Study: When Spine Images Don’t Match Symptoms
Researchers from the UK are stressing that there is no gold standard for diagnosis and the related indication for surgery in chronic lumbar back pain patients. Their study, “Predictability of the effects of facet joint infiltration in the degenerate lumbar spine when assessing MRI scans,” appears in the November 21, 2017 edition of the Journal of Orthopaedic Surgery and Research.
Ulf Krister Hofmann, M.D., orthopedic surgeon with University Hospital of Tübingen in Germany and co-author on the study, told OTW, “Due to advances in surgical techniques and perioperative management, spine surgery has seen great improvements over the past three decades. This is a blessing for many patients suffering from chronic lumbar back pain who in many cases today can be treated successfully by surgery.”
“The danger of being so successful with surgery is, that when your only tool available is a hammer, every problem tends to look a bit like a nail.”
“To identify patients who will actually benefit from surgery remains challenging. There are also many conditions that can manifest themselves as chronic lumbar back pain, and that can not be addressed by surgery, such as psychiatric disorders like depression, a nonspecific functional instead of a physical etiology, or referred pain from extraspinal causes (e.g., ovarian cyst, pancreatitis, ulcer).”
“In many patients, clinical history and symptoms and radiologic findings are conclusive, which makes the decision-making process easier. There are, however, also these patients where quite a discrepancy can be observed between their clinical presentation and the morphologic changes present in MRI or CT.”
“Like laboratory tests or histopathological findings, imaging results are often considered to be solid evidence by physicians and patients. The confidence in these imaging findings with respect to their ability to predict a painful condition appears however, somewhat anticipated given the available data in the literature.”
“In our centre of orthopaedic surgery we see many patients with a discrepancy between clinical and radiological findings.”
“It is in these patients that we additionally perform image-guided local analgesic or anti-inflammatory infiltrations at possible sites of pain generation to temporarily simulate the effect of surgery.”
“Such possible sites are, for example, the facet or sacroiliac joints, the epidural space, the deep back muscles, or the spinal nerves at their exit through the intervertebral foramen, as well as the hip as a differential diagnosis for chronic lumbar back pain.”
“From the achieved improvement reported by the patient, the specialist can draw further conclusions as to the cause of the patient’s symptoms. This allows to better identify patients who might and who might not benefit from surgery, and to define the actual scope of the planned surgery.”
“Reimbursement of these infiltrations can, however, be tedious since many insurance companies do not appreciate the diagnostic value of these procedures before surgery.”
“We, therefore, wanted to evaluate the ability of modern 3 tesla MRI to predict reported pain relief after facet joint infiltration in patients with chronic lumbar back pain. We hypothesized that, as pathological grading increased in MRI scans, pain alleviation would also increase after bilateral facet joint infiltration.”
“In our study we graded 50 MRI scans of patients with chronic lumbar back pain using a wide range of classification and measurement systems. The reported effect of facet joint injections at the site was recorded, and a comparative analysis performed.”
