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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 43–48 DOI 10.3233/BMR-140488 IOS Press

Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic Ulf Gunther Leichtlea, Markus Wünschela,∗, Marianna Soccia, Christophe Kurzea , Thomas Niemeyerb and Carmen Ina Leichtlea a

b

University Hospital Tübingen, Tübingen, Germany Department of Spine Surgery, Asklepios Hospital St. Georg, Hamburg, Germany

Abstract. BACKGROUND AND OBJECTIVES: Despite the recommendations of national and international societies for the treatment of patients with acute neck and back pain, still too many radiologic examinations were performed. The purpose of this study was to analyze and optimize diagnostics and treatment of patients with acute back pain. METHODS: The medical records of 484 patients presented to the emergency clinic with acute neck or back pain were analyzed for clinical history, physical examination, radiographic findings and therapy. RESULTS: Radiographs of the lumbar, cervical, or thoracic spine were performed in 338 cases (70%). Radiographs were normal in 142 patients (42%) and degenerative changes were identified in 123 patients (36%). Only 2 patients (0.4%) had radiographic findings that had direct therapeutic relevance: 1 patient with metastatic disease and 1 patient with posttraumatic C1-C2 instability. For most patients without sensorimotor deficits and absent specific indications for radiography (“red flags”), therapy was not affected by the results of radiography. CONCLUSIONS: Plain radiography of the spine was unnecessary in most patients initially evaluated with non-specific acute back pain and does not improve the clinical outcome. The implementation of national and international guidelines is a slow process, but helps to reduce costs and to protect patients from unnecessary ionizing radiation exposure. Keywords: Low back pain, x-ray, red flags, spine radiographs

1. Introduction Back pain is one of the most common symptoms of outpatients evaluated in orthopaedic departments. Epidemiologic data show that 15% to 20% adults report back pain during each year, and the lifetime prevalence of back pain is 50% to 80% [1]. Treatment of these patients is associated with high costs, with a significant proportion resulting from diagnostic imaging. It is widely accepted that unless “red flags” are present ∗ Corresponding author: Markus Wünschel, Department of Orthopaedic Surgery, University Hospital Tübingen, Hoppe-SeylerStr.3, D-72076 Tuebingen, Germany. Tel.: +49 7071/29 8 66 92; Fax: +49 7071/29 4091; E-mail: [email protected].

in the acute treatment of low back pain no radiological imaging is necessary [2–4]. In this context, we can find slogans such as “Less is more” and “Don’t do imaging for low back pain within the first 6 weeks unless red flags are present” [2]. In the 2011 national German guideline it was concluded that in acute nonspecific low back pain, diagnostic imaging is not indicated and should be avoided [4]. But the process to implement this knowledge in clinical practice is slow and laborious. Despite the recommendations of various national and international associations, many patients still receive radiographic examinations in primary evaluation. In treatment of patients with acute neck and back pain it is very important to differentiate between a non-

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U.G. Leichtle et al. / Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic

specific back pain and a serious underlying disease. Within this context “red flags” were defined to help the physician to decide in which cases a radiologic examination is necessary. “Red flags” are: adequate trauma, known osteoporosis, systemic steroid medication, immunosuppression, drug abuse, poor general health, nausea, tumor, history of cancer, fever, unexplained weight loss, severe neurological symptoms (cauda equina-syndrome), structural abnormalities, increasing or persistent pain, chest pain, age < 20 or > 55 years [5]. Regarding the definition of these “red flags”, there are minor differences between the various international associations [4,5]. In clinical practice a premature radiographic examination of the spine may often be ordered because of nonspecific clinical findings and limited experience of the physician. Although the radiographic examination may confirm the clinical diagnosis, often the radiographs contribute to a diagnosis that is not relevant to treatment, and the patient is exposed to unnecessary radiation [6]. Especially at maximum care hospitals with extensive diagnostic facilities the physician is tempted to do further and often unnecessary examinations. We hypothesized therefore that in the evaluation of patients with neck and back pain in the orthopaedic emergency clinic, radiographic examinations of the spine often are obtained unnecessarily and do not influence the subsequent therapy. The purpose of this study was to optimize the medical and economic aspects of treating patients presenting themselves to the orthopaedic on-call physician of our university hospital because of acute or acutely exacerbated neck and back pain. We evaluated how frequently a radiographic investigation had been initiated; the radiographic diagnoses; and whether the findings of plain radiography influenced subsequent therapy.

2. Materials and methods 2.1. Subjects This was a retrospective study of patients evaluated and treated for neck or back pain (cervical, thoracic, and lumbar). During a 32-month period, 2075 patients were evaluated and treated in the orthopaedic emergency clinic of the Orthopaedic University Clinic. All patients with acute pain, or acute exacerbation of chronic pain, in the cervical, thoracic, or lumbar back regions were included in the study. There were 484 patients (23%) who met these criteria and were enrolled

in the study. The ratio of female to male patients was 1.3:1, and most patients were treated for lumbar back pain (Table 1). 2.2. Evaluation The medical records of all patients were analyzed and data were collected using a standardized survey. Data about medical history included age, sex, time of presentation, duration of time, the causal event resulting in back pain, and other present and past medical conditions. Details about the pain were recorded, including location, radiation of the pain, and neurologic deficits. Physical examination findings were documented, including palpation and percussion of the spine, functional testing, nerve stretch test, and range of motion. The indications noted by the examining physician for radiography, type and quantity of radiographs, and radiographic findings were recorded. The radiographic studies included anteroposterior and lateral views of the affected spinal region and, when clinically indicated, functional images or oblique views were included. Any additional diagnostic imaging was documented including magnetic resonance imaging (MRI) or computed tomography (CT) scans. Treatment for the back pain was documented, including type of non-operative treatment (such as analgesic medication, muscle relaxant medication, physical therapy, heat therapy, or manual therapy), hospitalization, or surgical treatment. 2.3. Data analysis Statistical evaluation of outcomes was performed using the t test for normally distributed data. In the absence of normal distribution, the Wilcoxon rank sum test was used. Frequency differences in groups with nominal or ordinal variables were evaluated with the chi-square test (χ2 test). Comparison of groups with metric variables was performed with analysis of variance (ANOVA). Statistical significance was defined by P  0.05.

3. Results Most patients were between 30 and 50 years of age, and patients with lumbar pain were significantly older than those with cervical or thoracic pain (Table 1). There were significantly more female than male pa-

U.G. Leichtle et al. / Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic

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Table 1 Clinical features of patients with back pain evaluated in orthopaedic emergency clinic∗ Clinical feature Age (y) Sex Male Female Total Duration of symptoms (d)|| Symptoms and signs Acute pain Painful muscle tension Knock and pressure pain Radiation of pain Chronic pain exacerbation Physical findings Positive Lasègue test Neurologic deficit Sensory disturbance Paralysis

Cervical 36 ± 11 (15 to 69)

Thoracic 37 ± 15 (19 to 81)

Lumbar 43 ± 16 (11 to 95)†

Total 41 ± 15 (11 to 95)

30 (28%) 78 (72%)‡ 108 2.7

25 (51%) 24 (49%) 49 3.4

152 (46%) 175 (54%) 327 3.4

207 (43%) 277 (57%) 484 3.3

94/108 (87%) 68/75 (91%) 46/65 (71%) 49/108 (45%) 14/108 (13%)

48/49 (98%) 27/31 (87%) 31/50 (62%) 12/49 (24%) 1/49 (2%)

265/327 (81%) 110/139 (79%) 195/267 (73%) 148/327 (46%) 62/327 (19%)

408/484 (84%) 205/245 (84%) 272/372 (73%) 212/484 (44%) 76/484 (16%)

NA § 15/108 (14%) 15/108 (14%) 1/108 (1%)

NA 1/49 (2%) 1/49 (2%) 0/49 (0%)

59/267 (22%) 51/327 (16%) 50/327 (16%) 8/327 (2.5%)

59/267 (22%) 67/484 (14%) 59/484 (12%) 9/484 (2%)

∗ Data

reported as average ± SD; number patients (%); or number patients/total number patients (%); † Age: difference between patients with lumbar pain and thoracic or cervical pain, P < 0.0001; ‡ Cervical pain: difference between female and male patients, P < 0.0004; || Time between onset of pain and presentation for evaluation; difference between cervical, thoracic, and lumbar pain: not significant (P > 0.05); §NA, not applicable.

tients evaluated for cervical spine pain, but there were similar numbers of female and male patients evaluated for thoracic and lumbar back pain (Table 1). Duration of symptoms (time from onset of pain to the initial presentation to the doctor) was similar for cervical, thoracic, and lumbar pain (Table 1). The most frequent symptoms included acute pain, painful muscle tension, and knock and pressure pain (Table 1). The most common physical finding was a positive Lasègue test in patients with lumbar back pain (Table 1), and there were no patients with abnormal bowel or bladder signs. In 80% (386) of the treated patients the examining physician ordered a radiographic examination of the cervical, thoracic or lumbar spine. In 338 cases (70%) the radiographic examination was performed, while 48 patients (10%) refused the investigation. In six patients radiologic examination was contraindicated because of pregnancy. Only in 19% (92) of patients no indication for a radiolographic examination was identified by the examining physician, while 8 patients had previous images (Fig. 1). There was no significant correlation between the indications for radiographic examination and the pain localization. The most common radiographic findings in the cervical region were normal radiographs, hypolordosis, and osteochondrosis; the most common findings in the thoracic region were normal radiographs, scoliosis, and degenerative changes; and the most common findings in the lumbar region were osteochondrosis, normal radiographs, spondylolisthesis/instability, and scoliosis (Fig. 1).

Further diagnostic imaging was performed based on the clinical and radiographic findings in 37 patients (21 MRI and 16 CT scans). Findings from these scans included a herniated disc in 23 patients, spondylolisthesis in 2 patients, posttraumatic C1/C2 instability in 1 patient and spinal stenosis in 1 patient. The remaining 10 scans were interpreted as normal. Further oncologic diagnostic and therapeutic measures were initiated for a patient with a suspected metastatic destruction of C7. Most patients were treated non-operatively as outpatients, and the most common treatments included analgesic drugs, heat treatment, physiotherapy, and muscle relaxant drugs (Table 2). For all patients who were treated non-operatively as outpatients, the plain radiographs made during the initial treatment did not have any effect on therapy. Most patients admitted to hospital had lumbar back pain associated with radicular symptoms, and many of these patients had neurologic deficit (Table 2). In all patients admitted to hospital, the decision for hospital admission was made on the basis of clinical presentation, and imaging did not have any effect on the decision for hospital admission. Most inpatients were treated non-operatively (Table 2), and only 7 inpatients had surgery (open discectomy in 5 patients and decompression in 2 patients). The decision to recommend surgery was based on the correlation of clinical findings with the MRI or CT scans, and the initial plain radiography was of secondary importance. In only 2 of the 484 patients (0.4%), the ini-

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U.G. Leichtle et al. / Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic Region:

Radiographic findings:

77 x cervical spine:

- 29x Normal - 27x Hypolordosis - 16x Osteochondrosis - 2x Synostosis - 1x Spondylolisthesis - 1x Metastatic osteolysis - 1x Instability C1/C2

31 x thoracic spine:

- 20x Normal - 6x Scoliosis/Kyphosis - 4x Degenerative changes - 1x Compression fracture

230 x lumbar spine:

- 93x Normal - 105x Osteochondrosis - 11x Spondylolisthesis/Instability - 10x Scoliosis - 7x Hypolordosis - 2x Bony malformation - 1x Baastrup disease - 1x fracture

Fig. 1. Ordering history of spine radiographs and radiographic findings in patients evaluated in orthopaedic emergency clinic for back pain (N = 484 patients). Table 2 Outpatient and inpatient treatment received by patients evaluated in orthopaedic emergency clinic for back pain∗

stabilization was initiated. Both patients had red flags in their history.

Number (%) patients Treatment (all patients)∗ Non-operative Analgesic drugs Heat treatment Physiotherapy Muscle relaxant drugs Manual therapy Surgery Treatment setting (all patients)∗ Outpatient (all non-operative) Inpatient (admitted to hospital) Inpatient data† Anatomic region Lumbar Cervical Thoracic Symptoms Radicular symptoms Neurologic deficit Treatment Non-operative Surgery‡

477 439 331 179 179 70 7

(99) (91) (68) (37) (37) (14) (1)

440 44

(91) (9)

38 5 1

(86) (11) (2)

34 26

(77) (59)

37 7

(84) (16)

∗ N = 484 patients; data reported as number of patients (% of all 484 patients); † Data for inpatients reported as number of patients (% of 44 inpatients); ‡ Surgery included open discectomy in 5 patients and decompression in 2 patients.

tial plain radiographs had direct therapeutic relevance: 1 patient with esophageal cancer in history and suspected metastatic destruction of C7 got further oncologic diagnostic and therapeutic measures and 1 patient with trauma history and a posttraumatic C1-C2 instability got an immobilization of the cervical spine and a CT scan for evaluation of a possible later operative

4. Discussion The present results reveal that initial radiography performed during the evaluation of back pain in the orthopedic emergency clinic, rarely influenced treatment, in support of the hypothesis that initial radiographic examination of the spine usually is unnecessary in this setting. Despite the fact that 70% of patients had radiographs (Fig. 1), only 0.4% patients had relevant radiographic findings that had direct therapeutic relevance. Radiographs are ordered in Germany at a frequency of 1.2 radiographic studies per resident per year, the highest within the European Union. Only half that frequency of radiographic studies are ordered in Sweden and Denmark, and a frequency of 0.96 radiographs per resident per year are ordered in the United States (2003 data). In Germany, 33% patients who are treated for acute back pain have radiographs at the first visit [7], much more frequently than 6% patients in the Netherlands, Switzerland, or Great Britain [7,8]. The frequency in our study (Fig. 1) exceeded these previous findings, possibly because of the limited experience of the resident physicians in the emergency clinic of this university hospital, a problem previously identified in another study [9]. Inexperienced resident physicians may have a lower threshold to order radiographs to minimize potential for missing a diagnosis. The extensive diagnostic facilities at maximum care hospitals may also influence the decision of the physician

U.G. Leichtle et al. / Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic

to order further radiological imaging. Another important issue from our point of view within this context is, that not only orthopedic and trauma surgeons, but also general practitioners, internists, and radiologists are involved in the treatment of patients with back pain. These different professional groups sometimes have a very different approach to the problem. Hospitals as well as practicing orthopedic surgeons normally have an x-ray machine, practicing internists or general practitioners do not typically have these options available. The frequency of patients treated for acute back pain as an emergency during nights or weekends was high (23%). However, the present patient population was comparable to other studies, with similar peak age (41 y) as in previous studies [10]. The greater frequency of cervical spine complaints in female than male patients (Table 1) also is consistent with previous studies [11–17]. Neurologic deficits in the present population (14%) (Table 1) were less frequent than in other studies (24% to 40%) [14,18,19], and none of the present patients had cauda equina syndrome, possibly because those patients usually are not referred to the orthopedic department, but to other departments at this university that include specialists in neurology and neurosurgery. A previous British study which examined primary care patients found a higher frequency of abnormal findings (5.7%) that required immediate treatment, including fractures (4.8%), tumors, and infections [17]. The lower frequency of radiographs that had direct therapeutic relevance in the present study (0.4%) may be attributed to referral patterns in the local emergency department, with trauma patients primarily treated by the Department of Trauma Surgery and not included in the present, orthopedic population. Many (42%) patients had normal radiographic studies (Fig. 1), and many others (36%) had only degenerative changes including osteochondrosis (Fig. 1). Degenerative changes on spinal radiographs rarely have direct therapeutic relevance for patients with acute back pain; in approximately 1 of 3 patients with acute back pain, no pathologic abnormalities may be noted on diagnostic radiographs, and more than 50% of patients have radiographic findings of degenerative changes [14,18,20]. In the current study pain medication or non-steroidal anti-inflammatory drugs were prescribed in 91% patients with back pain, and this frequently (37% of patients) was supplemented with muscle relaxant drugs. This is according to the guidelines a possible procedure, but taking into account the high rate of spon-

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Table 3 Specific indications for diagnostic radiology in patients with back pain (“red flags”)∗ − Age < 20 years or > 55 years − Adequate trauma − Increasing or persistent pain − Chest pain − Known osteoporosis − Systemic steroid medication − Immunosuppression, drug abuse − Poor general health − Nausea − History of cancer − Fever − Unexplained weight loss − Severe neurologic symptoms (cauda equina syndrome) − Structural abnormalities ∗ Adapted

from Rudwaleit (2004) [4].

taneous recovery, the indication for pain medication should be seen critically [4]. Furthermore, most patients in the present study received heat treatment (68%), and many received physiotherapy (37%) (Table 2), although physiotherapy, even in cases of acute low back pain has only limited utility. Future treatment of patients in this setting may include patient education, because a comprehensive patient education program about the excellent prognosis of acute nonspecific low back pain is important for a good healing process [21]. In the present study, surgery was performed only in seven patients. The indications for surgery were based on clinical symptoms, physical examination, and detailed cross-sectional imaging (MRI or CT). The plain radiographs were thereby of secondary importance for diagnosis. In the two patients for whom a direct therapeutic consequence was derived from the radiographs (One patient with bony metastasis and one patient with C1-C2 instability), the need for a radiographic study could have been derived from the patient history. Guidelines with specific indications for obtaining plain radiographs in patients with back pain (so-called “red flags”) have been proposed by the Agency for Health Care Policy and Research and can be used as decision criteria for performing radiographic examinations of the spine (Table 3) [5]. The present findings confirm that in cases of acute nonspecific back pain routine radiographic examination of the spine is unnecessary after careful history and clinical examination are performed. This is consistent with the findings of a meta-analysis of randomized controlled trials involving more than 1800 patients, that demonstrated that radiographs, MRI scans, or CT scans are not necessary in patients with low back pain

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without signs of serious underlying diseases, because these tests may not improve clinical outcome [21]. In conclusion the present study showed that despite various national and international guidelines for the treatment of patients with acute low back pain still too often radiographs were made without resulting in a therapeutical consequence in most patients. A thorough history and physical examination, considering specific indications for radiography (Table 3), may avoid unnecessary radiographs in most patients [4,5]. But the implementation of these guidelines in clinical practice is – particularly at large hospitals with their extensive diagnostic facilities – a slow and tedious process and requires regular training of the staff. Considering the high and rising number of back pain patients, the opportunity exists to not only to reduce costs but also to protect patients from unnecessary ionizing radiation exposure.

[6]

[7]

[8]

[9]

[10] [11] [12]

[13]

[14]

Conflict of interest The study has been carried out without any technical help and financial or other sponsorship by a commercial company. No commercial company was involved in the planning of the experiments, the data collection, the analyses and the interpretation of data.

[15]

[16]

[17]

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Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic.

Despite the recommendations of national and international societies for the treatment of patients with acute neck and back pain, still too many radiol...
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