From the Guidelines
A CT scan of the back is not immediately necessary at this time, given the patient's presentation and X-ray findings, which show multilevel facet degenerative joint disease without severe fractures, and the absence of red flags or radiculopathy symptoms 1. The patient's persistent and worsening back pain following a motor vehicle accident, despite conservative measures, is concerning, but the current evidence suggests that CT imaging should be reserved for patients who are potential candidates for surgery or epidural steroid injection, or when diagnostic uncertainty remains after initial evaluation 1. Given the patient's visual impairments from retinitis pigmentosa and glaucoma, which increase fall risk and complicate recovery, it is essential to carefully consider the need for advanced imaging and weigh the potential benefits against the risks. The patient's worsening pain (now 6/10) despite acetaminophen, along with the history of trauma, warrants close monitoring and consideration of alternative treatment approaches, but the current evidence does not support the routine use of CT imaging in this scenario 1. Key considerations in this case include:
- The patient's lack of red flags or radiculopathy symptoms, which reduces the likelihood of requiring immediate surgical or interventional management 1
- The potential for CT imaging to detect subtle fractures or facet joint injuries, but also the risk of unnecessary radiation exposure and the possibility of incidental findings that may not be relevant to the patient's current symptoms 1
- The importance of careful clinical evaluation and monitoring, given the patient's complex medical history and increased fall risk 1.
From the Research
Patient's Condition
The patient presents with a constant dull ache in the right lower back that began 2 weeks ago following a motor vehicle accident. The pain has increased from 3/10 to 6/10 despite conservative measures, and worsens with movement and prolonged sitting.
Diagnostic Findings
- The patient's XR lumbar spine findings indicate multilevel facet DJD, with no severe burst or compression fracture seen 2.
- The presence of soft tissue calcifications, likely vascular, and spurring throughout the lumbar spine are also noted.
Considerations for Further Imaging
- The patient's visual impairments from retinitis pigmentosa and glaucoma increase concerns about fall risk during recovery, highlighting the need for careful consideration of further imaging and treatment options.
- A CT scan of the back may provide more detailed information about the patient's condition, but it is essential to weigh the benefits against the potential risks, including radiation exposure 3.
Radiation Exposure Considerations
- The use of CT fluoroscopy techniques can result in lower radiation doses compared to conventional fluoroscopy, but the overall radiation dose can still be higher due to the planning lumbar spine CT scan 3.
- Minimizing the dose from the preliminary planning lumbar spine CT scan is crucial to reduce radiation exposure.
Treatment Options
- The patient's persistent pain despite conservative measures may require further intervention, such as CT-guided transforaminal epidural injections with local anesthetic, steroid, and tramadol, which have been shown to be effective in treating persistent lumbar radicular pain 2.
- However, the patient's condition does not currently indicate radiculopathy, and therefore, the use of such injections may not be immediately warranted.