in-phase images, whereas malignant that for patients with acute LBP and without stitutions. An ongoing challenge is the mov-
fractures did not (sensitivity and specificity, any risk factor for serious spine abnormali- ing-target problem: by the time the study is
95%), using clinical criteria and other MRI ties, imaging within the initial 4–8 weeks finished, the evaluated technology is replaced
sequences to establish the index standard of should not be performed. either with a new generation of the same tech-
metastatic disease [83]. nology or with a more advanced technique
Although there are several published re- Outstanding Issues That [95]. Because of the size of the industry and
ports of newer MRI techniques, such as diffu- Warrant Research rapidly evolving new technologies, the FDA
sion-weighted MRI (DWI) and MR spectros- Economic Analysis of New Imaging Techniques has mainly focused on safety, adopting an en-
copy (MRS) for distinguishing benign from Although new technologies have been gineering approach rather than also consider-
malignant compression fractures [84–87], no quickly adopted for the management of LBP, ing the broader effectiveness of the new tech-
published reports have shown the influence limited attention has been paid to the cost- niques and not at all addressing costs [95]. In
of these new techniques on patient outcome. effectiveness of these new techniques [3, 19, addition, the FDA categorizes most imaging
For example, Baur and colleagues [86] used 89]. This issue is of paramount importance, techniques as low-risk technologies (class I
DWI to differentiate 22 benign from 17 ma- especially now that the health care system or II) that are not associated with significant
lignant compression fractures. They found is expecting a substantial overhaul. The fol- risks for human beings [94, 95]. As a result
that benign compression fractures were hypo- lowing might partially explain the scarcity of of this classification, companies are not re-
to isointense relative to normal adjacent ver- these studies. quired to provide intense premarket evidence
tebra, whereas malignant lesions were hyper- First, to perform a cost-effectiveness analy- regarding the effectiveness of their products.
intense. However, the authors were not able to sis, researchers should be able to confidently This issue leads to a lack of incentive for the
detect any statistically significant difference estimate the effectiveness of an intervention conduction of robust, controlled effectiveness
in bone marrow contrast ratios between be- (in this case, new imaging technology). De- evaluations [95].
nign and malignant lesions [86]. In a more re- fining the effectiveness of a diagnostic test is Many believe that the coverage of new im-
cent study, Oztekin and colleagues [85] eval- less straightforward than a therapeutic inter- aging techniques by payers is the best moti-
uated the validity of single-shot echo-planar vention. Fryback and Thornbury [90] defined vation for performing cost-effective analysis
DWI with a low b value for the same purpose. a hierarchic model of diagnostic test efficacy. [93]. However, insurance companies might or
A total of 64 lesions (27 benign and 37 malig- Depending on the purpose of the evaluation, might not use this sort of information. For ex-
nant) with low-intensity signal on T1-weight- efficacy or effectiveness can be defined in ample, the Centers for Medicare and Medic-
ed images were investigated using the single- terms of diagnostic accuracy, impact on diag- aid Services (CMS) does not and cannot use
shot echo-planar DWI method. All malignant nostic decision making, impact on therapeutic cost-effectiveness information in its coverage
lesions (except two sclerotic metastases) decision making, or patient outcome. decisions of new technologies [93]. Although
showed hyperintense signals relative to nor- Unfortunately, studies that focus on the di- other payers are not similarly constrained, as
mal bone marrow. Twenty-three of 27 benign agnostic accuracy of new lumbar spine imag- the largest payer in the United States, where
lesions had isointense signals relative to adja- ing technologies often do not compare their CMS leads, others follow [95].
cent normal bone marrow [85]. findings with a reference standard. As a result,
comparing different imaging techniques, and Other MRI-Based Imaging Techniques
Evidence-Based Guidelines even different studies evaluating the same im- That Require Further Research
In 1994, for the first time, the Agency for aging technique, is often difficult. In addition, MR spectroscopy—Although MRI exqui-
Health Care Policy and Research (AHCPR) as noted earlier, researchers frequently use sitely shows tissue anatomy, MRS is a non-
published a set of guidelines to assist physi- different outcomes, which makes the compar- invasive tool that evaluates function by mea-
cians in the management of LBP less than 3 ison even more cumbersome. suring the level of various tissue metabolites
months in duration [88]. Using an evidence- The second hurdle is the lack of robust fi- [96–102]. MRS has been extensively used for
based medicine approach, Jarvik and Deyo nancial information. This includes the true the diagnosis of brain tumors [96, 97, 100,
102, 103]. However, recently its use has been few studies have compared MR neurography domized controlled trial. JAMA 2003; 289:2810–
expanded to other health conditions, such as with nerve electrodiagnostic studies [123– 2818
prostate and breast malignancies, multiple 126]. These studies have shown that MR 4. Deyo RA, Mirza SK. The case for restraint in
sclerosis, epilepsy, and even traumatic brain neurography has a comparable sensitivity spinal surgery: does quality management have a
injuries [96, 99, 102]. Although no study has and specificity with electrodiagnostic studies role to play? Eur Spine J 2009; 18[suppl 3]:331–
rigorously investigated the potential role of in the diagnosis of ulnar and median nerve 337
MRS in LBP management, some exploratory entrapment [123, 124]. 5. Deyo RA, Weinstein JN. Low back pain. N Engl
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studies have been conducted, looking at disk MR neurography has also been used in J Med 2001; 344:363–370
degeneration [104] and marrow fat content as evaluation of non-disc-related sciatica. Es- 6. Airaksinen O, Brox JI, Cedraschi C, et al. Chap-
a risk factor for fracture [105] and the evalu- pecially among those who do not respond to ter 4: European guidelines for the management
ation of possible metastasis [106]. It is con- surgical interventions, visualization of the of chronic nonspecific low back pain. Eur Spine
ceivable that MRS could be a valuable tool, nerve by MR neurography can provide valu- J 2006; 15[suppl 2]:S192–S300
but this technique should be considered ex- able information regarding the factors that 7. Chou R, Qaseem A, Snow V, et al. Diagnosis and
ploratory for the time being. might have resulted in surgery failure. As a treatment of low back pain: a joint clinical prac-
Diffusion-weighted MRI—DWI is anoth- result, MR neurography may have an adjunc- tice guideline from the American College of
er noninvasive MRI-based technique that tive role to electrodiagnostic testing [127]. Physicians and the American Pain Society. Ann
was first developed for the diagnosis of acute In spite of the potentially valuable infor- Intern Med 2007; 147:478–491
brain ischemia [107–110]. In this approach, mation that MR neurography can provide, 8. Chou R, Fu RW, Carrino JA, et al. Imaging strat-
microscopic and random movements of wa- there is limited information on the validity egies for low-back pain: systematic review and
ter molecules within tissues are used to cre- of this method in LBP management. Simi- meta-analysis. Lancet 2009; 373:463–472
ate images with very high tissue contrast lar to most other MRI-based investigations, 9. Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical
[107–109]. studies suffer from lack of comparison with interventional therapies for low back pain: a re-
Recently, DWI has been adopted for detec- a current reference standard for diagnosis. view of the evidence for an American Pain Soci-
tion of different musculoskeletal abnormali- More important, the associations between ety clinical practice guideline. Spine (Phila Pa
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tion of the response to treatment in tumors, have not been well established. 10. Jarvik JG, Deyo RA. Diagnostic evaluation of
such as osteosarcoma, that in general do not low back pain with emphasis on imaging. Ann
shrink in response to treatment. Under these Summary Intern Med 2002; 137:586–597
circumstances, detection of necrosis with MRI and other MRI-based imaging tech- 11. Gilbert FJ, Grant AM, Gillan MG, et al. Does
DWI within the tumor may be a valid indi- niques provide valuable information regard- early imaging influence management and im-
cator of response to treatment and is associ- ing the underlying causes of LBP. However, prove outcome in patients with low back pain? A
ated with better outcome [111]. The decrease because of several factors that have been ad- pragmatic randomised controlled trial. Health
in DWI signal of a tumor is another indicator dressed in this article, utilization should be Technol Assess 2004; 8:iii, 1–131
that treatment has been effective. This can limited to those patients who are most like- 12. Gilbert FJ, Grant AM, Gillan MG, et al. Low
be seen in primary bone sarcomas and also ly to benefit from these tests. In addition, to back pain: influence of early MR imaging or CT
spine metastasis [112, 113]. be able to evaluate the effectiveness and ef- on treatment and outcome—multicenter ran-
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