National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy.

PURPOSE: To summarise recommendations about 20 non-surgical interventions for recent onset (<12 weeks) non-specific low back pain (LBP) and lumbar radiculopathy (LR) based on two guidelines from the Danish Health Authority. METHODS: Two multidisciplinary working groups formulated recommendations based on the GRADE approach. RESULTS: Sixteen recommendations were based on evidence, and four on consensus. Management of LBP and LR should include information about prognosis, warning signs, and advise to remain active. If treatment is needed, the guidelines suggest using patient education, different types of supervised exercise, and manual therapy. The guidelines recommend against acupuncture, routine use of imaging, targeted treatment, extraforaminal glucocorticoid injection, paracetamol, NSAIDs, and opioids. CONCLUSION: Recommendations are based on low to moderate quality evidence or on consensus, but are well aligned with recommendations from international guidelines. The guideline working groups recommend that research efforts in relation to all aspects of management of LBP and LR be intensified.

Reliability of standing weight-bearing (0.25T) MR imaging findings and positional changes in the lumbar spine.

OBJECTIVE: To test the reliability and absolute agreement of common degenerative findings in standing positional magnetic resonance imaging (pMRI). METHODS AND MATERIALS: Low back pain patients with and without sciatica were consecutively enrolled to undergo a supine and standing pMRI. Three readers independently evaluated the standing pMRI for herniation, spinal stenosis, spondylolisthesis, HIZ lesions and facet joint effusion. The evaluation included a semi-quantitative grading of spinal stenosis, foraminal stenosis and spinal nerve root compression. The standing pMRI images were evaluated with full access to supine MRI. In case lower grades or the degenerative findings were not present in the supine images, this was reported separately as position-dependent changes. A subsample of 20 pMRI examinations was reevaluated after two months. The reproducibility was assessed by inter- and intra-reader reliability (kappa statistic) and absolute agreement between readers. RESULTS: Fifty-six patients were included in this study. There was fair-to-substantial inter-reader reliability (κ 0.47 to 0.82) and high absolute agreement (72.3% to 99.1%) for the pMRI findings. The intra-reader assessment showed similar reliability and agreement (κ 0.36 to 0.85; absolute agreement: 62.5% to 98.8%). Positional changes between the supine and standing position showed a fair-to-moderate inter- and intra-reader reliability (κ 0.25 to 0.52; absolute agreement: 97.0% to 99.1). CONCLUSION: Evaluation of the lumbar spine for degenerative findings by standing pMRI has acceptable reproducibility; however, positional changes from the supine to the standing position as an independent outcome should be interpreted with caution because of lower reliability, which calls for further standardisation.

External pneumatic compression device prevents fainting in standing weight-bearing MRI: a cohort study.

OBJECTIVE: To investigate if a peristaltic external pneumatic compression device attached to the legs, while scanning, can reduce a substantial risk of fainting in standing weight-bearing magnetic resonance imaging (MRI). MATERIALS AND METHODS: This study comprised all patients with low back pain referred to standing MRI of the lumbar spine, using a 0.25-T open G-Scanner, from June 2011 to April 2012. The standing MRI protocol included a sagittal TSE T2w and an axial GRE T2w sequence giving a total scan time of 17 min. The first patients were scanned standing without a device (control group), and then from January to April 2012 the patients were scanned in the standing position using an external pneumatic compression device, attached to the legs (experimental group). RESULTS: One hundred and forty-nine patients (mean age 42.5, standard deviation 12.5, and range 20-77 years) were included and scanned standing. No significant difference in age (p = 0.51) or gender (p = 0.47) was observed between the control group (n = 86) and the experimental group (n = 63). Sixteen patients (19 %) fainted in the control group during the standing MRI scan, compared to one patient (2 %) in the experimental group where the pneumatic compression device was applied. The difference between groups was highly significant (p = 0.001; Fisher's exact test), with an OR = 0.071 (exact 95 % CI: 0.002 to 0.486) for the pneumatic compression device. CONCLUSIONS: A substantial risk of fainting during standing MRI was almost eliminated by using an external peristaltic pneumatic compression device.

Conventional Supine MRI With a Lumbar Pillow-An Alternative to Weight-bearing MRI for Diagnosing Spinal Stenosis?: A Cross-sectional Study.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To investigate if adding a lumbar pillow in supine position during magnetic resonance imaging (MRI) is superior to standing positional MRI for diagnosing lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: The upright standing position and especially extension of the lumbar spine seem to worsening symptoms of LSS. However, it is unclear whether a forced lumbar extension by a pillow in the lower back during conventional supine MRI may improve the diagnostics of LSS compared with standing MRI. METHODS: Patients suspected for LSS and referred to conventional MRI were included to an additional positional MRI scan (0.25T G-Scan) performed in: (1) conventional supine, (2) standing, (3) supine with a lumbar pillow in the lower back. LSS was evaluated for each position in consensus on a 0 to 3 semi-quantitative grading scale. Independently, L2-S1 lordosis angle, spinal cross-sectional diameter (SCSD), dural cross-sectional diameter (DCSD), and dural cross-sectional diameter (DCSA) were measured. The smallest dural diameter was defined as stenosis level and the largest control level for comparison. RESULTS: Twenty-seven patients (60.6 years; ±9.4) were included. The lordosis angle increased significantly from supine to standing (3.2° CI: 1.2-5.2) and with the lumbar pillow (12.8° CI: 10.3-15.3). One-way analysis of variance (ANOVA) showed significant differences between positions (P < 0.001). When compared with the supine position, pairwise comparisons showed decreased SCSD, DCSD, DCSA, and increasing semi-quantitative grading, during both standing and supine with the lumbar pillow. A difference in the semi-quantitative grades was only found between standing and supine with a lumbar pillow, and the scan with a lumbar pillow was significantly more painful. CONCLUSION: Standing MRI and supine MRI with a lumbar pillow resulted in equal changes in the lumbar spine, although standing MRI may be more sensitive in the assessment of patients suspected for LSS. LEVEL OF EVIDENCE: 2.

Imaging in mechanical back pain: Anything new?

Low back pain is common and relates to a variety of overlapping pathologies. Within the last few decades, almost every medical imaging modality has been applied in the evaluation of low back pain. Imaging of the spine has a high priority in the assessment of patients with low back pain, who seem to expect such procedures to be undertaken. However, the majority of conventional imaging techniques do not have adequate precision to identify the primary source of pain. Not only can this be frustrating to both clinicians and patients, but importantly, inadequate correlation between imaging findings and symptoms hampers the ability of clinicians to devise a specific treatment plan for the patient. Therefore, there is mounting interest in new imaging techniques of the lumbar spine that may increase the clinical correlation in low back pain. In this review, we will discuss the value and limitations of various lumbar spine imaging techniques with focus on new emerging technologies.