ORIGINAL ARTICLE Lumbar spine X-rays for back pain still justified as a • •screening examina- tion in South Africa A T Scher FCRad(D) SA Department of Radiology, Tygerberg Academic Hospital and University of Stellenbosch, Tygerberg, W Cape Abstract Standard teaching in the imaging approach to patients with back pain is that plain X-ray should only be obtained after 3 months of conserva- tive treatment and thorough clinical examination and appropriate labora- tory investigations. This approach, while appropriate in first-world coun- tries, may lead to conditions such as tuberculosis of the spine being over- looked. An analysis was therefore made of 1 383 patients with com- plaints of lower back pain who were referred for X-ray of the lumbar spine. In 28 patients active spinal tuberculo- sis was diagnosed; in 8 of these patients the diagnosis had not been suspected clinically. It is concluded that in South Africa with its unsophis- ticated patient population and poor facilities,limited X-ray (lateral and AP view) of the lumbar spine is justified in patients presenting with back pain for the first time . Introduction It is now accepted and well-docu- mented in both the European and American literature that radiological investigation in patients presenting with backache should be reserved for those patients who fail to respond after a 2 - 3-month period of conserv- ative treatment. In a frequently cited investigation, Nachemson 1 reported that in the absence of clinically suspi- cious features, routine radiographs in patients with backache have a 1 in 2 500 chance of detecting serious dis- ease. It is questionable, however, whether this well-reasoned approach can be adopted as the level of sophis- tication of the patient population dif- fers markedly between first-world and third-world countries, Certainly in South Africa, where diseases such as spinal tuberculosis are not only com- mon, but are increasing in frequency, there is perhaps justification for utilis- ing routine radiographs of the lumbar spine as a primary investigation in patients presenting with backache. Methods A retrospective review was under- taken of patients presenting either to the general outpatient or orthopaedic outpatient departments at Tygerberg 9 SA JOURNAL OF RADIOLOGY • August 2003 Hospital during a 9-month period. Patients with complaints of low back pain (N = 1 383) were referred for radiography of the lumbar spine. Antero-posterior (AP) and lateral views of the lumbar spine were obtained and reviewed by a single radiologist. In cases where spinal tuberculosis was detected, the clinical records were analysed in order to ascertain whether a diagnosis of spinal tuberculosis was suspected prior to the patient being X- rayed. Results Table I shows the radiological findings in the group of patients examined, In 805 patients no abnor- malitywas detected. In 515 there was evidence of either degenerative disk disease or facet joint disease. Fourteen patients had changes of Paget's dis- ease, while 6 patients showed changes of neoplastic disease and 20 patients had evidence of spondylolisthesis. In the group of 28 patients with active spinal tuberculosis, review of their clinical records revealed that in 8 patients the diagnosis had not been suspected clinically (Fig. Ia, b). Table I. Observation on X-ray examination of the lwnbar spine in 1 383 consecutive patients pre- senting with backache (N) Normal 805 Facet joint artluosis } 515Spondylosis Paget's disease 14 Neoplastic disease 6 Spondylolisthesis 20 Tuberculosis 28 Total 1383 ORIGINAL ARTICLE B Fig. 1a, b. AP and lateral views of the lumbar spine showing destruction of the vertebral body of L3 with narrowing of the L3-4 disk space due to spinal tuberculosis. Discussion Lumbar spine radiography is an examination associated with a high radiation dose. For an individual patient, the standard three film exam- ination involves an average absorbed radiation dose of 2.2 mSV; this is about 40 times the dose received dur- ing chest radiography;' Halpin et al: suggested that as every radiation exposure carries a 1/80 000 risk per mSV of inducing a fatal cancer, this would mean statistically that of the 700000 people who underwent lum- bar spine radiography in the UK in 1973, 19 people would die each year as a consequence of these X-rays. Nachemson 1 and Waddell,' in sep- arate reports, suggest that careful clin- ical evaluation together with appro- priate blood tests, including erythro- cyte sedimentation rate (ESR), are more appropriate initial investigations than X-ray. These authors reserve radiographic investigation for those patients whose symptoms have not settled after 3 months of conservative treatment. The above approach makes several assumptions which are not necessari- ly correct with regard to third-world patient populations. Language prob- lems are a major barrier to obtaining an accurate clinical history. Further, in South Africa many patients do not return for their follow-up appoint- ments. Patients from poor socio-econom- ic circumstances who have abnormal laboratory tests and fail to return for follow-up are extremely difficult to contact. As such it is difficult to request them to present for treatment. In light of all the above it is very difficult to ensure that patients with back pain who are not improving on treatment, or who have abnormal lab- oratory investigations, will return to hospital before their disease has advanced significantly. The primary purpose of plain film radiography of the lumbar spine is to exclude the presence of serious dis- ease. These are conditions which pro- duce symptomatology very similar to that experienced due to mechanical or discogenic back pain. In his compre- 10 SA JOURNAL OF RADIOLOGY • August 2003 hensive review of the value of radiolo- gy for back pain, Butt' mentions con- ditions such as spondylosis, ankylos- ing spondylitis, and in the older patient, metastasis to the base of the pedicle. Significantly, he does not mention infective conditions of the vertebral bodies and disc spaces. Our radiographic protocol for screening patients with back pain utilises only two radiographs, the lat- eral and AP views. Special attention is paid to ensuring that the thoraco- lumbar junction is demonstrated on the radiographs. We find that the AP view is of considerable value in the diagnosis of spinal tuberculosis. Paravertebral abscesses, early disk space narrowing and posterior spinal involvement are shown to advantage. Spinal tuberculosis is endemic in South Africa and tuberculosis is par- ticularly prevalent in the Western Cape. Amongst the coloured popula- tion, there has been an untoward, sus- tained rise in the incidence of tuber- culosis. This upward trend com- menced in 1971, and the predicated pulmonary tuberculosis incidence rate for the coloured group for the year2001 was 672/100 000 of the pop- ulation," Many patients with spinal tuber- culosis present with grumbling back pain. The degree of pain experienced is unreliable in predicting abnormal radiological findings as reported by Halpin et al.? and in a separate inves- tigation by Kelen et al? Conclusion In this series, utilisation of lumbar spine radiography as an initial investi- gation in patients presenting with backache, was responsible for the detection of spinal tuberculosis in 8 patients. Crosier has reported a time ORIGINAL ARTICLE lag of at least 4 months between the onset of backache and the first proper clinical examination in a series of patients with spinal tuberculosis in South Africa. The extra cost involved in routine radiography of the lumbar spine as an initial investigation as well as the irra- diation dose to the patient, must be weighed against the dangers of over- looking early spinal tuberculosis. Progression of untreated spinal tuber- culosis to spinal cord compression and paraplegia is a catastrophe for the patient, often resulting in life-long dis- ability. In our view, the use of a limit- ed two-film radiographic examina- tion of the lumbar spine as an initial investigation in patients presenting with backache is justified and should be performed in those countries where tuberculosis is endemic. References 1. Nachemson A. A critical look at conservative treatment for low back pain. In: Jayson M, ed. The Lumbar Spine and Back Pain. London: Sector, 1976: 355-366. 2. National Radiological Protection Board. Living Witll Radiation. London: HMSO, 1989. 3. Halpin SFS, Yeoman L, Dundas DD. Radiographic examination of the lumbar spine in a community hospital: an audit of current practice. BM1l992; 1: 87-89. 4. Waddell G. An approach 10 backache. British JOl/mal of Hospital Medicine 1982; 28: 187-219. 5. Butt WP. Radiology for back pain. Clin Radial 1989; 40: 6-10. 6. Grzybowski S. Exploring some hypotheses on tuberculosis with a distinguished visitor from abroad. Epidemiological Comments 1993; 20(6): 90-99. 7. Kelen GD, Noji EK, Doris PE. Guidelines for the use of lumbar spine radiography. AIlIi Emerg Med 1986; 15: 245-251. 8. Crosier JH. Spinal tuberculosis and paraplegia - a personal viewpoint. South African [ournal of Balle Joint Surgery 1993: Forum. 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