Management of Spine Exam Abnormalities

Initial Assessment and Diagnosis

For suspected spine infection, MRI without and with IV contrast is the preferred initial imaging modality due to its excellent tissue characterization and 96% sensitivity and 94% specificity, as recommended by the American College of Radiology 3, 4
In pediatric scoliosis, PA radiographs should be used to reduce radiation exposure, with lateral views only on initial examination or when clinically indicated, according to the American College of Radiology 5, 6
Spinal radiographs should not be repeated more frequently than every 2 years unless clearly indicated in individual cases, as suggested by the European League Against Rheumatism 1, 7
When evaluating abnormal spine findings, consider non-inflammatory causes such as fractures, which require appropriate imaging evaluation, as recommended by the American College of Rheumatology 1

NSAIDs, including COX-2 inhibitors, are recommended as first-line drug treatment for patients with inflammatory spine conditions with pain and stiffness, according to the European League Against Rheumatism 1, 2
Continuous NSAID treatment is preferred for patients with persistently active, symptomatic disease, with consideration of cardiovascular, gastrointestinal, and renal risks, as suggested by the European League Against Rheumatism 1, 7

Corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered, though systemic glucocorticoids are not supported by evidence for axial disease, as recommended by the European League Against Rheumatism 1, 2

Disease-modifying antirheumatic drugs (DMARDs) like sulfasalazine and methotrexate are not effective for axial disease but may be considered for peripheral arthritis, according to the European League Against Rheumatism 1, 2
Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments, as recommended by the European League Against Rheumatism 1, 2
There is no evidence supporting the obligatory use of DMARDs before or with anti-TNF therapy in patients with axial disease, as suggested by the European League Against Rheumatism 1

Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, regardless of age, according to the European League Against Rheumatism 1, 7
Spinal corrective osteotomy may be considered in patients with severe disabling deformity, as recommended by the European League Against Rheumatism 1, 7
For spinal cord injury, emergency surgical decompression should be performed within 24 hours of neurological deficit to improve long-term neurological recovery, as suggested by the Anaesthesia journal 8

Disease monitoring should include patient history, clinical parameters, laboratory tests, and imaging according to clinical presentation, as recommended by the European League Against Rheumatism 1, 7
MRI findings often lag behind clinical improvement, but resolution of fluid collections or decreased signal abnormality on follow-up MRI studies may suggest treatment response, according to the American College of Radiology 9

For suspected spine infection with neurological deficits or cauda equina syndrome, urgent MRI and specialist consultation are required, as recommended by the American College of Radiology 3, 10
In congenital scoliosis, neural axis anomalies occur in more than 20% of patients, who may benefit from routine preoperative MRI, according to the American College of Radiology 5, 6