Tests
Your Organizational Guidance
ebpracticenet urges you to prioritize the following organizational guidance:
Klinische richtlijn rond lage rugpijn en radiculaire pijnPublished by: KCELast published: 2018Guide de pratique clinique pour les douleurs lombaires et radiculairesPublished by: KCELast published: 20181st tests to order
Tests to consider
lumbar spine MRI
Test
MRI without intravenous contrast is the preferred first-line investigation for the majority of patients with symptom duration greater than 6 weeks.[3]
Can eliminate fracture, spondylolisthesis, and tumor/abscess diagnoses.
MRI should be ordered in the following circumstances: suspect radiculopathy or spinal stenosis in potential candidates for surgery; suspect cauda equina; postsurgical lower back pain; unexplained weight loss; immunosuppression; history of cancer; intravenous drug use; prolonged use of corticosteroids; or persistent pain >6 weeks' duration.[3]
MRI is of limited diagnostic value in acute nonspecific lower back pain. Studies have revealed disk protrusions, degenerative changes, and spinal stenosis in asymptomatic patients who should not undergo any intervention.[3][74][75][76]
Imaging is not required for musculoskeletal low back pain lasting <6 weeks in the absence of red-flag features or suspicion of an underlying disease or alternate diagnosis.[3][63][65][66][68][69][70][73]
CT should be ordered in the following circumstances: if MRI contraindicated; need to depict details of spondylolysis, pseudoarthrosis, or scoliosis; persistent suspicion of vertebral body fracture despite normal lumbar spine x-ray; or detailed view of surgical fusion, instrumentation, or bone graft integrity is needed.[3]
Result
visualizes scar tissue and degenerative changes
lumbar spine x-ray
Test
Plain films may be sufficient for the initial evaluation of the following patient groups: recent significant trauma (at any age), minor fall or heavy lift in a potentially osteoporotic or elderly person.[3]
Can eliminate fracture, spondylolisthesis, or tumor diagnoses.
X-rays should not be ordered for nonspecific lower back pain of <6 weeks' duration as it has no effect on outcomes.[3][63][65][66][67][68][69][70][73][77][78]
Result
degenerative changes
lumbar spine CT
Test
Not as useful as MRI for depicting disk protrusions.
Better than MRI for identifying bony pathology.
Imaging is not required for musculoskeletal low back pain lasting <6 weeks, in the absence of red-flag features or suspicion of an underlying disease or alternate diagnosis.[3][63][65][66][68][69][70][73]
CT should be ordered in the following circumstances: if MRI contraindicated; need to depict details of spondylolysis, pseudoarthrosis, or scoliosis; persistent suspicion of vertebral body fracture despite normal lumbar spine x-ray; or detailed view of surgical fusion, instrumentation, or bone graft integrity is needed.[3]
Result
identifies bony pathology
myelography
Test
Sensitivity of spinal stenosis using myelography (67% to 78%) is lower than with CT and MRI.[79]
Disadvantages include requirement for contrast and lumbar puncture, thus seldom used.
Result
absence of disk herniation and spinal stenosis
CBC
Test
Normal WBC count suggests active infections such as osteomyelitis are less likely.
Result
normal
erythrocyte sedimentation rate (ESR)
Test
Normal ESR suggests active infections (e.g., osteomyelitis), active rheumatologic disease, or neoplasia are less likely.
If ESR is elevated, further workup is warranted.
Result
normal
C-reactive protein (CRP)
Test
Normal CRP suggests active infections (e.g., osteomyelitis), active rheumatologic disease, or neoplasia are less likely.
If CRP is elevated, further workup is warranted.
Result
within normal limits
urinalysis and culture
Test
Normal urinalysis (absence of WBCs/RBCs) and culture suggests acute pyelonephritis is unlikely.
Result
normal
blood cultures
Test
Negative blood culture suggests osteomyelitis is less likely.
Result
negative
radionuclide bone scan
Test
Negative technetium polyphosphate test can rule out the diagnosis of osteomyelitis. In general, the test is only necessary if radiographic results are ambiguous.
Result
normal
electromyogram (EMG)
Test
If peripheral neuropathy or plexopathy is suggested by the pattern of motor, sensory, or reflex impairment, further investigation with EMG is indicated.
Normal EMG evaluation rules out a peripheral neuropathy or plexopathy (e.g., diabetic peripheral neuropathy/diabetic amyotrophy).
Do not order an EMG for low back pain unless there is leg pain (sciatica), weakness or numbness.[64]
Result
normal
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