To X-ray or not to X-ray? - Sports Medicine Doctor Malta - Dr Danica Bonello Spiteri

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To X-ray or not to X-ray?

To X-ray or not to X-ray? (First published on vida magazine on August 2013)

Last month we dealt with the presenting scenario of back pain. This month we will deal with medical imaging in relation to back pain. It is not uncommon for a client seen in clinic to demand some form of imaging, namely x-rays and/or MRI scans, as otherwise the doctor is thought of not doing the right assessment. Unfortunately, this is not the case.

When a person presents with back pain, a detailed history and clinical examination often provides enough information for the specialist to make the diagnosis and start treatment. The history, which is the story the client tells, and the examination of the back will provide information about the function of the lower back and related structures that may be attributing to the back pain.

On the other hand, an x-ray gives us information about bones mainly, whilst an MRI is preferred when looking at the intervertebral discs, which lie between the vertebral bones, and the nerves which may get pinched when exiting from the spinal cord. Hence imaging reveals the anatomy of the spine, but tells us nothing about the functioning of the movement of the spine and the surrounding structures.

Imaging any person over the age of 30years old will show ‘degenerative’ changes within the back, and these are often age related changes, or normal wear and tear and do not necessarily mean that they are the actual cause of the back pain. This is often incorrectly called ‘degenerative disc disease’, and clients are labeled as such, and they believe this is the cause of their back pain. Degenerative changes in the back include decreasing disc space and some bony outgrowths from the vertebral bones, known as osteophytes (part of the picture of osteoarthritis). Such changes occur in everyone as we grow older, and are similar to the wrinkling and grey hair that occurs in all of us, so they are not a ‘disease’.

A good clinician should not be treating the changes seen on the x-ray and/or MRI, but rather listening to the client’s story and aim towards restoring functionality. This does not mean that there is no role for imaging in back pain, but that it should be done in adequately selected cases.

Due to time restraints and/or lack of adequate clinical skills in performing a detailed back examination,  it is sometimes easier for a clinician to skip/skim through the examination and just write a piece of paper to request a scan. Once the scan returns as normal, the client may be waived off as having nothing ‘wrong’ with their backs, hence the client is once again at a loss.

On the other hand, if the scan comes back as abnormal, it may lead to more investigations, procedures, costs and risks to the client, all of which may be unrelated to the back pain, so this may also distress the client further, whilst going away from the actual back pain.

Unfortunately, in medical school, there is a lack of understanding and teaching about musculoskeletal conditions, including low back pain, hence a lack of clinical examination skills and understanding about the lower back. However, the increasing awareness about musculoskeletal medicine in Malta is changing, and will hopefully avoid unnecessary imaging being carried out on the wrong clients.


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