The guidelines provided by the New York State Workers Compensation Board offer general principles for conducting diagnostic studies for low back injury. These directives aim to assist healthcare professionals in determining appropriate diagnostic approaches as part of a comprehensive assessment.
Healthcare professionals specializing in diagnostic studies can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable diagnostic methods for their patients.
It is important to stress that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding diagnostic studies should involve collaboration between the patient and their healthcare provider.
Imaging Studies
Routine x-rays for acute non-specific back pain.
When dealing with acute non-specific back pain, the recommendation is to consider routine x-rays. This is particularly advised in cases where there are red flags indicating a potential for fractures or serious systemic illnesses, instances where the back pain shows no signs of improvement, or for non-acute back pain as an option to rule out other possible conditions.
It’s generally sufficient to obtain x-rays once, unless the patient has fractures, in which case more frequent monitoring might be necessary. For patients with non-acute back pain, it could be reasonable to obtain a second set of x-rays months or years later to reassess the patient’s condition, especially if symptoms undergo any changes.
However, it’s not recommended to opt for imaging tests in the initial four to six weeks of back pain symptoms unless there are red flags present. Red flags, which indicate potentially serious diseases, include symptoms like fever, weight loss, nocturnal pain, night sweats, bowel or bladder incontinence, or major trauma.
Flexion and Extension Views
In specific cases where there’s consideration for surgery or other invasive treatment, or in instances of trauma, obtaining flexion and extension views is recommended for evaluating symptomatic spondylolisthesis. The frequency of obtaining these views, including lateral flexion and extension, generally should not be more frequent than every few years, unless there’s a rapidly changing clinical course.
Magnetic Resonance Imaging (MRI)
MRI is considered the go-to diagnostic imaging method for accurately delineating anatomy, offering superb resolution without subjecting individuals to radiation exposure. Although CT remains valuable, especially for assessing the bone or calcified structures in the spine, the superior resolution of MRI, particularly in capturing details of soft tissue (like nerve root compression, spinal cord, and nerve root abnormalities), has diminished the current reliance on CT scans. It’s crucial to note that ferrous material or metallic objects within the body could be a contraindication for an MRI. The magnetic field during an MRI has the potential to dislodge metallic objects, posing significant harm or even a risk of death.
For patients with a history of thoracic or lumbar surgery, or those with concerns about malignancy or infection, the use of Gadolinium enhancement might be necessary for the MRI study. This decision should be made in consultation with the requesting physician, considering any underlying medical conditions that might contraindicate an enhanced MRI. In cases where the initial scan doesn’t provide sufficient resolution, a second MRI utilizing a different technique may be necessary. A follow-up diagnostic MRI might involve repeating the same procedure if the rehabilitation physician, radiologist, or surgeon notes that the initial study lacked the quality needed for an accurate diagnosis. Any queries regarding these matters should be addressed with the MRI center and/or radiologist.
Recommended – If a patient is experiencing acute back pain within the first six weeks and shows a significant neurological deficit, progressive neurologic deficit, cauda equina syndrome, significant trauma, a history of neoplasia (cancer), or an atypical presentation (such as a clinical picture suggesting multiple nerve root involvement), an MRI is advised.
For cases of acute radicular pain syndromes in the initial six weeks, an MRI is recommended if the symptoms are severe, not showing improvement, and both the patient and physician are open to considering prompt surgical treatment, assuming the MRI confirms ongoing nerve root compression. It’s important to note that repeating MRI imaging without significant clinical deterioration in symptoms and/or signs is not recommended.
Moreover, for patients with non-acute radicular pain syndromes persisting for at least six weeks, where the symptoms are not improving, an MRI is recommended if both the patient and surgeon are contemplating prompt surgical treatment, provided the MRI confirms ongoing nerve root compression.
In situations where an epidural glucocorticosteroid injection is being considered for temporary relief of acute or subacute radiculopathy, an MRI at three to four weeks (prior to the epidural steroid injection) may be considered reasonable
Suggested – as a potential choice for assessing specific nonacute back pain patients to rule out additional issues unrelated to the injury. However, this should be a rare consideration and typically only after three months have passed, and various treatment approaches (including NSAIDs, aerobic exercise, other forms of exercise, and potential manipulation or acupuncture) have been unsuccessful.
It’s generally not advisable for acute back pain or acute radicular pain syndromes within the first six weeks, especially in the absence of red flags.
Additionally, undergoing a standing or weight-bearing MRI is not recommended for any back or radicular pain syndrome or condition. Currently, this technology is deemed experimental/investigational, lacking studies demonstrating improved patient outcomes.
Computerized Tomography (CT)
Because MRIs provide much higher detail, especially for soft tissues in the spine, there’s less reliance on CT scans. Nevertheless, CT scans are still valuable for assessing the bony or calcified aspects of the spine. They’re particularly helpful when MRI isn’t an option, often due to implanted metallic devices. CT scans are non-invasive (or minimally invasive with contrast) with low risks but involve exposure to radiation. For individuals experiencing radicular symptoms, CT myelography might be recommended due to its superior sensitivity in detecting nerve root compression. It’s considered in cases where the benefits outweigh the risks, especially when MRI is inconclusive, unnecessary, or clinically contraindicated for certain patients.
Suggested – For specific cases where radicular pain persists despite a four to six-week period and there’s consideration for an epidural glucocorticoid injection or surgical discectomy , CT is recommended, although MRI is preferred.
Advised – In patients requiring an MRI but unable to undergo the examination due to contraindications like an implanted metallic-ferrous device or significant claustrophobia, CT is recommended. It’s important to note that obtaining serial CT exams is generally discouraged, but if there’s a notable worsening in the patient’s condition, repeat imaging may be necessary.
Not Advised – Routine CT scans are not recommended for either acute or non-acute nonspecific back pain or for cases of radicular pain syndromes.
Myelography (Including CT Myelography and MRI Myelography)
It might only come in handy when MRI or other tests can’t be done, aren’t considered conclusive, or simply aren’t available. This type of testing might be a good call for certain individuals where the benefits clearly outweigh the risks, especially if MRI isn’t giving a clear picture or is medically not suggested or even contraindicated. Just a heads up, this more invasive method can lead to issues like pain, infection, or allergic reactions.
Suggested – In specific and uncommon scenarios, myelography, which includes CT myelography, is recommended for certain patients. Examples of these situations include having implanted metal that rules out MRI, unclear findings of disc herniation on MRI suspected to be falsely positive, dealing with spinal stenosis, or being in a post-surgery situation that calls for myelography.
Discouraged – Using myelography, including CT myelography and MRI myelography, as the initial diagnostic study for identifying lumbar root compromise is not recommended. Conditions warranting this testing should be selective, where the benefits clearly outweigh the risks, especially in cases where MRI isn’t conclusive or is either not indicated or contraindicated. Keep in mind, though, that this more invasive approach can potentially lead to complications like pain, infection, or allergic reactions.
Bone Scans
Suggested – Bone scans are recommended in specific patients when clinically warranted. They prove to be a valuable diagnostic tool in particular situations involving a minority of patients, aiding in the diagnosis of conditions such as neoplasia, suspected metastases, infection (e.g., osteomyelitis), inflammatory arthropathies, and occult fractures.
Not Advised – Routine use of bone scans in patients with back pain is not recommended. Note that this technology is generally not employed for assessing most cases of occupational back pain.
Fluoroscopy
Discouraged – Fluoroscopy is not recommended for evaluating either acute or non-acute back pain.
Suggested – Single Proton Emission Computed Tomography (SPECT)
Is recommended in specific patients when clinically necessary. Typically, it’s not a go-to, unless there are suspicions of inflammatory arthropathies that other common tests couldn’t diagnose or to rule out potential acute spondylolysis. Keep in mind that SPECT has a limited role in assessing patients dealing with back pain.
Ultrasound
Not Advised – When it comes to patients experiencing back pain, diagnostic ultrasound is generally not recommended.
Videofluoroscopy
Discouraged – Videofluoroscopy is not recommended for evaluating both acute and non-acute back pain.
Other Tests / Procedures
Electrodiagnostic Studies (EDX)
EDX, which includes needle EMG, peripheral nerve conduction velocity studies (NCV), and motor and sensory evoked potentials, plays a crucial role in diagnosing conditions. Needle EMG is often the key in confirming radiculopathy or spinal stenosis for individuals dealing with back pain or radiculopathy issues. This test can even help determine whether the radiculopathy is of recent onset or has been chronic.
NCV is conducted alongside needle EMG to rule out other potential causes for the symptoms, such as co-morbidities or alternative diagnoses involving peripheral nerves, while also confirming the presence of radiculopathy. It’s highly recommended, especially in outpatient settings, that EDX procedures are performed and interpreted by physicians certified in Neurology or Physical Medicine and Rehabilitation.
EDX (must include needle EMG and NCV)
Suggested – In specific cases where clinically necessary, especially when a CT or MRI yields ambiguous results and there are ongoing complaints of pain, weakness, and/or numbness/paresthesias raising concerns about potential neurological compromise.
This typically involves leg symptoms consistent with radiculopathy, spinal stenosis, peripheral neuropathy, and similar conditions. Nerve conduction studies are performed alongside needle EMG to rule out other potential causes (such as compression neuropathies) and confirm radiculopathy, with the requirement that needle EMG is included in the testing.
It’s particularly relevant when suspected radicular pain doesn’t resolve or plateaus after a four to six-week waiting period, considering both sufficient time for the development of EMG abnormalities and the potential for conservative treatment to address the issues. This is especially applicable in cases where imaging findings on CT or MRI are inconclusive, and there’s suspicion, based on history and physical examination, that a neurological condition other than or in addition to radiculopathy may be present.
Not Advised – For individuals experiencing acute or non-acute back pain without significant leg pain or numbness, this testing is generally not recommended.
Surface Electromyography (Surface EMG)
Generally Not Advised
Lumbar Discography
Not recommended, whether done alone or in conjunction with imaging like MRI, for individuals dealing with acute or non-acute back pain or radicular pain syndromes.
It’s worth noting that the use of discography hasn’t been proven to enhance surgical outcomes, and there’s evidence suggesting that performing discography on normal discs may increase the risk of degenerative changes in those discs over time. Lumbar discography also carries the potential for complications, including but not limited to infection, discitis, and post-discogram herniation.
Myeloscopy
Not recommended for acute or non-acute back pain, spinal stenosis, radicular pain syndromes, or post-surgical back pain problems.
Thermography
Not recommended for evaluating acute or non-acute back pain or radicular pain patients.
