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1.  Randomized controlled trial of the effect of the Royal College of Radiologists' guidelines on general practitioners' referrals for radiographic examination. 
BACKGROUND. The Royal College of Radiologists' guidelines aim to encourage more appropriate use of diagnostic radiology and so reduce the use of clinically unhelpful x-ray examinations. AIM. The object of this study was to conduct a randomized controlled trial of the introduction of the guidelines into general practice. METHOD. A total of 62 practices (170 general practitioners) referring patients to St George's Hospital, London for diagnostic radiology were randomly allocated into two groups. Guidelines were sent to the 30 practices in the intervention group. Radiological referral patterns were compared in both groups before and after the introduction of guidelines. RESULTS. Practices which had received guidelines requested significantly fewer examinations of the spine, and made a significantly higher proportion of requests which conformed to the guidelines compared with practices which had not received the guidelines. There were no significant differences in the proportion of forms giving physical findings or in the proportion of positive findings at radiology. CONCLUSION. Introduction of guidelines can influence general practitioners' radiological referrals in the short term. Wider use of guidelines might help to reduce unnecessary irradiation of patients.
PMCID: PMC1238864  PMID: 8204331
2.  Development of a plain radiograph requesting algorithm for patients presenting with acute abdominal pain 
Radiologists at a large teaching hospital felt that plain radiograph imaging was being performed inappropriately for patients admitted with acute abdominal pain. They felt requests were either not indicated or CT was a more appropriate first line radiological investigation in certain circumstances.
An audit was performed looking at plain radiograph imaging requests for emergency admissions under general surgery, using Royal College of Radiologists (RCR) guidelines as the standard. The audit revealed that only 80% of plain radiograph requests met RCR guidelines. It also showed that 33% of acute admissions undergoing plain radiograph imaging proceeded to CT within forty-eight hours. These findings lead to the development of a plain radiograph algorithm. This aimed to improve plain radiograph imaging requests and to increase the use of CT as an earlier or first line radiological investigation where appropriate.
Outcome of discussion at local and regional clinical governance meetings was that earlier CT would be useful in specific circumstances. The algorithm provides a framework for appropriately expediting CT in patients presenting with acute abdominal pain where bowel obstruction or perforation was suspected. However, consultant surgeons felt that in patients presenting with acute abdominal pain, the plain abdominal radiograph often demonstrates findings associated with specific diagnoses not specifically indicated by RCR guidelines. If RCR guidelines for plain radiograph imaging are broadened, radiological interpretation would examine for a broader range of findings and, when combined with other clinical information, diagnoses can be made, thus avoiding the need for further imaging or explorative surgery.
doi:10.3978/j.issn.2223-4292.2012.09.06
PMCID: PMC3533591  PMID: 23289083
Radiograph; abdominal pain; algorithm; Royal College Radiologists guidelines
3.  Ionising radiation (medical exposure) regulations (Northern Ireland) 2000 and their implications for Accident and Emergency (A&E) doctors in training. 
The Ulster Medical Journal  2001;70(1):19-21.
With the introduction of the Ionising Radiation (Medical Exposure) Regulations (Northern Ireland) 2000 (IRMER) the medical practitioner faces greater accountability when requesting radiological investigations. The referrer (usually a doctor or dentist) must supply sufficient medical data to justify radiation exposure to a patient. These regulations can lead to criminal prosecution if breached. Our objectives were to identify the level of unjustified requests for plain abdominal radiography among A&E doctors and whether there is a statistically significant difference in the justification of request between doctors of differing experience. We reviewed and prepared statistical analysis of 100 A&E request forms for plain abdominal radiography. Royal College of Radiologist Guidelines were used as a "Gold standard" for justification of the investigation. A&E doctors of less than six months experience are at greater risk of breaching these regulations when requesting plain abdominal films, when compared to more experienced doctors. This is a serious issue which should be addressed at undergraduate and pre-registration level in addition to ongoing audit.
PMCID: PMC2449209  PMID: 11428319
4.  Degenerative Changes of Spine in Helicopter Pilots 
Annals of Rehabilitation Medicine  2013;37(5):706-712.
Objective
To determine the relationship between whole body vibration (WBV) induced helicopter flights and degenerative changes of the cervical and lumbar spine.
Methods
We examined 186 helicopter pilots who were exposed to WBV and 94 military clerical workers at a military hospital. Questionnaires and interviews were completed for 164 of the 186 pilots (response rate, 88.2%) and 88 of the 94 clerical workers (response rate, 93.6%). Radiographic examinations of the cervical and the lumbar spines were performed after obtaining informed consent in both groups. Degenerative changes of the cervical and lumbar spines were determined using four radiographs per subject, and diagnosed by two independent, blinded radiologists.
Results
There was no significant difference in general and work-related characteristics except for flight hours and frequency between helicopter pilots and clerical workers. Degenerative changes in the cervical spine were significantly more prevalent in the helicopter pilots compared with control group. In the cervical spine multivariate model, accumulated flight hours (per 100 hours) was associated with degenerative changes. And in the lumbar spine multivariate model, accumulated flight hours (per 100 hours) and age were associated with degenerative changes.
Conclusion
Accumulated flight hours were associated with degenerative changes of the cervical and lumbar spines in helicopter pilots.
doi:10.5535/arm.2013.37.5.706
PMCID: PMC3825948  PMID: 24236259
Vibration; Spine; Degenerative changes; Aircraft
5.  Primary care referrals for lumbar spine radiography: diagnostic yield and clinical guidelines. 
BACKGROUND: Primary care requests for radiographs of the lumbar spine have come under increasing scrutiny. Guidelines aiming to reduce unnecessary radiographs by limiting referrals to patients at high risk of serious disease have been widely distributed. Trial evidence suggests that guidelines can reduce radiography referrals. It is not clear whether this reduction has been achieved in routine practice. AIM: This study, using routine data, was conducted to measure trends in pnmary care referrals for lumbar spine radiography at two hospitals between 1994 and 1999. DESIGN OF STUDY: Analysis of primary care requests for lumbar spine radiography from computerised records. SETTING: Addenbrooke's Hospital, Cambridge (1 July 1994 to 30 June 1999), and Ipswich General Hospital (1 July 1995 to 30 June 1999), United Kingdom. METHOD: All primary care requests for lumbar radiography were identified electronically from computerised information systems. A random sample of 2100 radiography reports were classified according to clinical importance. These classifications were used to examine whether the proportion of radiographs demonstrating potentially more serious findings had increased between 1994 and 1999. RESULTS: There was no evidence that primary care referrals for radiography of the lumbar spine had decreased between 1994 and 1999 at either hospital. General practitioners did not progressively refer more high-risk patients for lumbar radiography. Only a small proportion of patients had important radiographic findings that might warrant specialist referral or specific therapy. CONCLUSION: The implementation of diagnostic guidelines offers much to the NHS. However in these two hospitals, the reduction in radiograph utilisation evident in trials was not achieved. Guideline development is a resource intensive process; distribution must be supported by more effective implementation strategies.
PMCID: PMC1314323  PMID: 12051212
6.  Influence of Royal College of Radiologists' guidelines on referral from general practice. Royal College of Radiologists Working Party. 
BMJ : British Medical Journal  1993;306(6870):110-111.
OBJECTIVE--To measure the effect on general practitioner referrals for radiography of introducing guidelines of good practice together with monitoring and peer review. DESIGN--Collection of referral data during 1 January 1989 to 31 December 1990. Guidelines were introduced on 1 January 1990. SETTING--Open access radiology services provided by one non-teaching district in England. SUBJECTS--144614 registered patients from 22 practices. MAIN OUTCOME MEASURES--Number of referrals per 1000 registered patients for radiography of the chest, skull, spine, abdomen, limbs, and joints and for barium investigation and excretion urography. RESULTS--Overall referrals fell from 88.4/1000 registered patients to 77.2/1000 after the guidelines were introduced. The commonest reasons for referral were for examination of the chest, spine, and limbs and joints and referrals for these fell by 9.4%, 17.5%, and 13.5% respectively. Referrals for skull radiography fell by 30% (from 241 to 168). CONCLUSIONS--By helping general practitioners to be more selective in their use of diagnostic radiology, the guidelines reduced the rate of referral and thus patients' exposure to radiation.
PMCID: PMC1676679  PMID: 8435606
7.  Interobserver Error in Interpretation of the Radiographs for Degeneration of the Lumbar Spine 
We examined 114 segments in 23 patients' lumbar spine plain radiographs affected by disc degeneration. Two consultant orthopaedic surgeons, two consultant radiologists, and one spine nurse practitioner made independent observations on the radiographs. MRI scan films of the corresponding 114 segments were used as a gold standard. Kappa coefficients were used to evaluate the interobserver error, and the error between the independent observers and the MRI scanning reports. The systematic differences between the observers for the diagnosis of the disc degeneration at each segment level was recorded.
There was significant interobserver error between the independent observers. The pairwise interobserver agreement ranged from fair to substantial on the plain radiograph observations [Weighted kappa coefficient, mean: 0.517 (CI=0.388-0.646)]. The pairwise interobserver agreement between the independent observers and the MRI scan ranged from fair to moderate [Weighted kappa coefficient, mean: 0.388 (CI=0.259-0.518)].
There is significant error in interpretation of the plain radiographs for the diagnosis of lumbar disc degeneration. MRI may be more accurate in the diagnosis of lumbar disc degeneration.
PMCID: PMC1888399  PMID: 14575250
8.  Ultrasonography compared with intravenous urography in investigation of urinary tract infection in adults. 
BMJ : British Medical Journal  1990;301(6745):221-224.
OBJECTIVE--To compare ultrasonography with intravenous urography for investigating adults with proved urinary tract infection. DESIGN--Prospective study of patients presenting consecutively for radiological investigation of urinary tract infection between October 1988 and December 1989. Both investigations were performed concurrently and performed independently on routine lists by different duty radiologists, each of whom knew the details on the request form but not the findings of the other investigation. SETTING--Radiology department of a teaching hospital. PATIENTS--158 Consecutive adults (89 women, 69 men; mean age 49.7 (range 18-83)) referred from general practitioners and hospital outpatient clinics with a history of proved urinary tract infection. INTERVENTIONS--Urography and ultrasonography performed concurrently. When both examinations gave normal findings no clinical or radiological follow up was sought. All abnormal findings detected with either investigation were confirmed by subsequent imaging studies or by operative procedures. MAIN OUTCOME MEASURE--Accuracy of detection of abnormalities of urinary system by ultrasonography compared with urography. RESULTS--113 Patients (72%) had normal urographic and ultrasonic findings. Overall, ultrasonography concurred with the findings of urography in 149 (94%) patients, and when a single abdominal radiograph was included in the procedure, in 152 (96%). Ultrasonography missed only one important diagnosis, that of mild papillary necrosis in normal sized kidneys in a diabetic patient. It detected one early bladder tumour not visible on urography and was able to clarify the nature of renal masses (simple cysts) evident on three urograms. CONCLUSION--Ultrasonography provides a safe and accurate method of imaging the urinary tract in adults with infection. Combined with a plain abdominal radiograph, it should replace urography as the initial imaging investigation in these patients. Major savings would result from adopting this policy, and the risks to patients from ionising radiation and intravenous contrast media would be appreciably reduced.
PMCID: PMC1663557  PMID: 2203487
9.  Survey of general practitioners' opinions on the role of radiology in patients with low back pain. 
Ninety general practitioners responded to a questionnaire about the role of radiology in patients with low back pain. Their clinical indications for requesting radiographs were mostly in agreement with the opinions of radiologists, but nearly 80% requested investigations for their own or patients' reassurance. Understanding of the terms used by radiologists was good, although 25% thought that acute disc prolapse could be demonstrated on plain films. Previous training in radiology did not seem to influence knowledge. When general practitioners understood radiological terms they had clear therapeutic and specialist referral preferences. Poorly understood terms and those with which they were familiar but unclear about the implications for management were also identified.
PMCID: PMC1371073  PMID: 2140692
10.  Magnetic Resonance Imaging Interpretation in Patients With Symptomatic Lumbar Spine Disc Herniations 
Spine  2009;34(7):701-705.
Study Design
Retrospective review of imaging data from a clinical trial.
Objective
To compare the interpretation of lumbar spine magnetic resonance imaging (MRIs) by clinical spine specialists and radiologists in patients with lumbar disc herniation.
Summary of Background Data
MRI is the imaging modality of choice for evaluation of the lumbar spine in patients with suspected lumbar disc herniation. Guidelines provide standardization of terms to more consistently describe disc herniation. The extent to which these guidelines are being followed in clinical practice is unknown.
Methods
We abstracted data from radiology reports from patients with lumbar intervertebral disc herniation enrolled in the Spine Patient Outcomes Research Trial. We evaluated the frequency with which morphology (e.g., protrusions, extrusions, or sequestrations) was reported as per guidelines and when present we compared the morphology ratings to those of clinicians who completed a structured data form as part of the trial. We assessed agreement using percent agreement and the κ statistic.
Results
There were 396 patients with sufficient data to analyze. Excellent agreement was observed between clinician and radiologist on the presence and level of herniation (93.4%), with 3.3% showing disagreement regarding level, of which a third could be explained by the presence of a transitional vertebra. In 3.3% of the cases in which the clinician reported a herniation (protrusion, extrusion, or sequestration), the radiologist reported no herniation on the MRI.
The radiology reports did not clearly describe morphology in 42.2% of cases. In the 214 cases with clear morphologic descriptions, agreement was fair (κ = 0.24) and the disagreement was asymmetric (Bowker’s test of symmetry P < 0.0001) with clinicians more often rating more abnormal morphologic categories. Agreement on axial location of the herniation was excellent (κ = 0.81). There was disagreement between left or right side in only 3.3% of cases (κ = 0.93).
Conclusion
Radiology reports frequently fail to provide sufficient detail to describe disc herniation morphology. Agreement between MRI readings by clinical spine specialists and radiologists was excellent when comparing herniation vertebral level and location within level, but only fair comparing herniation morphology.
doi:10.1097/BRS.0b013e31819b390e
PMCID: PMC2754781  PMID: 19333103
herniated disc; MRI; SPORT; reliability; imaging
11.  The diagnostic yield of magnetic resonance imaging (MRI) of the brain and spine requested by general practitioners: comparison with hospital clinicians. 
The rate of diagnosis of radiologically significant abnormalities in outpatients following requests of magnetic resonance imaging (MRI) of the brain and spine by general practitioners was compared with the rate following MRI scan requests by hospital clinicians. A similar rate of significant pathology was diagnosed in both groups in both the brain and the spine. Under carefully controlled conditions, open-access MRI scanning of the brain and spine can contribute to effective patient management.
PMCID: PMC1313478  PMID: 10621993
12.  Diagnostic and therapeutic efficacy of barium meal examination: a prospective evaluation in general practice. 
BMJ : British Medical Journal  1989;299(6713):1443-1445.
OBJECTIVE--To assess the efficacy of barium meal examinations in managing patients with dyspepsia in general practice. DESIGN--Prospective study by questionnaires completed by general practitioners before and within three to six months after the barium meal examination. Information was requested about the patients' symptoms, current treatment, reason for requesting the examination, and the working diagnosis, including degree of certainty and, after the examination, about any change in diagnosis, diagnostic confidence, or management and to determine whether the examination was judged to be helpful or not. SETTING--Inner city health district. PATIENTS--133 Patients with dyspepsia referred by general practitioners for outpatient barium meal examination, 31 of whom failed to attend for the examination, or refused it on arrival, or did not have fully completed questionnaires. Two patients were not available for follow up. MAIN OUTCOME MEASURES--Prevalence of radiological abnormalities and the influence of the examination result on management, particularly changes in drug treatment. RESULTS--Fully completed pairs of questionnaires were available for 100 patients, 58 of whom were aged below 50. Most of the barium meal reports (64) were to confirm the clinical diagnosis; only 22 were to exclude serious disease. Ninety nine patients were already receiving treatment, with 39 taking an H2 receptor antagonist. Fifty eight barium meal examinations showed abnormalities (31 major abnormalities); there were no cancers and in only 18 patients was the working diagnosis changed as a result of the findings. Although the barium meal result increased management confidence (63 patients) and allayed patients' anxiety (46), changes in management attributed directly to the examination occurred in only 22 patients. Management changes were minor, usually comprising interchange of antacids and H2 receptor antagonists. CONCLUSIONS--Young patients (aged below 50) with dyspepsia are still being overinvestigated. Although barium meal examination improves diagnostic confidence and allays patients' anxiety, fully utilising communication skills at the initial consultation might allay anxiety more economically.
PMCID: PMC1838301  PMID: 2575413
13.  A cross sectional study of requests for knee radiographs from primary care 
Background
Knee pain is the commonest pain complaint amongst older adults in general practice. General Practitioners (GPs) may use x rays when managing knee pain, but little information exists regarding this process. Our objectives, therefore, were to describe the information GPs provide when ordering knee radiographs in older people, to assess the association between a clinical diagnosis of osteoarthritis (OA) and the presence of radiographic knee OA, and to investigate the clinical content of the corresponding radiologists' report.
Methods
A cross sectional study of GP requests for knee radiographs and their matched radiologists' reports from a local radiology department. Cases, aged over 40, were identified during an 11-week period. The clinical content of the GPs' requests and radiologists' reports was analysed. Associations of radiologists' reporting of i) osteoarthritis, ii) degenerative disease and iii) individual radiographic features of OA, with patient characteristics and clinical details on the GPs' requests, were assessed.
Results
The study identified 136 cases with x ray requests from 79 GPs and 11 reporting radiologists. OA was identified clinically in 19 (14%) of the requests, and queried in another 31 (23%). The main clinical descriptor was pain in 119 cases (88%). Radiologists' reported OA in 22% of cases, and the features of OA were mentioned in 63%. Variation in reporting existed between radiologists. The commonest description was joint space narrowing in 52 reports (38%). There was an apparent although non significant increase in the reporting of knee OA when the GP had diagnosed or queried it (OR 1.95; 95% CI 0.76, 5.00).
Conclusion
The features of radiographic OA are commonly reported in those patients over 40 whom GPs send for x ray. If OA is clinically suspected, radiologists appear to be more likely to report its presence. Further research into alternative models of referral and reporting might identify a more appropriate imaging policy in knee disorders for primary care.
doi:10.1186/1471-2474-8-77
PMCID: PMC1963327  PMID: 17683606
14.  Ultrasonography compared with intravenous urography in the investigation of adults with haematuria. 
BMJ : British Medical Journal  1990;301(6760):1074-1076.
OBJECTIVE--To compare ultrasonography with intravenous urography in the investigation of adults with haematuria. DESIGN--Prospective study entailing the examination of all patients with both investigations concurrently. The investigations were performed independently on routine lists by different duty radiologists. Each was aware of the details of the request form but not of the findings of the other investigation. SETTING--Radiology department of a teaching hospital. PATIENTS--155 Consecutive adult patients (aged 18-93) referred from general practitioners and hospital outpatient clinics with a history of haematuria. FOLLOW UP--When results of both examinations proved normal no clinical or radiological follow up was sought. All abnormal findings of either investigation were correlated with results of subsequent imaging studies or operative findings. RESULTS--81 Patients (52%) had normal findings on urography and ultrasonography. Overall, the findings of ultrasonography concurred with those of urography in 144 cases (93%). Among the discrepant findings of the two investigations ultrasonography missed two ureteric calculi; one was in a non-dilated ureter, and in the other case ultrasonography detected the secondary ureteric dilatation. Ultrasound examination alone detected four bladder tumours not visible on urography with sizes ranging from 5 to 21 mm, representing one fifth of the 20 cystoscopically proved bladder tumours detected in the series. Ultrasonography detected all the 22 neoplastic lesions discovered in the study (20 bladder, two renal). Ultrasonography clarified the nature of renal masses evident in three urograms (simple cysts). CONCLUSIONS--Ultrasonography is a safe and accurate method of investigating the urinary tract in adults with haematuria. When combined with a single plain abdominal radiograph it proved to be superior to urography as the primary imaging study in this series. Ultrasonography should certainly be preferred to urography if cystoscopy is not planned. No urothelial tumours of the upper urinary tract were found in the series, reflecting their rarity. For those patients in whom ultrasonography and plain radiography have shown no abnormality and in whom cystoscopic appearances are normal urography would be advisable to exclude urothelial tumours of the upper urinary tract.
PMCID: PMC1664237  PMID: 2249070
15.  Rheumatism in Foundry Workers 
In order to investigate loss of work from rheumatic diseases in the metal trades, employees in 10 foundries were questioned.
Of 325 foundry workers aged 35 to 74 years, who had worked for at least 10 years on the foundry floor, 299 were examined clinically and radiologically for evidence of rheumatic disease. Radiographs of the hands, knees, and dorsal and lumbar spine were taken as a routine, and the pelvis was included in those aged 45 and over. A comparison was made with a control series of radiographs, from men, matched for age, in a random population sample examined earlier in the town of Leigh.
Rheumatic complaints in general were less frequent in the foundry workers than in the random sample, and the foundry workers less often gave a history of prolonged incapacity (three months or more) due to this cause.
Radiological evidence of disc degeneration in the lumbar spine, however, was more frequent in the foundry workers than in the controls and was of greater severity. Further, the foundry workers more commonly had symptoms and signs of lumbar disc prolapse. On the other hand, the controls had more osteo-arthrosis of the hips and knees and lost more work from pain at these sites. This was associated with a difference of body habitus, obesity being less frequent in the foundry workers.
Foundry workers directly exposed to hot conditions did not have less back or leg pain than those not so exposed despite a greater prevalence of disc degeneration.
Measurements of air temperature, humidity, and radiant heat were made in a foundry while pouring was in progress. The air temperature rose from 18°C. to 26°C. and the humidity ranged from 70% to 54%. The mean intensity of radiation incident on the clothed surface of a foundry worker was 0·12 watt/cm.2. This was compared with conditions during therapeutic exposure to radiant heat. The radiant heat under conditions of `heat therapy' varied between 0·16 and 0·37 watt/cm.2. The possible influence of radiant heat on the prevalence of rheumatic complaints is discussed.
PMCID: PMC1008347  PMID: 5295324
16.  Abdominal Radiograph Requesting in the Setting of Acute Abdominal Pain: Temporal Trends and Appropriateness of Requesting 
INTRODUCTION
The biannual turnover of house surgeons has long been dreaded by paramedical staff because of fears of increased workloads generated by ‘untrained’ junior doctors. The aim of this study was to address this issue by examining both the quantity and quality of requests made for emergency abdominal radiographs made by ‘experienced’ house surgeons during the month of July and by the ‘novices’ during August.
PATIENTS AND METHODS
All adult patients undergoing abdominal radiography (AXR) following admission as emergencies via the surgical directorate with abdominal signs were identified prospectively. The reports of the AXRs were reviewed to determine the total number of requests and the number of positive findings for the two groups. In addition, the hand-written request forms were recovered to determine the suitability of the requests according to nationally-accepted guidelines produced by the Royal College of Radiologists (RCR).
RESULTS
During the study period, a total of 252 radiographs were performed consisting of 98 in July and 154 in August. The number of unreported films in each month were similar at 11 (11.2%) and 16 (10.4%), respectively, leaving 87 reported radiographs in July and 138 in August. There was no difference in the number of radiographs with positive findings (excluding degenerative spinal disease) for July (n = 19; 22%) and August (n = 33; 24%). Of the 225 reported films, RCR guidelines were followed in only 73 (32%) of 225 cases. When guidelines were adhered to, positive findings were identified in 56 (76.7%) of 73 cases whereas when guidelines were not followed positive findings were seen in only 13/139 (8.9%) of AXRs.
CONCLUSIONS
We have demonstrated that the popular myth of the ‘August syndrome’ is unsubstantiated at least using the surrogate marker of abdominal radiograph requests. The worrying finding of a high number of unacceptable indications for the performance of abdominal radiographs deserves urgent attention both in terms of its financial implications and with regards reducing radiation exposure. A programme of education is proposed to emphasise the RCR guidelines with re-audit to assess adherence to the guidelines.
doi:10.1308/003588406X98586
PMCID: PMC1963673  PMID: 16719997
Abdominal radiograph; Guidelines; Acute abdominal pain
17.  Use of Radiological Facilities by General Practitioners 
British Medical Journal  1974;3(5933):732-734.
The 11,360 direct referrals to diagnostic radiological facilities by general practitioners in the Aberdeen area during 1973 were studied. These represented about 12% of the adult radiology performed in the main x-ray departments of the city, and barium meal examinations amounted to half of all such outpatient contrast examinations. Chest x-ray and barium meal examinations were the most frequently used procedures.
Some abnormality was detected at 34% of all examinations, and the barium meal examinations requested by general practitioners showed a similar percentage of abnormal findings to those requested by Aberdeen hospital doctors.
The average referral rate for all practices was 24·6 per 1,000 practice population per year. Singlehanded general practitioners referred fewer patients for diagnostic radiology than those working in group practices, and rural practitioners referred fewer than urban general practitioners. This trend was emphasized at a distance greater than 15 miles from the city.
Images
PMCID: PMC1611820  PMID: 4416823
18.  The role of cumulative physical work load in lumbar spine disease: risk factors for lumbar osteochondrosis and spondylosis associated with chronic complaints 
OBJECTIVES—To investigate the relation with a case-control study between symptomatic osteochondrosis or spondylosis of the lumbar spine and cumulative occupational exposure to lifting or carrying and to working postures with extreme forward bending.
METHODS—From two practices and four clinics were recruited 229 male patients with radiographically confirmed osteochondrosis or spondylosis of the lumbar spine associated with chronic complaints. Of these 135 had additionally had acute lumbar disc herniation. A total of 197 control subjects was recruited: 107 subjects with anamnestic exclusion of lumbar spine disease were drawn as a random population control group and 90 patients admitted to hospital for urolithiasis who had no osteochondrosis or spondylosis of the lumbar spine radiographically were recruited as a hospital based control group. Data were gathered in a structured personal interview and analysed using logistic regression to control for age, region, nationality, and other diseases affecting the lumbar spine. To calculate cumulative forces to the lumbar spine over the entire working life, the Mainz-Dortmund dose model (MDD), which is based on an overproportional weighting of the lumbar disc compression force relative to the respective duration of the lifting process was applied with modifications: any objects weighing ⩾5 kg were included in the calculation and no minimum daily exposure limits were established. Calculation of forces to the lumbar spine was based on self reported estimates of occupational lifting, trunk flexion, and duration.
RESULTS—For a lumbar spine dose >9×106 Nh (Newton×hours), the risk of having radiographically confirmed osteochondrosis or spondylosis of the lumbar spine as measured by the odds ratio (OR) was 8.5 (95% confidence interval (95% CI) 4.1 to 17.5) compared with subjects with a load of 0 Nh. To avoid differential bias, forces to the lumbar spine were also calculated on the basis of an internal job exposure matrix based on the control subjects' exposure assessments for their respective job groups. Although ORs were lower with this approach, they remained significant.
CONCLUSIONS—The calculation of the sum of forces to the lumbar spine is a useful tool for risk assessment for symptomatic osteochondrosis or spondylosis of the lumbar spine. The results suggest that cumulative occupational exposure to lifting or carrying and extreme forward bending increases the risk for developing symptomatic osteochondrosis or spondylosis of the lumbar spine.


Keywords: case-control study; physical work load; lumbar osteochondrosis; lumbar spondylosis
doi:10.1136/oem.58.11.735
PMCID: PMC1740072  PMID: 11600730
19.  Does applying the Canadian Cervical Spine rule reduce cervical spine radiography rates in alert patients with blunt trauma to the neck? A retrospective analysis 
BMC Medical Imaging  2008;8:12.
Background
A cautious outlook towards neck injuries has been the norm to avoid missing cervical spine injuries. Consequently there has been an increased use of cervical spine radiography. The Canadian Cervical Spine rule was proposed to reduce unnecessary use of cervical spine radiography in alert and stable patients. Our aim was to see whether applying the Canadian Cervical Spine rule reduced the need for cervical spine radiography without missing significant cervical spine injuries.
Methods
This was a retrospective study conducted in 2 hospitals. 114 alert and stable patients who had cervical spine radiographs for suspected neck injuries were included in the study. Data on patient demographics, high risk & low risk factors as per the Canadian Cervical Spine rule and cervical spine radiography results were collected and analysed.
Results
28 patients were included in the high risk category according to the Canadian Cervical Spine rule. 86 patients fell into the low risk category. If the Canadian Cervical Spine rule was applied, there would have been a significant reduction in cervical spine radiographs as 86/114 patients (75.4%) would not have needed cervical spine radiograph. 2/114 patients who had significant cervical spine injuries would have been identified when the Canadian Cervical Spine rule was applied.
Conclusion
Applying the Canadian Cervical Spine rule for neck injuries in alert and stable patients would have reduced the use of cervical spine radiographs without missing out significant cervical spine injuries. This relates to reduction in radiation exposure to patients and health care costs.
doi:10.1186/1471-2342-8-12
PMCID: PMC2442046  PMID: 18557998
20.  Correlations of Radiographic Findings in Patients with Low Back Pain 
Background:
Low back pain can cause severe debilitating pain that may lead to loss of productivity. The pain is usually non-specific and imaging request protocols varies. However, physicians may order lumbo-sacral x-ray in the initial radiologic assessment of the patient. This study aims to determine the frequency of occurrence of radiographic findings in patients reporting low back pain including the presence of osteophytes, spondylolisthesis and degenerative disc diseases and determine the relationship with patients’ features including age, sex, marital status, level of education, body mass index and other radiographic findings.
Method:
Patients who presented at our department for radiographic assessment of the lumbo-sacral spine were voluntarily recruited. Their radiographs were reviewed and questionnaire administered. Height and weight were measured. The radiographic findings were documented and data analysis using Chi square with significant level set at p < 0.05.
Result:
Lumbo-sacral x-rays of 337 patients were reviewed with more females than males, ratio 1:1.4. Osteophytes were demonstrable in 73.6%; spondylolisthesis, 13.4%; and disc degeneration, 28.2%. Disc degeneration correlated with age, educational status, osteophytosis, osteopenia and spondylolisthesis. Osteophytosis correlated with age, BMI and educational level. While spondylolisthesis correlated with educational level and sex.
Conclusion:
Osteophytosis was the commonest finding in patients presenting with LBP. Disc degeneration shows a strong association with osteophytosis and spondylolisthesis and it is reported to herald these changes. Radiography still shows some correlations between the findings in LBP and patients’ characteristics.
PMCID: PMC3180755  PMID: 21969104
Low Back Pain; spondylosis; osteophytosis; spondylolisthesis; radiographic findings
21.  Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? 
International Orthopaedics  2012;36(6):1185-1189.
Purpose
Whilst patients undergoing total knee replacements generally have good relief of their symptoms, up to 20% complain of persisting pain. Revision rates have therefore been rising, particularly so for unexplained pain. We reviewed the causes of painful total knee replacements including extrinsic causes.
Methods
Forty-five consecutive patients referred to our department with painful total knee replacement were reviewed with our standard protocol, including history and examination, inflammatory markers and radiological studies including radiographs of the hip and knee and computed tomography scan of the knee joint.
Results
Of the 45 patients, 15 patients had degenerative hip and lumbar spine disease which resolved after injections of the relevant joints. Nine patients had unexplained pain.
Conclusions
Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis. We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.
doi:10.1007/s00264-011-1473-6
PMCID: PMC3353065  PMID: 22234706
22.  Frequency and clinical meaning of long-term degenerative changes after lumbar discectomy visualized on imaging tests 
European Spine Journal  2009;19(1):136-143.
The aim of this retrospective controlled study was to evaluate radiographic degeneration in the lumbar spine of patients who had undergone lumbar discectomy minimum 21 years earlier and its clinical meaning. Indeed, no previous investigation on degenerative changes occurring after lumbar discectomy with a comparable long follow-up has been published. The study participants consisted of 50 patients who had undergone discectomy for lumbar disc herniation. The mean length of follow-up was 25.3 ± 3.0 years. Patients were assessed by Short Form-36 Health Survey (SF-36), Oswestry Disability Index, and a study-specific questionnaire. Radiographic views of the lumbar spine were obtained from all patients and compared to those of 50 asymptomatic controls. A five-step published classification was used to assess the increasing severity of radiographic changes. CT or MRI scans were also available for 27 patients who had undergone discectomy. Moderate to severe radiographic changes were present in 45 patients (90%) and 34 controls (68%), respectively (P = 0.013). The most prevalent MRI/CT changes were loss of disc height (89%), facet joint arthritis (89%), and endplate changes (57%). Thirty-two of 33 subjects (97%) reporting pain during the last 12 months had significant degeneration on their radiographs, and the frequency of changes was higher with respect to subjects without pain (P = 0.040). In conclusion, standard lumbar discectomy frequently leads to long-term degenerative changes on imaging tests. The presence of moderate to severe degeneration is associated with self-reported pain.
doi:10.1007/s00586-009-1201-8
PMCID: PMC2899737  PMID: 19894068
Discectomy; Low back pain; Long term follow-up; Lumbar spine; Radiography; Surgery
23.  Optimizing radiology in the new picture archiving and communication system environment 
Journal of Digital Imaging  1997;10(Suppl 1):165-167.
Picture archiving and communications systems (PACS) have inescapably altered the face of radiology. Images are available to radiologists and clinicians alike, nearly instantaneously. For patient care management, service has improved, but without inclusion of input from radiologists. Effecting timely report availability requires reorganization of radiology. In a hospital-wide PACS environment, we undertook to render a preliminary report on all nonprocedural computed radiography examinations within 30 minutes in a teaching environment. Two periods of time in the same month were analyzed, one before reorganization and one after. Of 686 reports, 117 were examined with a statistical significance of α=.05 (95% confidence) and a power of 90%. Average times for examination acquisition to preliminary report availability on the PACS decreased from 5 hours to 31 minutes. Standard deviation in report generation times decreased from 8 hours to 30 minutes. This preliminary study suggests that business process reengineering can effect improvement in information flow within a teaching facility resulting in radiologists rejoining the patient care management team. Successes, pitfalls, and future requirements are discussed.
doi:10.1007/BF03168687
PMCID: PMC3452801  PMID: 9268869
picture archiving and communications system (PACS); radiology reports; diagnostic radiology; department management
24.  Kinematic Evaluation of Association between Disc Bulge Migration, Lumbar Segmental Mobility, and Disc Degeneration in the Lumbar Spine Using Positional Magnetic Resonance Imaging 
Global Spine Journal  2011;1(1):43-48.
Degenerative disc disease and disc bulge in the lumbar spine are common sources of lower back pain. Little is known regarding disc bulge migration and lumbar segmental mobility as the lumbar spine moves from flexion to extension. In this study, 329 symptomatic (low back pain with or without neurological symptoms) patients with an average age of 43.5 years with varying degrees of disc degeneration were examined to characterize the kinematics of the lumbar intervertebral discs through flexion, neutral, and extension weight-bearing positions. In this population, disc bulge migration associated with dynamic motion of the lumbar spine significantly increased with increased grade of disk degeneration. Although no obvious trends relating the migration of disc bulge and angular segmental mobility were seen, translational segmental mobility tended to increase with disc bulge migration in all of the degenerative disc states. It appears that many factors, both static (intervertebral disc degeneration or disc height) and dynamic (lumbar segmental mobility), affect the mechanisms of lumbar disc bulge migration.
doi:10.1055/s-0031-1296056
PMCID: PMC3864483  PMID: 24353937
lumbar disc bulge; intervertebral disc degeneration; disc height; lumbar segmental mobility; positional MRI
25.  The association of spinal osteoarthritis with lumbar lordosis 
Background
Careful review of published evidence has led to the postulate that the degree of lumbar lordosis may possibly influence the development and progression of spinal osteoarthritis, just as misalignment does in other joints. Spinal degeneration can ensue from the asymmetrical distribution of loads. The resultant lesions lead to a domino- like breakdown of the normal morphology, degenerative instability and deviation from the correct configuration. The aim of this study is to investigate whether a relationship exists between the sagittal alignment of the lumbar spine, as it is expressed by lordosis, and the presence of radiographic osteoarthritis.
Methods
112 female subjects, aged 40-72 years, were examined in the Outpatients Department of the Orthopedics' Clinic, University Hospital of Heraklion, Crete. Lumbar radiographs were examined on two separate occasions, independently, by two of the authors for the presence of osteoarthritis. Lordosis was measured from the top of L1 to the bottom of L5 as well as from the top of L1 to the top of S1. Furthermore, the angle between the bottom of L5 to the top of S1was also measured.
Results and discussion
49 women were diagnosed with radiographic osteoarthritis of the lumbar spine, while 63 women had no evidence of osteoarthritis and served as controls. The two groups were matched for age and body build, as it is expressed by BMI. No statistically significant differences were found in the lordotic angles between the two groups
Conclusions
There is no difference in lordosis between those affected with lumbar spine osteoarthritis and those who are disease free. It appears that osteoarthritis is not associated with the degree of lumbar lordosis.
doi:10.1186/1471-2474-11-1
PMCID: PMC2824686  PMID: 20044932

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