Imaging studies

Imaging studies provide a view of the bones and the soft tissues, which comprise muscles, ligaments, cartilage, tendons, and blood vessels. These studies are needed mainly for potential candidates for surgery.

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X-rays should be the first imaging study for chronic pain and for new-onset back pain lasting longer than four to six weeks. They are especially useful for detecting fractures and invasion of bone by multiple myeloma. People should not be concerned about the possible risks of modern X-rays; the radiation doses are low and there is no evidence of harm even from repeated X-rays. Conventional X-rays are available almost anywhere and are relatively low in cost ($150 to $200).

A CT scan, also called a computerized axial tomography (CAT) scan, involves a series of X-rays that are taken as a special detector rotates 360° around the patient. A computer combines all the information into a cross-sectional picture. CT scans are 10 to 20 times more sensitive than X-rays; they provide better soft-tissue detail and good detail of the vertebrae. CT scans are considerably more expensive and deliver more radiation than conventional X-rays. The cost is about $550.

A CT myelogram involves a CT scan after the injection of a contrast material into the spinal canal. The injection carries the risk of infection and such side effects as nausea, headaches, and pain or discomfort at the site of the injection, and people are required to sit or lie with their head elevated for six to eight hours afterward. These scans offer the best detail of bone and soft tissue. CT myelograms are usually performed only prior to surgery or after failed surgery. The cost is about $600.

In MRI, the most sensitive imaging technique, the patient is surrounded with a powerful magnet while radio waves are passed through the body. No X-rays are involved. This test provides the best images of soft tissues and is completely safe. However, MRI may not give a useful image of the bones in the spine. MRI is not recommended for early diagnosis of back pain unless the doctor suspects a serious condition, such as cauda equina syndrome. Despite their sensitivity, studies have shown that MRIs should be reserved for preoperative evaluation or for people with a suspected herniated disk whose back symptoms do not respond to conservative treatment after four to six weeks. Because people must lie perfectly still for between 30 minutes and two hours in a relatively small space, MRIs may be uncomfortable and poorly tolerated by those who are claustrophobic. The cost is about $1,000.

Bone scans measure the amount of radioactivity emitted from bone after the injection of a bone-seeking compound that contains technetium, a radioactive metal. An area of bone that displays an increased uptake of technetium has a higher rate of bone turnover, which can be the result of a fracture not identified on an X-ray as well as metastatic cancer, Paget's disease, or osteomyelitis (a bacterial infection of the spine). The amount of radiation delivered is similar to that of a CT scan. This technique can be used to identify fractures in both the central and peripheral areas of the body. The cost is about $500.