Bone scintigraphy and radiography in young athletes with low back pain

Radiographs and bone scans of 40 young athletes with low back pain were reviewed retrospectively to correlate the imaging findings and assess the value of scintigraphy in the diagnosis of these patients. The radiographs were positive for spondylolysis with or without spondylolisthesis in 15 (38%), and scintigraphy showed focal disease in the posterior vertebral elements in 14 (35%). Five patients had positive radiographic studies but normal scans, indicating old injuries; four patients had positive scintigrams but normal radiographs, suggesting early or active injuries. The authors use radiography as the initial examination in the evaluation of patients with low back pain. Scintigraphy is most useful in early stages, when radiographs may be normal; and in cases in which the age and activity of a radiologic abnormality cannot otherwise be accurately determined before therapy.     

Chronic knee pain assessed by SPECT: comparison with other modalities

Twenty-seven patients with chronic knee pain were examined prospectively using conventional radiography, radionuclide angiography, planar bone scintigraphy, and single-photon emission computed tomographic (SPECT) bone scintigraphy. When the results of subsequent arthroscopic examination of all three compartments of the knee were correlated with those of the noninvasive methods, SPECT bone scintigraphy was found to be most sensitive for evaluating the extent of osteoarthritis. Differences in detection sensitivity for articular cartilage damage and synovitis were greatest in the patellofemoral compartment. The frequency with which hyperemia was present in association with cartilage damage and synovitis indicates that osteoarthritis of the knee is capable of producing hyperemia and further implies that increased perfusion cannot be used to distinguish with confidence between osteoarthritis and septic processes involving the knee. SPECT (1.00) and planar (0.91) bone scintigraphy were highly sensitive indicators of torn menisci in a subgroup of 14 patients, each having a prearthroscopic clinical diagnosis of a torn meniscus. This result suggests that for patients with chronic knee pain and clinical suggestion of a torn meniscus, bone scintigraphy has significant potential as a high-sensitivity, prearthroscopic screening examination.     

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

AIM: To review abnormalities reported on plain radiographic examination of the lumbar spine in patients referred with low back pain by general practitioners. Additionally, we evaluated and stratified the prevalence of these abnormalities by age. Finally, the diagnostic impact of lumbar spine radiography for the diagnosis of degenerative change, fracture, infection and possible tumour, was modelled. MATERIALS AND METHODS: A retrospective review of 2007 radiographic reports of patients referred with low back pain for lumbar spine radiography to a large radiology department was performed. The reports were classified into different diagnostic groups and subsequently stratified according to age. The potential diagnostic impact of lumbar spine radiography was modelled by using the prevalence of conditions studied as pre-test probabilities of disease. RESULTS: The prevalence of reported lumbar spine degeneration increased with age to 71% in patients aged 65-74 years. The overall prevalence of fracture, possible infection, possible tumour was low in our study population: 4, 0.8 and 0.7%, respectively. Fracture and possible infection showed no association with age. Possible tumour was only reported in patients older than 55 years of age. CONCLUSION: Although the prevalence of degenerative changes was high in older patients, the therapeutic consequences of diagnosing this abnormality are minor. The prevalence of possible serious conditions was very low in all age categories, which implies radiation exposure in many patients with no significant lesions.     

The diagnostic value of bone scintigraphy in patients with low back pain

Bone scintigraphy has been studied in two groups of patients presenting with low back pain. In one group of 38 patients suffering "nonspecific" back pain, bone scintigraphy and laboratory findings were negative in 24. There were abnormal laboratory findings in all of the remaining 14 and 7 had positive bone scans indicative of clinically significant disease. Selection of patients for bone scintigraphy in this group should therefore be influenced by abnormal laboratory findings and elevation of the erythrocyte sedimentation rate in particular. By comparison, the bone scans were reviewed from another group of patients suffering previously known malignancy. Out of 138 patients, nearly 40% showed a positive bone scan due to subsequently proven metastasis. Bone scintigraphy was positive in a further 14% as a result of osteoporotic rib fracture and vertebral body collapse. In half of these, it was not possible to exclude malignancy by scintigraphy. The present findings indicate that bone scintigraphy is not a useful procedure in patients with long-standing low back pain who have normal radiographs and normal laboratory findings.     

Chronic diffuse infiltrative lung disease: comparison of diagnostic accuracy of CT and chest radiography

The accuracies of chest radiography and computed tomography (CT) in the prediction of specific diagnoses in 118 consecutive patients with chronic diffuse infiltrative lung disease (DILD) were compared. The radiographs and CT scans were independently assessed by three observers without knowledge of clinical or pathologic data. The observers listed the three most likely diagnoses in order of probability and recorded the degree of confidence they felt in their first-choice diagnosis on a three-point scale. Confidence level 1 (definite) was reached with 23% of radiographic and 49% of CT scan readings, and the correct diagnosis was made with 77% and 93% of those readings, respectively (P less than .001). The correct first-choice diagnosis regardless of the level of confidence was made with 57% of radiographic and 76% of CT scan readings (P less than .001). The CT scan interpretations were most accurate in silicosis (93%), usual interstitial pneumonia (89%), lymphangitic carcinomatosis (85%), and sarcoidosis (77%). Observers correctly predicted whether a transbronchial or open lung biopsy was indicated with 65% of radiographs and 87% of CT scans (P less than .001). It is recommended that CT be performed before lung biopsy in all patients with chronic DILD.     

CT measurement of trunk muscle areas in patients with chronic low back pain

PURPOSE: The objective of this study was to determine the cross-sectional area changes of the paraspinal, isolated multifidus, quadratus lumborum, psoas, and the gluteus maximus muscles with CT in patients with chronic low back pain. MATERIALS AND METHODS: In this study, we evaluated 36 patients with chronic low back pain and 34 healthy volunteers. The mean age of the patients was 43.2 +/- 6.9 years (range, 30- 58 years) and the mean age of control group was 44.4 +/- 6.9 years (range, 31-61 years). We defined pain that lasts more then one year as chronic pain. Female patients were selected for standardization. All patients were housewives. None of the patients or controls engaged in physical activity other than routine housework. We used a visual analog scale and the Oswestry Pain Questionnaire for clinical evaluation. We made CT cross-sections of the paraspinal muscles at the upper and lower endplates of L4, and of the gluteus maximus at the head of the interfoveal level. RESULTS: In the patient group the multifidus, psoas, and quadratus lumborum cross-sectional areas were smaller than in the control group, and the P values were P = 0.002, P = 0.042, and P = 0.047, respectively, at the L4 endplate. At the L4 endplate level, cross-sectional areas of the multifidus and paravertebral muscles in the patient group were smaller than in the control group, and the difference was statistically significant (P = 0.001, P = 0.010, respectively). We did not find any significant difference between the patient and the control groups in gluteus maximus cross-sectional area. CONCLUSION: Chronic low back pain caused atrophy of the paraspinal, isolated multifidus, quadratus lumborum, psoas, and the gluteus maximus muscles to varying degrees, which was most prominent in the multifidus. Atrophy was noted in all of the studied muscles, except the gluteus maximus. The reliability of CT in measuring the cross-sectional areas of the back muscles was acceptable.     

SPECT in the management of patients with back pain and spondylolysis

PURPOSE: Single photon emission computed tomography (SPECT) bone scans of the lumbar spine were evaluated in the management of patients with low back pain and suspected spondylolysis. MATERIALS AND METHODS: Thirty-three patients (mean age, 30 years) with high clinical suspicion of pars interarticularis defects were included in the study. The results of lumbar radiographs and SPECT bone scintigraphy were compared and the influence of these results on patient management was evaluated. RESULTS: Twenty-six of the 33 patients had abnormal results of lumbar radiographs. Of the 21 patients with radiographs indicating spondylolysis, six had abnormal uptake in the pars regions on bone scintigraphy. One patient with normal results of lumbar radiographs had a SPECT bone scan showing uptake in the region of the pars interarticularis. CONCLUSIONS: SPECT bone scanning of the lumbar spine has a role in the treatment of patients with symptomatic spondylolysis.     

腰骶移行椎:与下腰疼的关系

目的评估自发性骨关节炎中腰骶移行椎的发生率与程度,评估腰骶移行椎与下腰部及臀部疼痛的联系,评估腰骶移行椎分级的可重复性。材料与方法研究经单位伦理委员会批准,获得病人的知情同意。4636例自发性骨性关节炎病人(男1992例,女2804例,年龄45～80岁)进行常规立位骨盆平片检查,包括L5双侧横突,并按照Castellvi标准进行分级。评价腰骶移行椎的发病率及其与下腰和臀部疼痛的相关性。结果腰骶移行椎的发病率为18.1%(841/4636),男性发病率高于女性(分别为28.1%和11.1%,P<0.001)。在841例腰骶移行椎中,41.72%属Ⅰ型(发育不良的宽大横突),41.4%属Ⅱ型(假关节型),11.5%属Ⅲ型(融合型),5.2%属Ⅳ型(一侧横突融合一侧假关节型)。无腰骶移行椎的受试者中,53.9%存在下腰部疼痛;而在Ⅰ、Ⅱ、Ⅲ和Ⅳ型腰骶移行椎者中下腰疼的发病率分别为46%、73%、40%和66%(χ2检验,P<0.05)。Ⅱ和Ⅳ型病人下腰及臀部疼痛的发病率较高,程度更重(P<0.001)。结论Ⅱ和Ⅳ型腰骶移行椎与下腰及臀部疼痛的发病率和严重性相关。     

Added value of SPECT/CT fusion in assessing suspected bone metastasis: comparison with scintigraphy alone and nonfused scintigraphy and CT

PURPOSE: To evaluate retrospectively if there is additional diagnostic value of fused single photon emission computed tomographic (SPECT) and computed tomographic (CT) images in assessing possible bone metastases. MATERIALS AND METHODS: Institutional review board approval was obtained, and each patient provided written informed consent. Bone scintigraphy--including planar and SPECT imaging-and CT were performed with a combined SPECT/CT system in 45 oncologic patients (24 men, 21 women; mean age, 64.7 years +/- 8.7), with a total of 42 metastatic bone foci and 40 benign foci. The reference standard was follow-up radiologic imaging. Two independent readers first analyzed only bone scintigraphic images and next analyzed two separate sets of bone scintigraphic and CT images. They then analyzed bone scintigraphic, CT, and fused images and focused on the additional value of fused images. Diagnostic confidence for each lesion was scored. The three analyses were performed 7 days apart, and the images were presented in random order at each session. The value of additional fused images was assessed by using receiver operating characteristic analysis. RESULTS: After review of fused images to classify indeterminate lesions, reviewer 1 became more confident in diagnosis of the 15 benign lesions and two metastases, and reviewer 2 became more confident in diagnosis of the seven benign lesions and one metastasis. The area under the receiver operating characteristic curve for reviewer 1 was 0.589 for scintigraphic images, 0.831 for separate data sets of scintigraphic and CT images, and 0.947 for fused images. The corresponding areas under the receiver operating characteristic curve for reviewer 2 were 0.771, 0.885, and 0.968, respectively. CONCLUSION: Results demonstrate the increased diagnostic confidence obtained with fused SPECT/CT images compared with separate sets of scintigraphic and CT images in differentiating malignant from benign bone lesions.     

Rehabilitation of the athlete with low back pain

The rehabilitation of athletes with low back pain should be considered an essential component of their care. Comprehensive rehabilitation begins at the time of acute injury and encompasses the period of acute care through sport-specific training and return to competition. Rehabilitation of athletes with spinal pain should include a thorough psychosocial evaluation to identify potential barriers to clinical improvement. For athletes with low back pain, establishing effective core stability is central to optimizing the functional performance of the athlete.     

CT in low back and sciatic pain due to lumbar canal osseous changes

Summary In a consecutive series of 600 patients scanned by CT for various spinal diseases, those with low back and sciatic pain without disc herniation were selected for study. The causes proved to be joint facet degeneration (32 cases), stenosis of the neural foramina (13 cases), stenosis of the spinal canal (13 cases), lateral recess stenosis (6 cases) and spondylolisthesis (6 cases). The predominance of joint facet pathology as the underlying cause of low back and sciatic pain in the absence of disc herniation is confirmed. CT scanning of the soft tissues as well as of the skeletal structures is crucial to the aetiological diagnosis of the condition under study and hence to the proper planning of treatment.     

Management of the athlete with low back pain

The evaluation of an athlete with LBP using the classification system proposed by Delitto et al has been outlined. For outpatient orthopaedic practice, evidence in the literature is available documenting the reliability and the effectiveness of treatment guided by TBC. This classification system provides framework for the clinician to evaluate athletes with LBP because it investigates the presence of serious pathology, considers the severity of the disease process, and provides matched treatment based on the athlete's clinical presentation. When treating athletes with episodes of acute LBP, pain modulation and return to daily function are the primary treatment goals. When treating athletes with episodes of chronic LBP, return to sport and prevention of recurrence are the primary treatment goals.     

Physcial exercise and low back pain

Health care providers often prescribe exercises as treatment for nonspecific low back pain. However, the effectiveness of this treatment is poorly documented in the literature. While the evidence suggests that exercise in general is beneficial, there is a lack of knowledge about the types, frequency and duration of exercises that should be prescribed and at what stage of injury they are most helpful. In addition, few studies have dealt with exercise treatment alone rather than in combination with other treatments, making it hard to decipher the unique contribution of exercise. Inadequate study designs also make conclusions difficult. Conversely, the literature clearly shows that inactivity has detrimental effects (i.e. delayed return to normal activity, and negative physiological and psychological effects) for low back pain patients.