Radiology 2000; 217:321-330
Brant-Zawadzki Michael N., Dennis Steven C., Gade George F., Weinstein Michael P.
Low back pain is the second most common complaint encountered by primary care physicians (after the common cold) (1). Up to 80% of all individuals will experience low back pain at some point in their lives. Unfortunately, a specific diagnosis is not made in 80% of low back pain syndromes (2,3). In patients with low back pain and even radiculopathy, the indications for surgical versus conservative management are difficult to specify, because the long-term outcome of conservative therapy appears to be the same as that of surgery (4-17).
Because of these statistics, treating patients with low back pain can be particularly frustrating for clinicians, and imaging is a common diagnostic tool used to gather information and direct therapy. The same frustrations of natural history, diagnostic dilemmas, and posttherapeutic outcomes prey on the radiologist. There is a considerable lack of standardization in terms of diagnosis, both clinically and in the imaging arena. For example, a group of experienced spine surgeons, when given a set of eight specific surgical observations, provided more than 50 diagnostic terms to label the conditions presented (18). Similarly, the terminology for disk abnormalities at imaging includes a variety of labels, including bulge, herniation, rupture, protrusion, extrusion, and sequestration, that can vary in meaning and importance from patient to patient and from location to location (9-20). Controversies in clinical management are paralleled by the choices of modalities within the diagnostic armamentarium. The choices of imaging modalities include radiography, computed tomography (CT), magnetic resonance (MR) imaging, myelography with postmyelographic CT scanning as an adjunct, and diskography. Each modality has certain strengths and limitations (21-23).