RADIOLOGY is one of those specialties that is rapidly advancing due to the almost daily advances in medical technology. The rapid advancement of computing power and the discovery of new, innovative ways to look inside the human body contribute to the vibrancy of radiology.

The benefit of being able to detect disease at an earlier stage is that treatment can be started earlier, increasing the chances of a cure. The danger lies in detecting abnormalities before they become diseases and instituting treatment in people that may not truly need it.

The guiding principle of medicine is that we as physicians should do no harm. This is a principle that guides me as a radiologist and plays a central role in determining the appropriateness of any test requested for a patient. Many of the tests we perform utilise radiation and must, therefore, be justified.

While the dose of radiation is generally low in most tests, inappropriate tests, which are often repeated, contribute to an unnecessary increase in the total patient dose, which does add up over time. Neither patients nor referring physicians should therefore be offended by a radiologist participating in medical management through the selection of appropriate imaging.

Back pain is one of the main conditions that are inappropriately imaged. Low back pain is common and costly. Health care expenditure for the management of low back pain rises to the billions of dollars in the United States of America. I am unaware of the total figures in Jamaica, but what I do know is that many young, otherwise healthy patients are quickly referred for at least an X-ray of the back at the first sign of back pain.

Are we doing the right thing? The answer is no.

Lumbar spine X-rays provide an estimated radiation dose equivalent to six months of background radiation (radiation associated with normal daily living). Female ovarian radiation from lumbar radiography is equivalent to a daily chest radiograph for several years.

Other modalities commonly used to image the lower back include computed tomography (CT) and magnetic resonance imaging (MRI). Harmful effects associated with inappropriate use include:

1. Radiation exposure (lumbar radiographs and CT)

2. Exposure to iodinated contrast (CT)

3. Increased risk of surgery (MRI)

4. Labelling when patients are told they have an abnormality (lumbar radiographs and MRI).

Labelling of a patient is an important point to highlight. MRI, in particular, is so good at detecting abnormalities that invariably one will be found in a patient. This doesn’t mean that the abnormality found on MRI is the abnormality responsible for the patient’s symptoms.

In fact, some patients may have glaring abnormalities on imaging that produce no symptoms. The end result is that many patients end up with surgeries that were not needed in the first place and ultimately end up being unsuccessful at relieving patients’ symptoms. As a matter of fact, studies have shown that the use of MRI early in the course of an episode of lower back pain resulted in a three-fold increase in surgical rates, with no improvement in outcomes in the subsequent year.

RECOMMENDATIONS

There are three key recommendations regarding diagnostic imaging in patients with low back pain:

1. Clinicians should not obtain imaging or other diagnostic tests in patients with non-specific low back pain.

2. Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurological deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination.

3. Clinicians should evaluate patients with persistent low back pain and signs and symptoms of nerve compression or spinal stenosis with MRI (preferred), only if they are potential candidates for surgery or epidural steroid injection.

In clinical trials utilising patients with no clinical or historical features of serious underlying conditions, there was no difference in outcomes for pain, function, quality of life, or overall patient rated improvement between those who were provided usual care without routine lumbar imaging (radiography, MRI or CT) versus those provided with usual care and the addition of lumbar imaging.

The key point to remember is that the patient should be treated and not the imaging findings. As radiologists, we do our best to keep radiation exposure to patients as low as reasonable, while obtaining the highest quality imaging. As always, working together as a team ensures the best outcome.

Dr Duane Chambers is a consultant radiologist and founding partner of Imaging and Intervention Associates located at shops 58 and 59 Kingston Mall, 8 Ocean Boulevard. He may be contacted through the office numbers 618-4346 or 967-7748.