Page 131 - Registrar Orientation Manual 2016

Reference:
1257
Effective date:
7 July 2015
Expiry date:
6 July 2018
Page:
14 of 35
Title:
Imaging Guidelines
Type:
Clinical Guideline
Version:
02
Authorising initials:
The ‘Choosing Wisely’ recommendations include:
Don’t perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.
Don’t routinely perform surveillance joint radiographs to monitor juvenile idiopathic arthritis (JIA) disease activity.
Avoid ordering a knee MRI for a patient with anterior knee pain without mechanical symptoms or effusion unless the patient has not improved following completion of an appropriate functional rehabilitation program.
Don’t use DEXA screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
Don’t routinely repeat DEXA scans more often than once every two years.
Back Pain
The prevalence of previously undiagnosed serious pathology in patients presenting with acute low back pain in the primary care setting is very rare.
Routine or immediate imaging for back pain without indications of serious underlying conditions does not usually affect management or improve outcomes and is associated with radiation exposure.
Imaging is usually only indicated if there are red flags or neurological findings.
The National Community Radiology Access Criteria have the following indications for plain X-ray:
• spine pain >8 weeks
• spine pain with red flags
• spine pain and osteoporosis or prolonged use of corticosteroids
• focal neurological deficit
• significant spinal deformity
'Red flags' that prompt imaging in primary care include:
• recent significant trauma (mild trauma if age = 50)
• unexplained weight loss
• fever
• age <22 or >55 years
• history of malignancy or immune compromise
• intravenous drug use
• osteoporosis or glucocorticoid use
• suspicion of ankylosing spondylitis
• compensation or work injury issues
If there are no 'red flags', imaging is indicated only after a period of conservative therapy is trialled first. Initial investigation is usually with plain films.
Further imaging may be indicated if plain X-rays are abnormal or the cause of the pain remains uncertain or for specific indications like suspected spinal infection.
If there are neurological findings MRI is the best modality. Cases should always be discussed with the on call radiology SMO.
A bone scan may be an option if bone metastases are strongly suspected and if there are no neurological findings. Always consider whether the findings will change management. A repeat scan in patients with known metastatic prostate cancer is rarely helpful.
Clinical urgency: MRI should be done ASAP in an acute presentation with progressing neurology