Correlation of clinical signs and magnetic resonance imaging findings in patients with lumbar spondylosis

Abstract

Objectives: The purpose of the study was to contribute further to this debated topic by investigating the correlation of magnetic resonance imaging (MRI) findings with the clinical picture in lumbar spondylosis patients.

Patients and methods: This multicenter retrospective study (as part of the epidemiological project of the TLAR-OASG [Turkish League Against Rheumatism-Osteoarthritis Study Group]) included 514 patients (101 males, 413 females; mean age: 63.6±10.8 years; range, 40 to 85 years) who were diagnosed as lumbar spondylosis by clinical examination and direct X-ray between December 2016 and June 2018. Demographic characteristics of patients, Visual Analog Scale for pain, presence of radiating pain, Roland-Morris disability questionnaire, straight leg raise test, deep tendon reflexes, neurogenic intermittent claudication symptoms, any decrease of muscle strength, and abnormality of sensation were recorded. Lumbar MRI findings of the patients were recorded as positive or negative in terms of disc herniation, intervertebral disc degeneration, root compression, osteophytes, spinal stenosis. Statistical analysis was done to assess the correlation between the clinical symptoms, physical examination, and MRI findings.

Results: Correlation analysis of the MRI results and the clinical findings showed a significant correlation between straight leg raise test and root compression (p<0.001, r=0.328) and a significant correlation between neurogenic intermittent claudication and spinal stenosis (p<0.001, r=0.376). Roland-Morris disability questionnaire had a significant correlation with all MRI findings (p<0.05, r<0.200).

Conclusion: The results of this study corroborate the notion that diligent patient history and physical examination are more valuable than MRI findings, even though a higher incidence of abnormal MRI findings have been obtained in patients with disability and dermatomal radiating pain.

Introduction

Low back pain (LBP) is one of the most common health problems and is known to affect two-thirds of the adult population at least once in their lifetime.[1] LBP becomes a chronic condition and causes disability in 10% of the patients, creating further burden on the affected individuals, their families, and the society by increasing the costs of medical expenses, insurance, loss of productivity, and disability compensation.[2,3]

Lumbar spondylosis (LS) is a chronic noninflammatory condition characterized by degenerative changes in the discs or facet joints. The incidence of intervertebral disc degeneration (IDD) is 10% in the patients at age 50 but increases up to 60% around 70 years of age.[4] These degenerative changes in the lumbar spine are a major etiological factor in the development of LBP and disability in the elderly population.[5]

Intervertebral disc degeneration is strongly related to LBP, and while it is asymptomatic in most cases, it may give rise to sciatalgia in some cases and to spinal stenosis in the long term, which is an important cause of pain and disability particularly in elderly patients.[6,7] The clinical picture in LS patients include discomfort in the lower back, radiating leg pain, and neurogenic intermittent claudication (NIC).[8]

Lumbar spondylosis diagnosis is made by clinical examination and imaging methods. Joint movement may be restricted and painful. Root compression symptoms may accompany the clinical picture. Detection of degenerative changes in the lumbar X-rays, such as osteophytes, intervertebral narrowing, and subchondral sclerosis, support the diagnosis.[9] Magnetic resonance imaging (MRI) is the best imaging tool for the assessment of detailed structural changes in the spinal canal, the ligaments, the discs, and the nerve roots.[10] However, in studies examining MRI findings in asymptomatic individuals, it was reported that a significant proportion of patients had bulging, annular tears, facet arthropathies, and it was emphasized that degenerative changes increased with age.[11] Weiner et al.[12] have pointed to the excessive diagnostic tests in elderly patients with LBP and emphasized unnecessary employment of MRI in most of the patients, which contributed substantially to the increased health costs. It is crucial to delineate the correlation between the imaging findings, the history, and the physical examination of the patients when the high prevalence of disc protrusion and degenerative spinal stenosis (SS) in elderly patients is considered.[7,13] Although MRI is a proven method for precisely detecting the structural changes, correlation of MRI findings with patient history and clinical condition is still debated.[14]

There are several clinical studies in the literature focusing on the clinical findings in radiculopathy,[15-17] but there is limited evidence on the correlation of MRI findings with patient history and clinical symptoms in the patients with LS.[18] The purpose of our study was to contribute further to this debated topic by investigating the correlation of MRI findings with the clinical picture in LS patients. We also aimed to determine which findings are significant in LS patients, when MRI should be requested, and clinical findings for which an expensive diagnostic method such as MRI is unnecessary.

Patients and Methods

The retrospective study was conducted between December 2016 and June 2018. The patients who applied to the physical medicine and rehabilitation outpatient clinics of 33 university or training and research hospitals (as part of the epidemiological project of the TLAR-OASG [Turkish League Against Rheumatism-Osteoarthritis Study Group]) with complaints of chronic LBP and diagnosed as LS by clinical examination and direct X-ray were evaluated for eligibility. The radiological findings (osteophytes on X-ray, narrowing of intervertebral joints, and subchondral sclerosis) of patients aged between 40 to 85 years with chronic low back or leg pain who were suspected of having LS by a clinician were evaluated, and those with the diagnosis of LS were included. The patients with peripheral and central nervous system diseases, inflammatory rheumatic disease, metabolic bone diseases (Paget’s disease, osteomalacia, and hyperparathyroidism), chronic thyroid, renal, and liver disease, those using drugs that increase bone loss, such as glucocorticoids and anticonvulsants, atherosclerotic occlusive peripheral vascular disease, spinal tumor, restless legs syndrome, and malignancy were excluded from the study.

Of the 550 evaluated patients, 36 patients were not eligible for participation; thus, 514 patients (101 males, 413 females; mean age: 63.6±10.8 years; range, 40 to 85 years) were included in the study. Demographic characteristics of the patients were recorded. Visual Analog Scale (VAS) values for pain during the day (at rest and with movement) and at night, presence of radiating pain, Roland Morris disability questionnaire (RMDQ) for functional status evaluation, straight leg raise test (SLRT) for sciatalgia, deep tendon reflexes (DTRs; as hypoactive, normal, or hyperactive), NIC findings, and motor strength and sensory loss were recorded. MRI findings of patients who already had a recent (past six months) lumbar MRI were analyzed. MRI findings were recorded from reports evaluated and written by radiologists. Lumbar MRI findings (disc herniation, IDD, root compression, osteophyte formation, and SS) of the patients were recorded as positive or negative. The patients with available MRI findings included in the final analysis, which evaluated the relationship between patient history, physical examination, and lumbar MRI findings, are demonstrated in the study’s flowchart (Figure 1).

Figure 1. Study flowchart.

Roland Morris disability questionnaire is a questionnaire developed to evaluate functional disabilities in patients with LBP. In the questionnaire consisting of 24 sentences about functional deficiencies, patients are asked to answer each sentence as “yes” if it fits their situation, and “no” if it does not. Calculating “yes” answers as “1” and “no” answers as “0”, the total score is between 0-24, with a higher score indicating more disability.[19] The validity and reliability study of this questionnaire was conducted in our country.[20]

Statistical analysis

Data analysis was performed using the IBM SPSS version 22.0 (IBM Corp., Armonk, NY, USA) software. While evaluating the study data, demographic characteristics were measured with descriptive statistical tests. The conformity of the data to the normal distribution was evaluated with the Shapiro-Wilk test. Pearson’s correlation analysis test was applied for correlation analysis as it was observed that the data were normally distributed. A p value <0.05 was considered statistically significant.

Results

The mean body mass index (BMI) was 30.58±5.27 kg/m². Demographic data and the clinical findings of the patients are listed in Table 1. The mean VAS scores for pain during motion and resting pain were 6.63±1.86 and 3.51±2.22, respectively (Table 1).

Table 1. Demographic characteristics and clinical findings of the patients (n=514)

Straight leg raise was positive in 115 (22.50%) patients, 421 (82.07%) patients had normal DTRs, 345 (67.12%) patients showed positive NIC findings, 422 (82.1%) patients had no sensory loss, and 467 (91.03%) patients had no motor loss (Table 1).

An MRI performed during the past six months was available for 319 patients. According to the MRI reports, 245 (76.8%) had disc hernia, 285 (89.3%) had IDD, 149 (46.7%) had root compression, 256 (80.3%) had osteophytes, and 119 (37.3%) showed SS findings (Table 2).

Table 2. Rates of MRI findings in patients undergoing MRI (n=319)

Evaluation of the MRI results of the 90 patients who had a positive SLR showed disc hernia in 81 (90%) patients, IDD in 91.10%, and root compression in 72.20% (Table 3).

Table 3. Magnetic resonance imaging findings in straight leg raise test-positive patients

Correlation analysis of the MRI results and the clinical findings showed a weak but significant correlation between SLRT and disc hernia (p<0.001, r=0.2) and root compression (p<0.001, r= 0.328), and between pain during motion and disc hernia (p<0.001, r=0.2), IDD (p=0.048, r=0.111), root compression (p<0.001, r=0.228), and SS (p=0.014, r=0.137, Table 4).

Table 4. Correlation of MRI findings and clinical findings

There was no significant correlation between MRI results and resting pain (p>0.05). A weak but significant correlation was found between sensory loss and root compression (p<0.001, r=0.218) and SS (p=0.015, r=0.137), between motor loss and root compression (p=0.015 r=0.137), and between radiating pain and all MRI findings (p<0.05), except for SS. NIC showed a weak but significant correlation with root compression (p=0.003, r=0.165) and osteophytes (p=0.002, r=0.174), and a moderate and significant correlation with SS (p<0.001, r=0.376, Table 4). RMDQ had a weak but significant correlation with all MRI findings (p<0.05, r<0.200, Table 4).

Discussion

The results of our study showed that 70% of the patients with LBP due to LS had dermatomal radiation, one-third complained of NIC and had positive SLR test results, and most of them had normal neurological findings. There was also a strong statistically significant correlation between NIC and SS, as well as between SLRT and root compression.

The incidence of LS is known to increase with age, and 75% of the adult population have been reported to have LS findings.[21] IDD is asymptomatic in most cases,[7] but it may cause local pain and even dermatomal radiating pain with disc herniation and constriction of the foramina.[22] With advancing age, the intervertebral discs become dehydrated and flat and transfers the increased axial load to the facet joints, which leads to hypertrophy of these joints, osteophyte formation, and thickening of the ligamentum flavum. These changes cause the narrowing of the spinal canal, lateral recesses, and neural foramina, thus lumbar stenosis.[23,24] NIC, or pseudoclaudication, which was observed in one-third of the patients in our study, is the most common symptom of LS and may substantially restrict the mobility by causing back and leg pain and muscle weakness.[25]

Magnetic resonance imaging has been found to be highly accurate and effective in the comparative assessment of spine morphology and the clinical picture of LBP.[10] The MRI results showed relatively high incidence of IDD (91%), disc hernia (90%), osteophytes (72%), and root compression (70%) in our patient population. In one of the few studies investigating the MRI findings in LS patients, Siddiqui et al.[18] reported disc hernia according to MRI findings in 89% and root or thecal sac compression in 73% of the patients, who had a significantly younger age average (mean age: 47 years) than our patients. They found severe root compression in 48 (40%) patients and observed that root compression and disc extrusion was correlated with pain radiating below the knee. We also observed such correlation between the dermatomal radiating pain and disc hernia, IDD, root compression, and existence of the osteophytes, corroborating the significance of this clinical symptom as a clue for severe pathological conditions.

The indication and timing of MRI in patients with back pain has been a debated topic. Evidence-based clinical guides have suggested the indication for MRI in the “red flags” (including infection, cancer, and cauda equina syndrome) but not in patients with nonspecific LBP.[26] These guides also maintain that MRI should be delayed in patients with a probable diagnosis of disc hernia or SS according to the consistent clinical symptoms and findings to allow the natural course of healing, which is observed in 50% of the disc hernia and radiculopathy cases.[27]

These guides emphasize that since pathological MRI findings can be detected in healthy people not infrequently, unnecessary imaging might lead to overdiagnosis and overtreatment, which then may create a burden both on the patient and the health insurance system.[28] Cheung et al.[29] detected lumbar IDD in 40% of the people under the age of 30 and 90% of the people in the age range of 50 to 55 in a study where they performed MRI on 1,453 healthy subjects. In another study with a smaller population, 38% of the healthy subjects were found to have a pathological condition in at least one disc according to MRI.[13] Therefore, in patients who do not have red flags and are not considered for operation, it can be concluded that there is more harm than benefit of MRI.

Deyo et al.[30] reported in 2009 that employment of MRI had increased by 307% in the past 12 years, a significant contradiction to the suggestion of the above guides. Weiner et al.[12] stated that MRI was performed in 61% of the LBP patients with no diagnostic red flags and that caused a 33.2% increase in health expenses. Webster et al.[28] suggested that physicians and patients should be informed and educated about the risks of unnecessary medical procedures that may be imposed by nonspecific employment of MRI during the early clinical stages.

The complaint of pain during motion showed a low but statistically significant correlation with the MRI findings of disc hernia, IDD, root compression, and SS, but no correlation was found for the presence of osteophytes and any MRI finding in our study. Radiating pain was correlated with disc pathology and osteophytes, but resting pain had no correlation with any MRI finding. These results suggest that MRI may have a diagnostic value in radiating pain and pain during motion.

Endean et al.[11] concluded in a meta-analysis focusing on the correlation of back pain with the abnormal MRI findings that disc protrusion, nerve root compression, and annular tears might indeed be correlated with back pain; however, there was no strong indication at an individual level for attributing these abnormal findings with certainty to the underlying pathology. They found the odd ratio in the studies investigating the correlation of IDD with LBP to range between 1.39 and 8.7 and calculated their meta-estimate of the odds ratio as 2.5. They reported the incidence of SS as 3 to 13% in patients without back pain in contrast to 31% in patients with back pain, which is close to the results obtained in our study.[11]

Indications for conservative treatment versus surgery in LBP patients depend on the existence and severity of nerve root compression.[1] The incidence of symptomatic lumbar disc herniation (LDH) is known to be 1 to 3% in the general population, yet only 15 to 20% of these cases have an indication for surgery.[31] The incidence of LDH and root compression according to MRI results was 76.80% and 46.70% in our study; however, strength was normal in 91%, DTR was normal in 82%, and 78% had no sensory deficit. Loss of strength was only correlated with root compression. This finding points to the lack of a strong correlation between MRI findings and clinical symptoms, particularly in elderly patients, and the priority of the clinical picture in treatment decisions. We observed a significant correlation between the loss of DTR and SS, as well as with disc hernia and root compression. This emphasizes the importance of including SS in diagnosis in the presence of loss of DTR in elderly patients. For this reason, the patient's history should be taken very carefully, specifically in elderly patients, degenerative findings should be questioned, and clinical examination should be performed diligently.

Lower extremity neurodynamic tests (femoral nerve stretch test and SLRT) are known to be effective in the lumbosacral radiculopathy diagnosis.[32] Based on this, we used SLRT in our study. In the correlation of MRI findings and SLRT, a statistically positive correlation was found only between disc herniation and root compression. However, when we examined the MRI values of 90 patients with SLRT positivity, we found the rate of patients with root compression to be 72.2%, while surprisingly, we detected much higher rates of IDD (91.10%), LDH (90%), and osteophytes (85.60%). This may be interpreted as an indication of the low reliability of SLRT in detection of radiculopathy findings, particularly in the elderly population. It is also possible that the existence of osteoarthritis (coxarthrosis or gonarthrosis) accompanying LS may have interfered with the evaluation of SLRT.

We found a significant correlation between all MRI parameters and the RMDQ, which reflects the disability status of the patients with back pain. Arana et al.[33] employed a different disability score in their study and did not find any correlation with disability and MRI findings, except for spondylolisthesis. Carragee[34] employed MRI and discography in a prospective study in patients with resistant LBP and could not find a correlation between MRI findings and negative clinical conditions according to the Oswestry disability index. The contradictory results obtained in our study may be due to the employment of a different disability index; nevertheless, our results suggest a significant correlation between higher disability scores and abnormal MRI findings.

The major limitations of this study are the interpretation of MRI results by different radiologists owing to its multicentric status and the lack of interrater analysis. In addition, the lack of MRIs for all patients, the inability to evaluate all MRIs by a single radiologist or physiatrist since it is a multicenter study, and the inability to evaluate the use of standard diagnostic criteria for radiology can be counted among the limitations.

In conclusion the results of this study corroborate the notion that diligent patient history and physical examination are more valuable than MRI findings, even though a higher incidence of abnormal MRI findings have been obtained in patients with disability and dermatomal radiating pain. The indications for MRI should be in accordance with the guidelines, and the causative relationship between the MRI findings and the clinical picture should be unequivocally defined, especially before surgical intervention.[35]

Citation: Altan L, Metin Ökmen B, Tuncer T, Sindel D, Çay HF, Hepgüler S, et al. Correlation of clinical signs and magnetic resonance imaging findings in patients with lumbar spondylosis. Arch Rheumatol 2023;38(4):512-520. doi: 10.46497/ ArchRheumatol.2023.9806.

The study protocol was approved by the Akdeniz University Faculty of Medicine Ethics Committee (date: 20.01.2016, no: 56). The study was conducted in accordance with the principles of the Declaration of Helsinki.

Informed consent was obtained from all individual participants included in the study.

All authors contributed to the study design, material preparation, data collection, analysis, interpretation and writing of the manuscript and take full responsibility for the integrity of the study and the final manuscript. All authors read and approved the final manuscript.

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

The authors received no financial support for the research and/or authorship of this article.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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