By January 30, 2015 Read More →

Imaging Findings In Asymptomatic Lumbar Spines – Research Update – January 2015

The plan this year is to shorten my posts, and post more regularly. Here we go……wish me luck!

Imaging findings in asymptomatic lumbar spines and other areas of the body, are recurring theme on this site. Mainly because of the experiences I have routinely had where patients are managed purely based on their imaging findings.

Here is some more research (free to access and download – follow the link below) that has cropped up since my last posts above:

Brinjikji et al (2014) conducted a Systematic Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Key points and conclusions from the review being:

Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria.

The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals.

Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age.

Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age.

The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.

Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age.

Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.

These imaging findings must be interpreted in the context of the patient’s clinical condition.

Now I might start to show my age here……..isn’t it interesting that even in very young (20 year old) asymptomatic spines:

  • 37% have disc degeneration
  • 30% have disc bulges
  • 29% have disc protrusions
  • 19% have annular fissures

In addition this is a table from the above publication (credit to the authors) that outlines the age changes, and prevalence of some other imaging findings, even more specifically:

LBPImaging

Remember……these are asymptomatic patients.

Now for those who have seen my previous posts the key point I like to make on the above can probably boil down to a simple reflective question that you can ask yourself, your colleagues, the spinal surgeon and importantly your patients:

If we can see pain free, normally functioning people with these sorts of findings then why can’t we think that you/the patient should have the potential to achieve the same with appropriate conservative management?

Now I cannot tell you the answer to that question as all patients are different, but it is an interesting question to ponder, and one I am keen to hear your thoughts on. In addition I think the type of information seen above is critical for us to convey to our patients, as once again I see many patients who believe the reason they still have pain is because of what is found on their scans.

Thanks for reading.

Posted in: Medical Imaging, Research Evidence, Spinal and Pelvic Pain

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.

8 Comments on "Imaging Findings In Asymptomatic Lumbar Spines – Research Update – January 2015"

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  1. Cam says:
    January 30, 2015 at 10:38 am

    Hi Mark,

    Thanks for the posting this study and your interpretations/conclusions.

    Brinjikji’s paper is so definitive, so black-and-white. It is impossible to argue that radiological investigations and findings are useful for the average client. And this goes not just for back pain, but pain pretty much anywhere in the body, as your links show. I can only think of a few situations where I’d suggest scans or xrays.

    1) concern about an undiagnosed problem needing medical care (rare)
    2) possibility of a fracture (rare)
    3) possibility of a tendon rupture in a young or very active person (more common in sports clinics)
    4) When I can’t significantly reduce symptoms

    Conditions such as meniscal/labral tears seem to fix themselves often enough with conservative Rx. At least the pain fixes itself, God knows if the tear does. Partial cuff tears seem to take a bit longer, but that might just be me. The evidence for surgical intervention is poor or non-existent, so I try to avoid suggesting that path unless I fail with my approach.

    Mark, I’d really like to see you post some material and opinion on treatments that *do* work! Maybe something from Norman Doidge or Mark Jensen? Or perhaps some updates on the psychosocial factors tab?

    Cheers, Cam

    • Mark Gibson says:
      February 4, 2015 at 2:57 am

      Hi Cam,

      Thanks for the comment. I similarly agree with your situations re: suggesting scans, well outlined.

      Thanks also for the suggestions re: Doige and Jensen, whilst I am not overly familiar with the names I will look into their work. More psych factor posts to come, and I will get onto some treatments that work!

      Cheers
      Mark

  2. Rebecca Crawford says:
    January 30, 2015 at 11:08 am

    Hey Mark

    Great study to focus on! An appreciation of what represents the natural history of aging is absolutely necessary in managing expectations of ourselves as clinicians, and our patients!

    Aligned to the study you present is a recent one by McCullough BJ et al. 2014 Radiology 262(3): 941-946. They showed an influence on narcotics prescription by primary care providers when normative epidemiologic information was included in a patient’s LS MRI reports.

    There are other studies emerging that examine the influence on patients of informing them as to how their imaging results compare to ‘normal’ asymptomatics [Jarvik JG as an author to search]. This is a super direction for radiology to be taking; good on them!

    ‘Healthy aging’ is my broad area of investigation at ZHAW, so hopefully stay tuned for papers that centre on muscle across the lifespan 🙂

    I’m pleased to be receiving your feeds via LinkedIn!

    Bests
    Bec

    • Mark Gibson says:
      February 4, 2015 at 2:47 am

      Hey Bec!

      Great to hear from you and thanks for the additional info that is now on my list to chase up.

      Looking forward to following the research you are involved with!

      Cheers
      Gibbo

  3. Michael says:
    January 30, 2015 at 12:32 pm

    Excellent post Mark, i wonder when our medical colleagues specifically the surgeons will accept this data. Too many people with chronic pain undergo surgery and never improve due to peripheral and central nervous system changes ie chronic pain

    • Mark Gibson says:
      February 4, 2015 at 2:49 am

      Hi Michael,

      Thanks for the comment. I wonder also when the medical and surgical professions will accept this data. Unfortunately I think many have vested interests. Having said that I know of one or two orthopaedic surgeons here in Perth who now resort to surgery as a last option, if at all, and are aware of this type research. So perhaps the pendulum is, slowly, starting to swing.

      Thanks again.

      Cheers
      Mark

  4. Mike says:
    June 11, 2015 at 1:43 pm

    Great stuff Mark wonderful findings. I think we often are too image diagnostic although the physiotherapists are generally a lot better than the doctors and surgeons. Funny ho many doctors don’t have this knowledge or many simply refuse to use it and they are the main decision makers in clinical plans for patients.

    It would be a wonderful world if all practitioners used the same clinical guidelines of when to refer for imaging and what to tell patients about imaging results. I really think what we say to patients plays such an important role in preventing nociceptive input from centralising and becoming centrally driven.

    • Mark Gibson says:
      June 14, 2015 at 1:05 am

      Hi Mike,

      Thanks for taking the time comment.

      Unfortunately I far to often, much like you probably do, see doctors and surgeons diagnosing patients based PURELY on imaging findings. Most of these patients have “normal” looking scans apart from some “grey hairs” or “wrinkles” (I like these terms – great way to describe it to patients!).

      Fingers crossed we might start to see a shift in the above but I think far too many practitioners are lacking the knowledge base and/or to entrenched in the biomedical/pathoanatomical approach. But I will keep my fingers crossed!! 🙂

      I couldn’t agree with you more about what we say to patients being critical. For me personally this has been a critical, but highly rewarding, shift in my practice over the years.

      Thanks again for reading the blog and taking the time to comment.

      Cheers
      Mark