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A SURVEY OF THE ORTHOPEDIC SURGEONS’ OPINION ON THE ROLE OF LUMBOSACRAL X-RAY IN THE MANAGEMENT OF PATIENTS WITH LOW BACK PAIN

 ABSTRACT

This study involved the orthopedic surgeons in Government Hospital in Enugu urban. The sampling technique used, being purposive sampling. A population of twenty (20) orthopedic surgeons was used and this included only senior registrars and consultant orthopedic surgeons. The source of data was primary, collected from orthopedic surgeons working at the University of Nigeria Teaching Hospital (UNTH) and National Orthopedic Hospital (NOHE), Enugu. All data were from self-administered semi-structured questionnaires. Descriptive statistics of frequency distribution and percentage were used to analyze the data.

Data collected showed that low back pain was one of the most frequent diagnoses in practice as it constituted about 50-70% of the clinical cases attended to by 55% of the orthopedic surgeons in a week on the average. The incidence of low back pain peaked at ages 41-50 and 55% of patients that presented with low back pain were within that range. The common radiographic finding was spondylosis as it constituted about 50% of the major cause of the low back pain cases. The diagnostic yield of lumbosacral x-ray was fairly reliable as 85% of the orthopedic surgeons sent patients that presented with low back pain for the lumbosacral x-ray.  Lumbosacral x-ray was useful in the management of patients with LBP from the orthopedic surgeons’ opinion (100%). CT and MRI were found to be the other possible diagnostic alternative to lumbosacral x-ray from the orthopedic surgeons’ point of view.

 

TABLE OF CONTENT

Title page…………………………………………………………….i

Approval page………………………………………………………ii

Certification………………………………………………………….iii

Dedication………………………………………………………….iv

Acknowledgement…………………………………………………..v

Abstract…………………………………………………………….vi

Table of contents……………………………………………………..vii

CHAPTER 1

1.1 Background of the study

1.2Imaging modalities for low back pain

1.3 Lumbosacral x-ray

1.4 Statement of the problem

1.5 Objective of the study

1.6 Significance of the study

1.7 Scope of the study

1.8 Literature review

CHAPTER 2

2.0 Anatomy of the lumbosacral spine

2.1 The intervertebral disc

2.2 Intervertebral foramen

2.3 Nerves of the lumbosacral spine

2.4 Pathogenesis of low back pain

2.5 Factors predisposing to low back pain

2.6 Differentiation of low back pain

2.7 Common types of dysfunction and injury to the lower back

CHAPTER 3

3.0 Research methodology

3.1 Research design

3.2 Source of data

3.3 Method of data collection

3.4 Target population

3.5 Sample size

3.6 Sampling method

3.7 Data analysis and presentation

CHAPTER 4

4.0 Data presentation

4.1 Discussion

CHAPTER 5

5.0Summary of findings

5.1 Recommendations

5.2 Limitation of the study

5.3Areas of further research

REFERENCES

 LIST OF TABLES

Table 1: Age and sex of respondents

Table 2: Respondents place of work

Table 3: % of low back pain cases attended to by the respondents

Table 4: Major causes of low back pain

Table 5: Respondents answer on how often patients with low back pain are sent for a lumbosacral x-ray

Table 6: Respondents rating of this modality

Table 7: Diagnostic yield of lumbosacral x-ray

LIST OF FIGURES

Figure 1:  usefulness of lumbosacral x-ray in the management of patients with low back pain from the respondent’s point of view.

 

INTRODUCTION

1.1 BACKGROUND OF STUDY

Low back pain is a common musculoskeletal disorder affecting 80% of people at some point in their lives. Low back pain can range from mild, dull, annoying pain, to persistent, severe, disabling pain in the lower back. Pain in the lower back can restrict mobility and interfere with normal functioning. Low back pain is one of the most significant health problems. [1]

Causes of lower back pain are varied. Most cases are believed to be due to a sprain or strain in the muscles and soft tissues of the back.[2] Overactivity of the muscles of the back can lead to an injured or torn ligament in the back which in turn leads to pain. An injury can also occur to one of the intervertebral discs (disc tear, disc herniation). Due to aging, discs begin to diminish and shrink in size, resulting in vertebrae and facet joints rubbing against one another. Ligament and joint functionality also diminish as one age, leading to spondylolisthesis, which causes the vertebrae to move much more than they should. Pain is also generated through lumbar spinal stenosis, sciatica and scoliosis. At the lowest end of the spine, some patients may have tailbone pain (also called coccyx pain or coccydynia). Others may have pain from their sacroiliac joint, where the spinal column attaches to the pelvis, called sacroiliac joint dysfunction which may be responsible for 22.6% of low back pain.[3] Physical causes may include osteoarthritis, rheumatoid arthritis, degeneration of the discs between the vertebrae or a spinal disc herniation, a vertebral fracture (such as from osteoporosis), or rarely, an infection or tumor[4].

Low back pain can be either acute, subacute, or chronic in duration. With conservative measures, the symptoms of low back pain typically show significant improvement within a few weeks from onset. Low back pain may be classified by the duration of symptoms as acute (less than 4 weeks), sub-acute (4–12 weeks), chronic (more than 12 weeks).[2]The majority of lower back pain stems from benign musculoskeletal problems, and are referred to as non specific low back pain; this type may be due to muscle or soft tissues sprain or strain, particularly in instances where pain arose suddenly during physical loading of the back, with the pain lateral to the spine. Over 99% of back pain instances fall within this category.[5]

Most people with acute lower back pain recover completely over a few weeks regardless of treatments.[6] 60% of people recover after seven weeks, regardless of the treatments they receive.[7] Consistent with these statistics, a recent study found that almost 30% of patients did not recover from the presenting episode of low back pain within a year.[8]

1.2 IMAGING MODALITIES FOR BACK PAIN

Conventional x-ray

X-ray is useful for diagnosing skeletal lesions due to trauma, systemic disease or iatrogenic causes such as steroid use [9]. Radiographs (X-rays) can also give information about unstable or degenerating intervertebral discs by showing change in vertebral structure early in the disease [10]. Two orthogonal views are generally sufficient to characterize the nature and location of a lesion in bone, but soft tissue damage cannot be assessed [11] .Generally, X-ray is a good starting point and is best used as a screening test for misalignment or shape change of the vertebrae. The cause (osteoporotic fracture, tumor, infection, etc.) of such a finding may not be clear from the radiograph [12] .Diseases of the soft tissues like ligaments, tendons, cartilage, and discs in between the bones of the spine do not show up well on X-rays, hence disease of these structures in the lumbosacral spine may go undetected. Pathologies of the nerves coming from the spinal canal causing pain, numbness or weakness in the pelvis or legs cannot be seen on the plain lumbosacral X-ray. Overlapping or blurring of shadows on the X-ray image may result in small fractures of bone in the spine to go undetected or may sometimes incorrectly display a bone defect, or fracture where there is none. "Artefacts", due to overlapping can produce false non-anatomical structures on the final X-ray image. This can be caused by incorrect film handling or problems in processing such as spots, lines or fingerprints.

Computed tomography

Computed tomography (CT) can take the place of more invasive imaging techniques such as myelography, epidural venography and epidurography [10]. It is more helpful than radiographs because of the fast acquisition times, high resolution, and 2-dimensional and 3-dimensional detail it provides, especially for complex vertebral fractures. It should be performed when radiography is inadequate [13]. CT is optimal for imaging of bony lesions and may catch problems that will be missed on traditional X-rays, which provide more limited views [14]. Imaging of soft tissue is better with CT than with radiography (although CT is inferior to MRI in this respect). CT may not distinguish symptomatic findings from incidental ones, however, leading to overdiagnosis. For example, herniated discs may show up on CT, but may not be the cause of pain [11]. CT subjects the patient to more radiation and is more expensive than a plain radiograph, but it gives more information than an X-ray and is a good alternative when MRI is contraindicated, as in the case of claustrophobic patients or those with pacemakers.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) and CT myelography are comparable in diagnosing spinal stenosis or herniated discs. MRI may be somewhat more sensitive to and specific for herniated discs. It is superior in detecting infections like osteomyelitis and bone or soft tissue tumors, in terms of both sensitivity and specificity [15]. It is also best for soft tissue imaging. In general, MRI is the best tool for diagnosing patients with lower back pain because it picks up a greater number of abnormalities than radiograph or CT [16]. MRI is the only imaging technique that allows direct visualization of the spinal cord and is therefore the best means for diagnosing congenital spinal lesions, myelopathies and metastatic cancers[13]. Because MRI does not use radiation, it is safer than X-ray and CT, but it is more expensive than they are, which may be a concern for some patients.

Ultrasound

Ultrasound is noninvasive, inexpensive and able to image soft tissues. Moreover, there are no contraindications for ultrasound as there are for MRI. Ultrasound scans have been able to provide structural information about intervertebral discs that can be related to their pathology [17].This is not a common technique though, and while sensitivity in finding painful and degenerative discs is high, specificity is low[18] . More studies must be conducted to determine its value in diagnosing disc pathology. It is very helpful in determining whether pain may be due to visceral organs. For example, ovarian cysts are easily diagnosed this way and may be the cause of back pain.

Nuclear scan

Bone scans (skeletal scintigraphy) are informative in excluding tumor, fracture, metabolic or degenerative changes in the bone, necrosis or infection. Bone scans are more sensitive than radiographs and are able to determine various pathologies with high specificity by identifying areas of new bone growth or breakdown [19]. Positron emission tomography (PET) is also revealing, especially for finding cancers. While PET scans do not offer as much detail as CT or MRI, they can detect changes in metabolic activity and are highly sensitive for early detection of cancers that may be causing pain. It may even pick up on a cancer earlier than CT or MRI and therefore may be the best imaging option if cancer is suspected. Nuclear scans expose the patient to about the same amount of radiation as a radiograph.

1.3 LUMBAR SPINE X-RAY

This is a plain X-ray of the five lumbar vertebrae that form the lumbar spine that is the sacrum and coccyx which are the back part of the pelvis and tail bones.

Antero- Posterior View: This is the most common view that is taken with the patient facing the X-ray beam and the spine is visible from the front to the back. In the AP view, the interpedicular distances are noted to increase from L1 to L5.

Lateral View: In the lateral view the X-ray beam comes from the side so as to show the side view of the spine. In the lateral view, the vertebral body of L1 is often slightly anteriorly wedged without buckling of the anterior cortex or condensation of endplates. Soft tissue swelling may indicate a fracture even if the fracture is not directly visualized

Oblique View: In this view, the x-ray of the spine may be recorded in different positions such as bending over forwards or bending backward. Structures that are best seen on the oblique views include the transverse process and pedicle on the dependent side and the pars interarticularis.

Uses of Lumbar Spine X-ray

Lumbosacral spine X-rays are used to detect various symptoms with which the patient presents such as pain in the spine, numbness and weakness in the pelvis and legs. They are also used to search for inflammation of joints between the backbones e.g.arthrites, and degeneration changes of the discs between the bones of the spine or tumors. Scoliosis and kyphosis which are abnormal curvatures of the spine can also be detected on X-rays. X-rays are used to detect dislocation or fracture of the spine that may occur due to spinal cord injuries. Congenital anomalies such as spina bifida can be diagnosed at an early age by use of X-rays. Post surgery spine X-rays are used to detect the complications that may arise after surgery e.g infection, malalignment of bones or failure of orthopaedic implants like joint replacement prostheses, plates, rods and screws. The X-ray procedure itself is painless. The position of the patient may be changed to the side in case of a side view or made to bend over forwards or arch backwards, so as to take exposures in different angles. The procedures are performed with the patient standing or lying flat on the X-ray table. [20]

Routine Projections for Lumbar Spine X-ray

Features noted on viewing X-ray images in the different Lumbar spine X-ray projections.

Anterior-Posterior (AP) L-S Spine

  • Vertical alignment of spinous processes
  • Intervertebral disc space uniformity
  • Pelvis and femoral heads

Lateral L-S Spine

  • Vertebral body
  • Facet joint
  • Lordotic curvature of L-S Spine
  • Intervertebral foramen
  • Intervertebral disc space height shortening

Oblique L-S Spine (tube angled at 45 degrees)

  • Neural foramina narrowing
  • Pars interarticularis defect
  • Spinal tumor
  • Facet hypertrophy
  • Spondylosis
  • Flexion and extension views
  • Used to assess ligamentous and bony injury[21]

Low back pain is one of the most frequent diagnoses in general practice. And before any treatment plan is embarked upon, the patient has to be x-rayed to confirm or to rule out low back pain. This research is undertaken to establish the orthopedic surgeons opinion on the role of lumbosacral x-ray in the management of patients with low back pain.

1.4 STATEMENT OF PROBLEM

  1. The diagnostic yield of lumbosacral x-ray in the management of low back pain has not been established in our locality.
  2. The orthopedic surgeons opinion on the usefulness or otherwise of the lumbosacral x-ray in the management of low back pain has not been ascertained.
  3. The possible diagnostic alternative from the surgeons’ point of view has not been established.

 1.5 OBJECTIVE OF STUDY

  1. To ascertain the diagnostic yield of lumbosacral x-ray in the management of low back pain in our locality.
  2. To ascertain the orthopaedic surgeons opinion on the usefulness or otherwise of the lumbosacral x-ray in the management of low back pain.
  3. To determine the possible diagnostic alternative to lumbosacral x-ray in the management of low back pain from the surgeons point of view.

1.6 SIGNIFICANCE OF STUDY

  1. The study will reveal the diagnostic yield of lumbosacral x-ray in the management of low back pain in our locality.
  2. The study will define the orthopaedic surgeons opinion on the usefulness of lumbosacral x-ray in the management of patients with low back pain.
  3. The study will reveal the possible diagnostic alternative to lumbosacral x-ray in the management of low back pain from the surgeons perspective.

1.7 SCOPE OF STUDY

The study will be carried out among orthopedic surgeons in government hospitals in Enugu urban.

1.8 LITERATURE REVIEW

Mcphail Sarah in her work on the role of lumbar spine x-rays in the diagnosis and management of patients with low back pain stated that lumbar spine x-rays were often overutilized, but the results from the x-ray findings were influential in the diagnosis and management of patients with low back pain. She found out that spondylosis was the most common radiographic finding. No suitable reason for obtaining the x-ray was provided in 14.6% of the x-rays requested and 27% were requested to examine for an unspecified pathology.  [22]  

Malmqvist Stefan et al, in their study on the Prevalence of low back and pelvic pain during pregnancy in a Norwegian population, stated that nearly 50% of the women experienced moderate and severe Pelvic pain during pregnancy. Approximately 50% of them had Pelvic Pain syndrome, whereas the other half experienced lumbopelvic pain. Ten percent of the women experienced moderate and severe Low Back Pain alone. These pain syndromes increased sick leave and impaired general level of function during pregnancy. They stated that Pelvic pain in pregnant women is a health care challenge in which moderate and severe pain develops rather early and has important implications for society. [23]

Macfarlane Gary J et al Conducted a study to determine the prevalence of low back pain (LBP) and associated disability; the frequency of consultation to general practice; whether there were differences in management by age. The 1-month period prevalence of LBP was 28.5%. It peaked at age 41-50 years, but at ages over 80 years was reported by 1 in 4 persons. Older persons were more likely to consult, and the prevalence of severe LBP continued to increase with age. Management by general practitioners differed by age of the patient. They stated that it was important that older persons, who have the highest prevalence of LBP with disability and are most likely to consult, are receiving optimal pharmacological and nonpharmacological management. [24]

Bartholomeeusen Stefaan et al, in their work noted that Low back pain is one of the most frequent diagnoses in general practice. The incidence of the most frequent diseases was compared in patients with and without LBP in 2004.The highest incidence was recorded in the age group of 50 to 54 years. The most frequent "other" diagnoses in patients with and without LBP were comparable, but some were more frequent in patients with LBP. Respiratory infections and diseases of the locomotor apparatus (neck syndrome, bursitis) were more frequent in patients with LBP. Striking is the relatively higher frequency of common self-limiting diseases in patients with a diagnosis of LBP during the same year. [25]

Leone A et al in their study stated that Multislice CT with multiplanar reformats is the most accurate modality for detecting the bony defect and may also be used for assessment of osseous healing; however, as with radiographs, it is not sensitive for detection of the early edematous stress response without a fracture line and exposes the patient to ionizing radiation. They also noted that Magnetic resonance (MR) imaging should be used as the primary investigation for adolescents with back pain and suspected stress reactions of the lumbar pars interarticularis. They concluded that MR was the imaging modality of choice for identifying associated nerve root compression. [26]

Deyo, RA et al, in their review in March 2009 found the following: Four randomized clinic trials showed that the benefits of spinal surgery are limited when treating degenerative discs with spinal pain (no sciatica). The review also found that higher spinal surgery rates are sometimes associated with worse outcomes and that the best surgical outcomes occurred where surgery rates were lower. It also found that use of surgical implants increased the risk of nerve injury, blood loss, overall complications, operating times and repeat surgery while it only slightly improved solid bone fusion rates. There was no added improvement in pain levels or function.[27]

  Turk Zmago et al conducted a study to investigate the prevalence of nonspecific low back pain (LBP) in a population of schoolchildren in Maribor, north-eastern Slovenia. 43% of children from elementary schools and 44% of children from secondary schools experienced back pain which lasted more than one day. They found out that among important reasons for LBP, 44% of children mentioned carrying a school bag, 28% sitting on school chairs, and 18% intensive sport activity. Clinical examination of cervical, thoracic, and lumbar spine has shown that 12% of primary children and 12% of secondary children have increased cervical lordosis and 15% of primary school children have increased lumbar lordosis. In 5% of schoolchildren, we found mild spinal scoliotic changes. Among our schoolchildren sedentary behavior and low physical activity dominate. They stated that  LBP may have an impact on their daily life, therefore it was important to recognize and treat it as soon as possible.[28]

Xu Guangxing et al in their study to measure the prevalence of low back pain in Chinese coal miners and to investigate the role of occupational factors stated that Low back pain is common among Chinese miners and that they were strong associations with occupational factors. Among the coal miners, 64.9% self-reported LBP in a 12-month period. Occupational factors associated with LBP were identified, including tasks with a high degree of repetitiveness. [29]

Jöud Anna et al in their work noted that Low back pain (LBP) affects most people at some stage in life. The 1-year consultation prevalence of LBP in the population was 3.8% (4.3% for women, 3.3% for men) and increased with age. LBP had been recorded in 17.1% of all patients (16.5% for women, 18.0% for men) who had been diagnosed with any musculoskeletal condition. The rate of first-time consultation was 238 per 10,000 adults (265 for women, 209 for men). They concluded that LBP was diagnosed in every sixth patient who consulted due to a musculoskeletal problem and that it was a public health concern that needs structured management.[30]

Lin Pei-Hsin et al in their work stated that Low back pain is a common health problem among hospital nurses. This study used a cross-sectional survey of 217 hospital nurses to gather self-reported information on the prevalence of back pain, demographic and pain characteristics, and work-related risk factors from 178 respondents who indicated a past history of back pain. The association between the characteristics of back pain and work-related risk factors was also examined. The lifetime prevalence of back pain was 82.03%, and the point prevalence of back pain was 43.78%. They concluded that low Back pain is common among hospital nurses in Taiwan. Years at work are significantly associated with pain severity and disability caused by back pain. [31]

 De Vitta Alberto et al carried out a study  to determine the prevalence of lower back pain in adolescents and its relationship to sports and sedentary activities. They conducted a cross-sectional study of 5th to 8th-grade students (n = 1,236) in Bauru, São Paulo State, Brazil. Bivariate and multivariate analyses showed independent associations between lower back pain and female gender, time watching TV, and sports. They concluded that low back pain in schoolchildren can persist as chronic pain in adults and an Understanding the relationships between variables would provide useful measures for maintaining, improving, and promoting students' wellbeing. [32]
 Espeland A et al in their work on Patients' views on importance and usefulness of plain radiography for low back pain stated that Seventy-two percent (68 of 93) of patients rated radiography as very important. The proportion was higher for men than women (85% vs. 65%, P = 0.04), higher for those with worsening than those with improving/unchanged symptoms (86% vs. 65%, P = 0.03), and higher for inappropriately than appropriately referred patients (NR: 76% vs. 61%, P = 0.17; BR: 81% vs. 56%, P = 0.01). They concluded that patient's view may be a substantial barrier to appropriate use of radiography. [33]

The studies stated above shows that work has been done by different authors on the prevalence of low back pain and the role of imaging in the management of patients with low back pain. But that which concerns the orthopedic surgeons’ opinion on the role of lumbosacral x-ray in the management of patients with low back pain has not been done to the best of the researchers’ knowledge.

Attached Files

A SURVEY OF THE ORTHOPEDIC SURGEONS’ OPINION ON THE ROLE OF LUMBOSACRAL X-RAY IN THE MANAGEMENT OF PATIENTS WITH LOW BACK PAIN.docx
THE IMPACT OF PETROLEUM PRICE VOLATILITY ON NIGERIA’S ECONOMY
LEARNING ENVIRONMENT AND ACADEMIC PERFORMANCE OF SECONDARY SCHOOL STUDENTS IN LOCAL GOVERNMENT AREAS OF ABIA STATE.

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