Adult Patient Acute Neck Injury X-RAYS ARE INDICATED
• When ANY of the following CCSR criteria are fulfilled:
- Over 65
- Paraesthesias in extremities
- Not a simple rear end collision
- Immediate cervical pain onset
- Presence of midline cervical tenderness
- Patient unable to actively turn head to 45 degrees in both directions
In Acute Neck Injury X-RAYS NOT INDICATED
• When ALL of the following CCSR criteria are fulfilled:
- Simple rear end collision
- Delayed cervical pain onset
- Absence of midline cervical tenderness
X-rays Are Indicated In Acute Uncomplicated Neck Pain In Certain Circumstances
• If prior to seeing you the patients has had treatment with no success
take X-rays
• Consider X-ray or other tests in the absence of expected response to
your care or if there is worsening of symptoms
• BE SURE TO RECOGNIZE CHRONIC RECURRENT PAIN VERSUS ACUTE
PAIN
X-rays ARE Indicated In Nontraumatic Neck Pain AND Arm Pain or Paraesthesia
true or false?
true
X-rays ARE Indicated In Uncomplicated Subacute and Chronic Neck Pain With or Without Radicular Symptoms
true or false?
true when present for 4 or more weeks
X-rays ARE Indicated In Uncomplicated Subacute and Chronic Neck Pain With or Without Radicular Symptoms
⦿ Patient < 20 and> 50, particularly with S&S suggesting systemic
⦿ Significant activity restriction > 4weeks
⦿ No response to care after 4 weeks
⦿ Intractable pain, constant or progressive S&S
⦿ Neck rigidity in the sagittal plain in the absence of trauma
⦿ Cont. next slide
disease
Dysphagia
• Impaired consciousness
• Cranial n signs, pathological reflexes, long
tract signs
• High risk lig laxity populations/suspected
atlantoaxial instability
• Arm or leg pain with movement
• Suspected neoplasm
• Euro Commission radiation protection 118, 2001
• Suspected infection
• Kim JCCA 2004; 48(2): 132-6
• Suspected failed surgical fusion
• Progressive painful or structural deformity
• Elevated lab exam and positive S&S
X-Rays ARE Indicated with Recent (<2 weeks) Acute T, L, or T/L Trauma With ANY of the Following:
- Moderate to severe localized back pain
- Midline tenderness on palpation
- Neurological deficits
- MVA > 50 mph
- Fall of 10 ft or more
X-Rays Are NOT Indicated with Recent (<2 weeks) Acute T, L, or T/L Trauma With:
- Absence of pain
- Normal ROM
- Absence of neurological deficits
X-Rays are NOT Indicated in Acute Patients with Uncomplicated LBP, T pain
- Uncomplicated means:
- Nontraumatic
- No neurological deficits
- No Red Flags
or worsening after 4-6 weeks X-Rays are NOT Initially Indicated with Subacute or Chronic LBP, T pain AND No Previous Treatment Trial
⦿ When no prior treatment has been attempted, a trial period of 4-6
⦿ X-rays are indicated in the absence of expected treatment response
weeks is suggested prior to radiographs
X-Rays are NOT Initially Indicated with Nontraumatic Acute LBP AND Sciatica (Suspicion of Disc Herniation)
- Unless the patient is > 50
- Or has progressive neurological deficits
- Or has unexpected response to care after 4-6 weeks
- Or worsens with care
- MRI would be of value
Signs of Disc Herniation: Need 3 of 5 (consistent to same N level)
- Primarily leg pain
- Leg pain confined to dermatome
- Neural stretch tests recreate or exacerbate the leg pain
- At least 2 of 4 neurologic findings consistent with dermatome
- Muscle weakness
- Decreased reflex
- Abnormal pinwheel
- Atrophy
- MR or CT correlating to dermatome
X-Rays ARE Indicated with Suspected Degenerative Spondylolisthesis/ Lateral Recess Stenosis
true or false?
true
Signs of Degenerative Spondylolisthesis in Lumbar Spine
- Primarily scleratogenous leg pain (one or both legs)
- Comes and goes
- Often reduced by leaning forward or sitting down
- No neurologic findings
- Very common
- 4 F’s: fat, female (I didn’t come up with this ladies), forty, L4
X-rays ARE Indicated in Complicated (Red Flag) Thoracic and Lumbar pain
⦿ S & S of systemic disease especially <20 or >50
⦿ Absence of expected treatment results or worsening after 4-6 weeks
⦿ Significant activity restriction > 4 weeks
⦿ Unrelenting pain at rest
⦿ Constant or progressive S & S ⦿ Cont. next slide
X-rays ARE Indicated in Complicated (Red Flag)
- Suspected inflammatory spondyloarthropathy
- Suspected compression fracture
- Suspected neoplasm
- Suspected infection
- Suspected failed surgical fusion
- Progressive or painful structural deformity
- Elevated lab and positive S & S
Criteria for Inflammatory Back Pain
- Morning stiffness for > 30 minutes
- Improvement of back pain with exercise but not rest
- Awakening in the second half of the night due to back pain
- Alternating buttock pain
Signs of Suspected Neoplasm
- Considerable LBP > 50 • Hx of CA
- Unexplained weight loss
- Failure of conservative care
- Intractable pain
- ESR >50 mm/hr
- Systemically unwell
- Lymphadenopathy
Special Circumstances for X-Ray
• Pt unable to give a reliable Hx
• Crippling cancer phobia
• Need for immediate decision about career or athletic future or legal
evaluation
• Hx of significant radiographic abnormalities elsewhere
• Hx of finding from outside study (abdomen, etc.) that requires spine
evaluation
X-Rays Are NOT Indicated with Non Painful Non Progressive Adult Scoliosis
• In a skeletally mature patient, scoliosis is > 10 degrees
