Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 3: Spinal Disorders
 
   

Diagnostic Imaging Practice Guidelines for
Musculoskeletal Complaints in Adults —
An Evidence-Based Approach:


Part 3:   Spinal Disorders

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   J Manipulative Physiol Ther 2008 (Jan);   31 (1):   33-88 ~ FULL TEXT

André E. Bussières, DC, John A.M. Taylor, DC, Cynthia Peterson, DC, RN, MMedEd

Chiropractic Department,
Université du Québec à Trois-Rivières,
Québec, Canada.
andre.bussieres@uqtr.ca


PURPOSE:   To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for spinal disorders.

METHODS:   A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research were invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer reviewed by practicing chiropractors, and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence.

RESULTS:   Recommendations for diagnostic imaging guidelines of adult spine disorders are provided, supported by more than 385 primary and secondary citations. The overall quality of available literature is low, however. On average, 45 Delphi panelists completed 1 of 2 rounds, reaching more than 85% agreement on all 55 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. Dissemination and implementation strategies are discussed.

CONCLUSIONS:   The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.


From the FULL TEXT Article:

Preliminary Considerations and Disclaimer

What is the Role of These Guidelines?


These evidence-based diagnostic imaging practice guidelines are intended to assist primary care providers and students in decision making regarding the appropriate use of diagnostic imaging for specific clinical presentations. The guidelines are intended to be used in conjunction with sound clinical judgment and experience. For example, other special circumstances for radiographic imaging studies may include: patient unable to give a reliable history, crippling cancer phobia focused on back pain, need for immediate decision about career or athletic future or legal evaluation, history of significant radiographic abnormalities elsewhere reported to patient but no films or reliable report reasonably available, and history of finding from other study (eg, nuclear medicine or imaging of the pelvis) that requires radiograph for correlation. [8] Application of these guidelines should help avoid unnecessary radiographs, increase examination precision, and decrease health care costs without compromising the quality of care.

The descriptions of clinical presentations and proposed clinical diagnostic criteria, the recommendations for imaging studies, and the comments provided throughout this article are a synthesis of the vast body of literature consulted before and during the various phases of this research project. Where the literature was found to be of poor quality or absent, consensus based on expert opinion was used. Although the investigators and collaborators carefully searched for all relevant articles, it is probable that some have been missed. Furthermore, as many new important studies are published in the near future, these will be incorporated in subsequent revisions of the guidelines and recommendations may change accordingly.

What These Guidelines Do and What They Do Not Do

These guidelines are intended to address issues faced by first-contact professionals only. These guidelines do not address all possible conditions associated with musculoskeletal disorders, only those that account for most initial visits to a practitioner.

Like other diagnostic tests, imaging studies should only be considered if (a) they yield clinically important information beyond that obtained from the history and physical examination, (b) this information can potentially alter patient management, and (c) this altered management has a reasonable probability to improve patient outcomes. [9-11] Investigators and collaborators in the development of these imaging guidelines believe that liability insurance companies, third-party payers, and courts of law should not rely solely on descriptions of patient presentations, proposed recommendations, and/or corresponding comments found throughout the documents because patient presentations are unique and the application of any guideline always requires clinical judgment and thus needs to be considered in the proper context. In addition, laws and regulations may vary between geographical regions and should be considered when applying the proposed indications for any imaging study.

What is Evidence-Based Health Care?

Evidence based is about tools, not about rules. [12] Evidence-based health care is an approach in which clinicians and health care professionals use the current best evidence in making decisions about the care of patients. It involves continuously and systematically searching, appraising, and incorporating contemporaneous research findings into clinical practice. The overall goal is improving patient care through life-long learning. [12-13]


Thanks to the National Guideline Clearinghouse for access to these tables!


Table 1. Thoracolumbar, Lumbar, and Thoracic Spine Trauma

Patient Presentation Recommendations
Adult patient with recent (<2 weeks [wk]) acute thoracolumbar, lumbar, or thoracic spine trauma

Absence of pain, normal Range of Motion (ROM), and absence of neurologic deficits
Radiographs not routinely indicated [C]
Adult patient with thoracolumbar, lumbar or thoracic spine blunt trauma or acute injuries (falls, motor vehicle accidents (MVAs), motorcycle, pedestrian, cyclists, etc.)

High-risk screening criteria for spinal injuries include any of the following:
  1. Back pain
  2. Midline tenderness on palpation
  3. Distracting painful injury and other high-risk mechanism of injury
  4. Neurologic deficits
  5. Altered consciousness (caused by head trauma, intoxication/ethanol, or drugs)
Radiographs indicated [B]

Lumbar AND thoracic spine: anterioposterior (AP), lateral views

Special investigations [C]
  • Computed tomography (CT) scan (multidetector [multislice], spiral CT)
  • Magnetic resonance imaging (MRI)
Adult patient with posttraumatic chest wall pain

Minor trauma
Radiographs not routinely indicated [D]
Major trauma Radiographs indicated [GPP]

Posteroanterior (PA), lateral chest radiographs

Specific rib radiographs (AP), oblique)

Additional views: PA chest in full expiration, thoracic and /or lumbar spine views

Special investigations [GPP]
  • CT for sternum injury, pulmonary, pleural, and osseous abnormalities
Adult patient with pelvis and sacrum trauma (including falls with inability to bear weight) Radiographs indicated [D]

AP pelvis and lateral hip "frog leg"

Additional views: lateral lumbar view

Angulated AP sacrum view (15-45° cephalad)

Special investigations [D]
  • Nuclear medicine (NM), MRI or CT may be helpful if radiographs are normal or equivocal.
Coccyx trauma and coccydynia

Consider views of the sacrum if distal sacrum fracture is suspected
Radiographs not routinely indicated: (spot AP, lateral coccyx) [C]

Additional views: AP, lateral sacrum, dynamic sitting lateral views of the coccyx


Table 2. Cervical Spine Trauma

Patient Presentation Recommendations
Adult patient with acute neck injury and negative CCSR (Canadian Cervical Spine Rule for Radiography in Alert and Stable Trauma Patients) Radiographs not routinely indicated [B]
Adult patient with acute neck injury and positive CCSR (Canadian Cervical Spine Rule for Radiography in Alert and Stable Trauma Patients)

Conventional radiographs recommended in the presence of any of the Canadian Cervical Spine Rule criteria are fulfilled:

A. High-risk factors in alert and stable patient?
  1. Age >65
  2. Dangerous mechanisms of injury
  3. Parethesias in extremities
B. Low-risk factors that allow ROM assessment?
  1. Simple rear end collision
  2. Patient seated in the waiting room
  3. Ambulatory at one time since trauma
  4. Delayed cervical pain onset
  5. Absence of midline cervical tenderness
C. ROM Assessment: Is patient able to actively turn his/her head to 45 degrees in both directions?
Radiographs indicated [B]

APOM, AP lower cervical, neutral lateral

If fracture is suspected: 3 views + CT scan recommended

Additional views: CT now replaces oblique, pillar, dynamic flexion/extension (F/E) in suspected fracture [GPP]

Special investigations [C]
  • CT, MRI


Table 3. Adult Nontraumatic Lumbar Spine Disorders

Patient Presentation Recommendations
Adult patient with acute uncomplicated* LBP (<4 wks' duration)

*Uncomplicated definition: nontraumatic LBP without neurologic deficits or indicators of potentially serious pathologies)—(see red flag list for details in the original guideline document).

For most young or middle-aged adults, early diagnostic evaluation of low back complaints may focus on 3 basic questions (diagnostic imaging is infrequently required) (Jarvik, 2002).
  1. Is there underlying systemic disease?
  2. Is there neurologic impairment that might require surgical intervention?
  3. Is social or psychological distress amplifying or prolonging the pain?
Radiographs not initially indicated [B]



Special investigations not indicated [B]
Adult patient with uncomplicated subacute (4-12 wks' duration) or persistent low back pain (LBP) (>12 wks' duration) AND no previous treatment trial.

A trial of up to 4-6 wk of conservative care is appropriate before radiographs
Radiographs not initially indicated [B]
Adult patient with nontraumatic acute LBP AND sciatica (no red flags)

The first clinical clue to neurologic impairment usually is a history of sciatica: sharp pain radiating down the posterior or lateral aspect of the leg, often associated with numbness or paresthesia.
Radiographs not initially indicated [B]
Specific Clinical Diagnoses
Common causes of sciatica

A. Suspected LDH:
  • Risk factors for lumbar disc herniation (LDH) include: men (1.6 times more likely), middle age (35-54 years [y]), repetitive/heavy lifting, current smoking, obesity (high body mass index (BMI), and type of occupation.
  • Predominantly leg pain, typically involving the foot
Radiographs not initially indicated [B] unless patient age >50 or has progressive neurologic deficits
B. Suspected degenerative spondylolithesis/lateral stenosis
  • Back pain with or without leg pain
  • Increased pain with activity
  • Signs and symptoms (S&S) with or without neurologic deficit
Radiographs indicated if patient age >50 or has progressive neurologic deficits: PA (or AP), lateral lumbar views [GPP]
C. Suspected lumbar degenerative spinal stenosis
  • More common (MC) >65 years of age (YOA) (sensitivity of 0.7; specificity of 0.69)
  • Neurogenic claudication
  • Variable neurologic deficit (numbness, weakness, etc)
Radiographs indicated if patient age >50 or has progressive neurologic deficits: PA (or AP), lateral lumbar views [C]
Suspected causes of sciatica:

A. Lumbar disc herniation

B. Degenerative spondylolithesis/lateral stenosis

C. Lumbar degenerative spinal stenosis
Special investigations not initially indicated [C]

Co-management or specialist referral recommended even if conventional radiographs are unremarkable:
  1. After failed conservative therapy (4-6 wk)
  2. For preoperative planning
  3. If patient's neurologic status is deteriorating (progressive deficit, disabling leg pain)
    • MRI, CT
Adult patient reevaluation in the absence of expected treatment response or worsening after 4-6 wk

Should patient fail to improve as expected or marginally improve within 4-6 wk of initial evaluation, the clinician must review history and physical findings and request appropriate diagnostic imaging studies.
Radiographs indicated [B]

PA (or AP), lateral lumbar views

Additional views not routinely indicated [C]

Spot lateral, oblique. lateral flexion films may be indicated in scoliosis evaluation

Comanagement or specialist referral recommended even if conventional radiographs are unremarkable
  1. And if conventional radiography reveals suspected pathology.
  2. After failed conservative therapy (4-6 wk)
  3. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain)
  4. If clinical signs suggest instability. Presumed instability is loosely defined as >10° of angulation or 4 mm of vertebral displacement on flexion and extension lateral radiographs. However, diagnostic criteria, natural history, and surgical indications remain controversial
  5. For preoperative planning
Special investigations [C]
  • MRI or CT scan
Adults with complicated (i.e., "red flag") LBP and indicators of contraindication to spinal manipulative therapy (SMT) (relative/absolute):

Presence of the following indicator(s) should alert the clinician to possible underlying pathology. Presence of a red flag alone may not necessarily indicate the need for radiology.
  • Patient <age 20 and >age 50, particularly with S&S suggesting systemic disease
  • No response to care after 4 wk
  • Significant activity restriction >4 wk
  • Nonmechanical pain (unrelenting pain at rest, constant or progressive S&S)
  • Suspected inflammatory—spondyloarthritides
  • Suspected compression fracture
  • Suspected neoplasia
  • Suspected infection
  • Suspected failed surgical fusion
  • Progressive or painful structural deformity
  • Elevated laboratory examination and positive S&S

**Risks of having a serious pathology may be higher before the age of 20 or over the age of 55. Particular attention to indicators of possible underlying pathology should be given for patients in these age categories.

Radiographs indicated [B] PA (or AP), lateral lumbar views.

Additional views: Hibb's

(Spot angled PA or AP lumbosacral), oblique SI views

Advanced imaging and specialist referral recommended:
  1. In the presence of a potentially serious pathology as suggested by the patient history, examination, and/or radiograph
  2. In the absence of clinical improvement after 4-6 wk of therapy
  3. If function does not improve or deteriorates
  4. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain)
  5. With painful or progressive structural deformity
  6. For unstable segment (spondylolisthesis or pathological process)
  7. When patient has persisting S&S
  8. In complication from treatment (possible fracture, new/progressive neurologic deficit, considerable pain, or disability, etc)
Special investigations [B] Even if conventional radiographs are negative
  • MRI, CT, NM
  • Suspected Cauda equina syndrome (CES)
  • The classic syndrome includes LBP, bilateral or unilateral sciatica, saddle anesthesia, motor weakness of the lower extremities that may progress to paraplegia, urinary retention, or bowel and bladder incontinence.
    Emergency referral without imaging [B]

    Special investigations [C] (see above for details)
    • Suspected abdominal aortic aneurysms (AAA)
    Early S&S may include abdominal pain, backache, and feeling of fullness or abdominal pulsation.
    Referral for specialized investigations [B]
    • Management (ultrasound screening/monitoring and surgical consultation) according to patient history and size of AAA
    • Truncal symptoms attributed to the presence or worsening of aortic aneurysms including dissection/rupture/occlusion or traumatic aortic injury
    Cardiovascular shock and/or syncope, severe tearing/ripping midabdominal sensation, back, groin or testicular pain; pressure upon lumbar spine causing excruciating boring pain in the abdomen or back; hypotension; absence distal lower limb pulses
    Emergency referral without imaging [GPP]
    • It is vital to recognize the S&S of dissecting AAA as this is a surgical emergency


    Table 4. Nontraumatic Thoracic Spine Disorders

    Patient Presentation Recommendations
    Adult patient with uncomplicated* acute thoracic spine pain (<4 wks' duration)

    AND

    Adult patient with uncomplicated* subacute (4-12 wks' duration) or persistent (>12 wks' duration) thoracic spine pain and no previous treatment trial.

    *Uncomplicated definition: Nontraumatic thoracic pain without neurologic deficits or indicators of potentially serious pathologies
    Radiographs not routinely indicated [B]

    Special investigations not indicated [B]
    Adult patient: reevaluation in the absence of expected treatment response or worsening after 4 wk.

    Should patient fail to improve as expected or marginally improve within 4 wk of initial evaluation, the clinician must review history and physical findings and request appropriate diagnostic imaging studies.
    Radiographs indicated [B]

    AP, lateral thoracic spine views

    Additional views: Swimmer's view

    Co-management or specialist referral recommended
    1. In suspected pathology as seen on conventional radiography
    2. After failed conservative therapy (4 wk)
    3. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain)
    Special investigations [C]
    • MRI or CT scan
    Adult patient with nontraumatic chest wall pain

    History and physical exam first need to rule out life-threatening conditions including pathologies of the heart, lungs and large vessels.
    Emergency referral without imaging in life-threatening conditions [GPP]

    Special investigations [C]
    • CT and MRI
    Musculoskeletal causes of chest wall pain (diagnosis of exclusion) Radiographs not routinely indicated [D]
    Adult patient with complicated (i.e., "red flag") thoracic pain and indicators of contraindication to SMT (relative/absolute)

    Presence of the following indicator(s) should alert the clinician to possible underlying pathology.

    Note well (NB). Presence of a red flag alone may not necessarily indicate the need for radiography.

    Patient <age 20 and >age 50, particularly with S&S suggesting systemic disease**
    • No response to care after 4 wk
    • Significant activity restriction >4 wk
    • Nonmechanical pain (unrelenting pain at rest, constant or progressive S&S)
    • Persistent localized pain (>4 wk)
    • Progressive or painful structural deformity: scoliosis, kyphoscoliosis (Otani, Konno, & Kikuchi, 2001)
    • Symptoms associated with neurologic signs in the lower extremities
    • Suspected inflammatory spondyloarthropathy
    • Suspected neoplasia
    • Suspected infection
    • Suspect failed surgical fusion
    • Elevated laboratory examination and positive S&S
    • In recent significant trauma (any age)

    **Risks of having a serious pathology may be higher before the age of 20 or over the age of 55. Particular attention to indicators of possible underlying pathology should be given for patients in these age categories.

    Radiographs indicated [B]

    AP, lateral thoracic spine views.

    Additional views: Spot view. In suspected inflammatory spondylo-arthropathy, consider: Hibb's (spot angled AP lumbosacral), oblique SI views

    Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable:
    1. In presence of a potentially serious pathology as suggested by the patient history, examination and/or radiograph
    2. In the absence of clinical improvement after 4 to 6 wk of therapy
    3. If function does not improve or deteriorates
    4. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain)
    5. With painful or progressive structural deformity
    6. For unstable segment (spondylolisthesis or pathological process)
    7. When patient has persisting S&S
    8. In complication from treatment (possible fracture, new/progressive neurologic deficit, considerable pain or disability, etc.)
    Special investigations [B]
    • MRI, CT, NM
    • Suspected acute thoracic aortic aneurysms dissection/rupture/occlusion or traumatic aortic injury
    Severe, tearing/ripping chest sensation, back pain; hypotension; absent distal pulse. High index of suspicion in connective tissue disorders and diseases with genetic predisposition for ascending aortic aneurysms.
    Emergency referral without imaging [GPP]
    • Suspected compression fracture
    Severe onset of pain (with or without appearance of spinal deformity) after minor trauma in older patients. Patients with thoracic or lumbar spine osteoporotic fractures report pain mainly in the lumbosacro-gluteal area. Look for history (Hx) of repetitive stress of sufficient severity or Hx of high risk osteoporosis

    Risk factors for additional vertebral fractures:

    Histories of a previous fracture, greater age, lower femoral neck bone mass density, shorter height
    Radiographs indicated [B]: AP, lateral thoracic spine views

    Additional views [D]: Supine cross-table lateral view in suspected osteoporotic vertebral pseudoarthrosis

    Special investigations [D]
    • MRI/CT if initial radiographs are positive, difficult to interpret, in presence of complex lesions, for suspected ligamentous instability or neural injuries.
    Suspected osteoporosis

    See osteoporosis clinical decision rules in the original guideline document.
    Radiographs are unreliable for assessment of bone mass changes before at least a 30%-50% loss

    Special investigations [B]

    If clinical decision rules are positive
    • Bone densitometry or dual-energy x-ray absorptiometry (DXA)
    Adult patient with nonpainful and nonprogressive scoliosis Radiographs not routinely indicated [C]
    Adult patient with painful or progressive scoliosis Radiographs indicated [B]

    Erect sectional radiographs (better detail) or standing full-length PA (14 × 36 in) and lateral sectionals

    Additional views:
    1. Right and left lateral bending
    Follow-up evaluation dictated by clinical progression [C]

    Repeat radiographs, specialist referral and advanced imaging recommended [B]:
    1. In the absence of clinical improvement; after 4 to 6 wk of therapy
    2. If function does not improve or deteriorates
    3. In presence of persisting S&S or considerable pain
    4. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain)
    5. With painful or progressive structural deformity (scoliosis, kyphoscoliosis)
    6. With suspected segmental instability (this is common in adult scoliosis and should be considered with all manual therapy intervention)
    7. With suspected pathological process
    8. With new or progressive neurologic deficit including claudication, significant radiculopathy or suspected syrinx
    9. To plan surgical intervention
    Special investigations [C]
    • Spiral CT, MRI, sequential discograms, facet blocks, epidural blocks, CT-myelogram


    Table 5. Nontraumatic Cervical Spine Disorders

    Patient Presentation Recommendations
    Adult patient with acute uncomplicated* neck pain (<4 wks' duration)

    * Uncomplicated definition: Nontraumatic neck pain without neurologic deficits or indicators of potentially serious pathologies)—(see red flag list in original guideline document for details).
    Radiographs not initially indicated [C]

    Special investigations not indicated [C]
    Adult patient with nontraumatic neck pain and radicular symptoms

    A. Suspected acute cervical disc herniation (CDH)

    B. Suspected acute cervical spondylotic radicular syndrome/lateral canal stenosis
    Radiographs indicated [D/consensus]

    Anteroposterior open mouth (APOM), AP lower cervical, neutral lateral

    Additional views: Oblique views, swimmer's view

    Comanagement or specialist referral recommended even if conventional radiographs are unremarkable
    1. After failed conservative therapy (4 wk)
    2. For preoperative planning
    3. If patient neurologic status is deteriorating (progressive deficit, disabling arm pain)
    Special investigations [B]

    MRI
    Adult patient with uncomplicated* subacute (4-12 weeks duration) and persistent neck pain (>12 weeks) with or without arm pain.

    * Uncomplicated definition: See above definition
    Radiographs not initially indicated [consensus]

    APOM, AP lower cervical, neutral lateral

    N.B. This recommendation was modified according to the recent findings of The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (see articles published in Spine 2008; 33(4S)).  (Boyle et al., 2008; Cassidy et al., 2008) A majority of Delphi panelists agreed with this change (92% of 50 respondents).
    Adult patient reevaluation in the absence of expected treatment response or worsening after 4 weeks Radiographs indicated [C]

    APOM, AP lower cervical, neutral lateral

    Additional views: Oblique views, Swimmer's view, Flexion/Extension

    Comanagement or specialist referral recommended (even if conventional radiographs are unremarkable)
    1. If conventional radiography reveals suspected pathology
    2. After failed conservative therapy (4 wk)
    3. If patient neurologic status is deteriorating (progressive deficit, disabling arm pain)
    4. If clinical signs suggest subaxial cervical spine instability (Moore, Vaccaro, & Anderson, 2006)
    5. For preoperative planning
    Special investigations [B]
    • MRI
    Adult patient with complicated (i.e., "red flag") neck pain and indicators of contraindication to SMT

    Presence of the following indicator(s) should alert the clinician to possible underlying pathology.

    N.B. Presence of a red flag alone may not necessarily indicate the need for radiography.
    • Patient <age 20 and >age 50, particularly with S&S suggesting systemic disease
    • No response to care after 4 wk
    • Significant activity restriction >4 wk
    • Nonmechanical pain (unrelenting pain at rest, constant or progressive S&S)
    • Neck rigidity in the sagittal plain in the absence of trauma (discitis, infection, tumor, meningitis, etc)
    • Dysphasia
    • Impaired consciousness
    • Central nervous system S&S (cranial nerves, pathological reflexes, long tract signs)
    • High risk ligament laxity populations/suspected atlantoaxial instability  (see original guideline document for details)
    • Arm or leg pain with neck movements, suspected cervical myelopathy and radiculo-myelopathy (see original guideline document for details)
    • Sudden onset of acute and unusual neck pain and/or headache (typically occipital) with or without neurologic symptoms, suspected cervical artery dissection (vertebral artery dissection (VAD), cervical artery dissection (CAD), Transient ischemic attack (TIA) (Vertebrobasilar insufficiency (VBI), carotid artery ischemia), stroke (see details below)
    • Hx of severe trauma (see Trauma section)
    Radiographs indicated [B]

    APOM, AP lower cervical, neutral lateral

    Additional views: Flexion/extension, oblique views, pillar view

    Advanced imaging and specialist referral recommended:

    Special investigations [B]
    • MRI
    In addition, also consider general red flags (usually applied to LBP) which may apply to the cervical spine
    • Suspected neoplasia
    • Suspected infection (discitis, osteomyelitis, tuberculosis)
    • Suspect failed surgical fusion
    • Progressive or painful structural deformity
    • Elevated laboratory examination and positive S&S
     
    • Suspected atlantoaxial instability (AAI)
    High risk ligament laxity populations/possible atlantoaxial instability include
    1. Active inflammatory arthritides
    2. Congenital disorders and hereditary connective tissues disorders
    Radiographs indicated [B]

    APOM, AP lower cervical, neutral lateral

    Additional views [D]: Flexion/extension laterals

    Monitoring, advanced imaging and specialist referral recommended:
    1. ADI >3 mm, vertical dislocation, lateral, posterior or subaxial subluxations
    2. Upward odontoid translocation (pseudobasilar invagination)
    3. In presence of neurologic S&S
    Special investigations [C]
    • CT, MRI
    • Suspected cervical compressive myelopathy (CCM) and radiculo-myelopathy
    Radiographs indicated [C]

    APOM, AP lower cervical, neutral lateral and bilateral oblique views

    Additional views: Swimmer's view

    Refer patient for investigation and possible surgical intervention:
    1. After failed conservative therapy (4 wk)
    2. If patient's neurologic status is deteriorating (progressive deficit, disabling arm pain)
    3. For preoperative planning
    Special investigations [C]
    • MRI (CT-myelography if not available). Electrophysiologic testing such as somatosensory evoked potentials (SSEP) may be useful.
    • Suspected cervical artery dissection
      (Vertebral artery dissection [VAD], Cervical artery dissection [CAD]), Transient ischemic attack (TIA) (Vertebrobasilar insufficiency [VBI], carotid artery ischemia), stroke
    The most important points in the history and chief complaint, which would warn of a possible cervical artery disease, are:
    1. S&S of VBI—the "5D's And 3 N's": Dizziness, dysphasia, dysarthria (hoarseness), drop attacks, diplopia (or other visual problems), ataxia of gait (hemiparisis), nausea (possibly with vomiting), numbness (hemianesthesia), nystagmus

    2. S&S of carotid artery ischemia/stenosis: Confusion, dysphasia, headache, anterior neck and/or facial pain, hemianesthesia, hemiparesis or monoparesis, visual field disturbances

    3. Neck or occipital pain with sharp quality and severe intensity or severe and persistent headache that is sudden and unlike any previous experienced pain or headache (even when it is suspected the pain is of a musculoskeletal or neuralgic origin)
    Should cervical artery problems be suspected, a thorough workup is indicated.
    Emergency referral without imaging [GPP]

    Urgent referral should be made for appropriate investigation and treatment in patient presenting S&S of cerebrovascular ischemia or when S&S of head/neck pain is suspicious for an acute cervical artery disease.

    Special investigations [C]
    • Initial investigation often includes CT scan to R/O hemorrhagic stroke.
    Appropriate consultation and/or diagnostic procedures to evaluate the status of the cerebral circulation required in patients presenting with significant risk factors for cervical artery dissection. In such cases, approach the treatment with caution until a specific determination is made.


    Definitions :

    Levels of Evidence

    Classification based on Stroke Prevention and Educational Awareness Diffusion (SPREAD) validated methodological criteria.

    1++:   High-quality meta-analyses without heterogeneity, systematic reviews of randomized controlled trials (RCTs) each with small confidence intervals CI), or RCTs with very small CI and/or very small alpha and beta

    1+:   Well-conducted meta-analyses without clinically relevant heterogeneity, systematic reviews of RCTs, or RCTs with small CI and/or small alpha and beta

    1−:   Meta-analyses with clinically relevant heterogeneity, systematic reviews of RCTs with large CI, or RCTs with large CI and/or alpha or beta

    2++:   High-quality systematic reviews of case-control or cohort studies. High-quality case-control or cohort studies with very small CI and/or very small alpha and beta

    2+:   Well-conducted case-control or cohort studies with small CI and/or small alpha and beta

    2−:   Case-control or cohort studies with large CI and/or large alpha or beta

    3:   Nonanalytic studies, (e.g., case reports, case series)

    4:   Expert opinion

    − (minus): Meta-analyses with clinically relevant heterogeneity; systematic reviews of trials with large confidence intervals; trials with large CIs, and/or large alpha and/or beta


    Grades of Recommendation

    This tool has been developed to grade recommendations according to the strength of available scientific evidence (level A to D)

    A:   At least one meta-analysis, systematic review or RCT rated as 1++, and directly applicable to  the target population; or a systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+,directly applicable to the target population and demonstrating overall consistency of results

    B:   A body of evidence including studies rated as 2++, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+

    C:   A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++**

    D:   Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+; or evidences from trials classified as (minus) regardless of the level /

    Good practice point: Recommended best practice based on the clinical experience of the guideline development group, without research evidence.

    This tool aims to evaluate the scientific evidence according to prespecified levels of certainty (1++ to 4). In this study, Good Practice Point also represents consensus of the Delphi panel. CI indicates confidence intervals.

    CLINICAL ALGORITHM(S)

    None provided



    EVIDENCE SUPPORTING THE RECOMMENDATIONS

    REFERENCES SUPPORTING THE RECOMMENDATIONS

    TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

    The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").



    IDENTIFYING INFORMATION AND AVAILABILITY

    BIBLIOGRAPHIC SOURCE(S)



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