General Guideline Principles for Imaging Studies of
Mid and Low Back Injury for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Imaging Studies of Mid and Low Back Injury.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Imaging Studies of Mid and Low Back Injury

1. Roentgenograms (X-Rays

   Routine x-rays for acute non-specific back pain

   Routine x-rays for acute non-specific back pain are recommended probable conditions in cases of acute back problems with red flags indicating fracture or major systemic illness, joint pain that is not recovering, or non-NYS acute back pain.

   Frequency/Duration: Except for patients with fractures, where more data monitoring may be needed, getting an x-ray once is usually sufficient. For individuals with quasi-back pain, it might make sense to get another set of results months or years later to reassess the patient’s health, especially if their symptoms alter.

   Routine x-rays for acute non-specific back pain not recommended – Imaging studies are not advised during the first four to six weeks of backache symptoms if there are no red flags (signs of potentially dangerous disease, such as temperature, weight loss, nocturnal discomfort, night sweats, stool or bladder incontinence, or major trauma).

    

2. Flexion and Extension Views are recommended – to assess the symptomatic spondylolisthesis when surgery or other invasive treatment is being considered, or occasionally in the aftermath of trauma.

   Frequency/Duration: In the absence of a clinical course that is rapidly changing, extensions and flexion and lateral flexion and extension images are typically only required every few years.

    

3. Magnetic Resonance Imaging (MRI)

   For defining anatomy, MRI is regarded as the industry standard since it provides exceptional resolution without radiation exposure. Although CT is still a valuable analytical tool, it is less frequently used nowadays due to the higher resolution of MRI, especially when it comes to the skin of something like the spine (spinal nerve compression, abnormalities of the spinal cord, and abnormalities of the nerve root).

   The use of an MRI may be prohibited by the presence of ferrous material or metallic objects in tissue. The magnetic field of an MRI frequently causes a metallic object to become loose, which can result in serious injury or even death.

   Gadolinium augmentation for the MRI examination may be necessary for individuals who have undergone prior thoracic as well as lumbar surgery, have concerns about malignancy, or have an infection.

   Any underlying medical issues that might preclude the use of an enhanced MRI should be taken into consideration as this should be done in cooperation with the requesting doctor. If the initial scan’s resolution was insufficient, a second MRI utilising a different method might be necessary.

   When the recovery physician (e.g., physiatrist, injury prevention physician, etc.), radiologist, or surgeon certifies that the study, a technical tools MRI may be a repetition of the same process.

    

   1. Magnetic Resonance Imaging (MRI) is recommended

      Patients with acute back problems during the first six weeks are advised to receive this treatment if they have a history of neoplasia (cancer), a significant neurological deficit, a progressive neurologic deficiency, cauda equina syndrome, significant trauma, or an unusual presentation (e.g., the clinical article claims multiple nerve root involvement).

       

   2. Magnetic Resonance Imaging (MRI) is recommended

      Patients who experience severe back problems during the first six weeks are advised to receive this treatment if they have a legacy of neoplasia (cancer), a significant neurological deficit, a progressive neurologic deficiency, cauda equina syndrome, significant trauma, or an unusual presentation (e.g., the clinical article claims multiple nerve root involvement).

      If the patient and the doctor are willing to explore immediate surgical treatment for acute pain disorders in the first six weeks and the symptoms are serious and not improving, and assuming the MRI demonstrates continued nerve root compression, this is advised.

      Frequency/Duration: duplicate MRI imaging is not advised in cases where symptoms and/or indicators have not significantly worsened clinically.

       

       

   3. Magnetic Resonance Imaging (MRI) is recommended

      If the patient and the doctor are thinking about early surgical therapy for a patient with non-acute radicular pain syndromes spanning at least six weeks and whose symptoms are not improving.

      An MRI at three to four weeks (before the epidural steroid injection) may be suitable in situations where an intravenous glucocorticosteroid injection is being explored for momentary alleviation of acute or subacute radiculopathy (Injections: Therapeutic Spinal).

       

   4. Magnetic Resonance Imaging (MRI) is Recommended as an alternative for the assessment of a subset of non-acute back pain patients to exclude coexisting pathology unrelated to injury.

      Before three months and the failure of various therapeutic modalities (including NSAIDs, aerobic activity, other forms of exercise, and recommendations for manipulation and/or acupuncture), this should only very infrequently be taken into consideration.

       

   5. Magnetic Resonance Imaging (MRI) is not Recommended if you have a severe backache or radicular pain syndromes within the first six weeks without warning signs.

       

   6. Magnetic Resonance Imaging (MRI) is not Recommended Standing or weight-bearing MRI is not recommended for any syndrome or illness that causes back or radiating pain. In the lack of evidence indicating better patient outcomes results, this technology is presently thought experimental/investigational.
4. Computerised Tomography (CT) of Imaging Studies

   There is a lower need for CT because MRIs have a much higher resolution, especially when it comes to the soft tissue components of the spine. CT is still a useful test for assessing the spine’s calcified or bony structures, though. When MRI is not an option for a patient, a CT scan is the most helpful (most typically an implanted metallic-ferrous device).

   Although CT is minimally invasive (or non-invasive when contrast is required), it does expose patients to radiation. Given its higher sensitivity for detecting nerve root compression, CT myelography should be taken into consideration in patients with radicular complaints.

   In a restricted group of individuals for whom the procedure’s advantages outweigh its hazards and in whom an MRI is not diagnostically necessary nor appropriate nor clinically contraindicated.

    

   1. Computerised Tomography (CT) is recommended for individuals with radicular pain syndrome who don’t get better in four to six weeks, a CT scan is advised (MRI is ideal), and surgical discectomy or an epidural glucocorticoid injection may also be considered.

       

   2. Computerised Tomography (CT) is recommended in individuals who need an MRI but are unable to have an exam because of a contraindication, such as an implanted metallic-ferrous equipment or severe claustrophobia.

      Frequency/Duration: Repeat imaging may be necessary if there has been a marked worsening in the patient’s examination history, but serial CT tests are not advised.

       

   3. Computerised Tomography (CT) is not recommended as routine CT for radicular pain syndromes or acute or non-acute nonspecific back pain.

       

5. Myelography (Including CT Myelography and MRI Myelography)

   Only when MRI is not recommended, is not regarded as a diagnostic test, or is not available, may it be beneficial. This examination may be recommended for a small number of patients whose clinical advantages outweigh their hazards and in whom an MRI is neither diagnostically useful nor clinically appropriate or contraindicated.

   Note: Pain, infection, and allergic responses are possible side effects of this more invasive procedure.

   Myelography (Including CT Myelography and MRI Myelography) are Recommended In rare, specific circumstances (such as those involving implanted metal that prevents MRI, ambiguous disc herniation findings on MRI that are suspected of being falsely positive, spinal stenosis, and/or a post-surgical situation that necessitates myelography), myelography, including CT myelography, is advised in certain patients.

   Myelography (Including CT Myelography and MRI Myelography) are not recommended Using myelography as the initial diagnostic test to determine whether the lumbar root is compromised, along with CT and MRI myelography.

   Indications: This examination may be recommended for a small number of individuals whose clinical benefits outweigh their hazards and in whom an MRI is neither diagnostically useful nor clinically appropriate.

   Note: Pain, infections, and allergic responses are possible side effects of this more invasive method.

    

6. Bone Scans
   • Bone Scans is recommended In certain cases, when clinically appropriate,

     Bone scanning is a useful diagnostic tool for some conditions that only affect a small percentage of patients. These conditions include neoplasia, presumed metastases, infection (such as osteomyelitis), inflammatory arthropathies, and concealed fractures.

   • Bone Scans is not recommended For frequent use in lower back patients,

     Note: Most scenarios involving occupational back pain are not evaluated using this method.

      

7. Fluoroscopy

   Fluoroscopy is not recommended for the evaluation of acute or non-acute back pain.

    

8. Single Proton Emission Computed Tomography (SPECT)

   Single Proton Emission Computed Tomography (SPECT) are recommended In certain cases, when clinically appropriate.

   Indications: SPECT is rarely used in the evaluation of individuals with back pain, except for suspected reactive arthropathies that are not identified by more routine tests or to check out potential acute spondylolysis.

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