Appropriateness in diagnostic imaging

Anatomy of a Lumbar Spine MRI: Indications for Imaging and Interpretation of Imaging for Surgical Referral


1Samuel Yoon MD, MSc, 2Tiffany Lung MD, BKin, 3 Albert Yee MD, MSc, FRCSC, FIOR,

1Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada.2Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada. 3 Professor of Surgery, Department of Surgery, University of Toronto, Marvin Tile Chair Division Chief of Orthopaedic Surgery, Division of Spine Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.


Abstract: Despite guidelines from multiple medical organizations including Choosing Wisely Canada, routine screening for low back pain symptoms with advanced imaging modalities such as Magnetic Resonance Imaging (MRI) persists. While sensitive, the high prevalence of asymptomatic or non-correlative degenerative findings limits their usefulness for routine screening. Given the constraints on Canadian healthcare resources this is a cause for significant concern. Lumbar MRI examinations should be ordered only with clear clinical indications and never for simple triage. Suitable indications include patients with symptoms of Cauda Equina Syndrome, suspected spinal malignancies, vertebral infections, or a progressive neurologic deficit correlating to a dermatomal and/or myotomal distribution.
Key Words: Appropriateness in diagnostic imaging, lumbar MRI, low back pain, surgical indications.

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Lumbar spine MRI is not a useful screening tool as incidental degenerative findings are extremely common.
Routine lumbar MRI usage to investigate low back pain is inappropriate and can cause harm to patients through wasted time and resources, as well as possible nocebo effects.
Lumbar spine MRI is indicated if accompanying Red Flag symptoms, such as recent systemic illness, high suspicion for tumour, or progressive/severe neurological symptoms/signs are present with the back pain.
Elective referrals to spine surgical specialists should confirm that the patient's clinical spinal condition aligns with advanced imaging findings.
The majority of patients with low back pain will improve with conservative management modalities.
Understanding clinical patterns of lumbar related axial pain and lower extremity referred neurologic symptoms is a more useful guide for determining whether or not patients are surgical candidates than obtaining images of structural change.
Patients suspected of having Cauda Equina Syndrome or exhibiting rapid progressive neurological decline in a dermatomal/myotomal distribution should be referred immediately for surgical evaluation.
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