The thecal sac containing the conus medullaris and nerve roots are located within the central vertebral canal. The lumbar spine consists of five separate vertebrae separated by intervertebral discs and reinforced by multiple ligaments and paravertebral muscles. 7 Therefore, when reviewing the imaging, one must exert a degree of care when attributing the patient's symptoms to the appearance of their lumbar spine. 6 In a group of 57 patients with unilateral lower limb radiculopathy, only 30% of these patients had MRI findings of disc herniation and nerve root compression at the same level as the clinical prediction. 4,5 The lower specificity, 43–97% for disc herniation has been highlighted in previous literature and relates to the prevalence of asymptomatic disc degeneration and protrusions resulting in a large number of false positives. 3 For example, high sensitivity ranging between 89–100% for disc herniation have been described in previous studies. The quality of these images allows the diagnostician to make more detailed and accurate assessments of the intervertebral disc and its relation to the neural structures when compared with more traditional methods, such as lumbar and computed tomography (CT) myelograms.Ī systematic review of the available literature involving spinal MRI found MRI to be a highly sensitive and but less specific imaging modality for lumbar spinal conditions. Magnetic resonance imaging utilises proton resonance technology to obtain soft tissue cross-sectional representations of the spine. Guidelines, such as those developed by the American College of Physicians and Pain Society, can direct diagnostic testing for 'red flag' causes of lumbar back pain. This would direct further investigation with appropriate serum tests and imaging. steroid use) and pattern of stiffness may also raise suspicion of ankylosing spondylitis or compression fractures. Certain risk factors such as the patient's age, medication history (eg. The importance of determining symptom chronicity and identifying 'red flags' in the history and clinical examination, such as fevers and perineum paraesthesia, are crucial in the formulation of the clinical diagnosis and differentiating benign causes, such as musculoskeletal strain, from more serious conditions such as epidural abscesses or spinal metastases. Central vertebral canal stenosis is a common cause of neurogenic claudication and has a variable pattern, while vascular claudication it is more consistent and reproducible. It is often described as impaired mobility and dull aching pain in the lower limbs. This can occur due to the direct compressive effects of an intervertebral disc herniation on a nerve root or an underlying inflammatory process, such as infection causing acute pain in the distribution of a dermatome.Ĭlaudication is traditionally divided into two categories: neurogenic or vasogenic, depending on the underlying cause. Sciatica, on the other hand, has a different pattern of pain in terms of distribution and is caused by irritation of a nerve root. The pain is mainly localised in the back as the term suggests, and tends to arise from locally affected structures. Lumbar back pain can result from several conditions ranging from facet joint arthropathy to muscular strain. While magnetic resonance imaging (MRI) is sensitive in detecting spinal pathology, often it discovers a multitude of conditions that may not have any significant clinical impact. It is useful to differentiate the three most common symptoms – lumbar back pain, sciatica and claudication – as they can assist in determining the source of the patient's symptoms. Patients with spinal pathology often present with a range of symptoms. This article aims to clarify the terms commonly used and its clinical implications in lumbar spinal imaging. Multiple modalities are used with spinal imaging and with increasing access to magnetic resonance imaging and better imaging quality, primary care physicians are being exposed to nomenclature utilised by neuroradiologists and specialists in the field of spinal medicine.
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