Radiology-To Scan or not to Scan?

1. Radiology-To Scan or not to Scan? Dr Sue Rowe Consultant Radiologist HUH

2. Topics • Thyroid Ultrasound • MSK Imaging • CT KUB

3. Justification • IRMER • Also helps radiology do the correct test

4. Why Are You Requesting This Test? • What information are you hoping to gain? • Will this information alter patient management? • What information may you gain that creates anxiety?

5. Thyroid Ultrasound • Worldwide increase in thyroid ultrasound • GP demand stable at HUH but recent increase in requests with predicted rise of 35% this year (compared to 12-13).

6. CLINICAL HISTORY • Previous cancer • Immunocompromised • Previous radiation • Relevant previous operations/treatments • Imaging at another hospital • Relevant family history

7. Thyroid • Nearly 70% of the population have a thyroid nodule at ultrasound, 45% of this group>1 nodule • 52 million adults in the UK • 35 million nodules.. and some more follow ups… and some FNA’s • 87% increase in papillary cancer in USA is nodule <2cm and 49% <1cm.

8. In the USA • 2.4 fold increase in reported incidence of thyroid nodules over the last 30 years due to ultrasound. • 3 fold increase in FNA

9. Thyroid Cancer • Incidence of and mortality from thyroid cancer in the US, 1975-2009 and advent of new technologies Fine needle aspiration of thyroid nodules. Increase in use of CT and MRI Ultrasound guided aspiration of thyroid nodules. BMJ 2013; (347):18-21.

10. The incidence of thyroid cancer for men and women in England approximately doubled between 1990-94 and 2006-10.

11. Overdiagnosis Potential Harm • Unnecessary anxiety due to follow up ultrasounds, FNA’s, OPD’s • Potential ‘unnecessary’ thyroidectomy if inadequate FNA or papillary cancer which may have not progressed.

12. How Do We Avoid This? • Do not ultrasound purely for over or underactive thyroid • Ultrasound if palpable lump

13. MSK

14. Justification and Clinical History

15. Effective Dose in mSv (days of background radiation) • CXR 0.02 (1 day) • AXR 0.7 (50 days) • T Spine 1 (35 days) • L Spine 1.5 (65 days) • Knee 0.005 (< 1 day)

16. 6mSv background radiation a year in Cornwall or the Scottish Highlands

17. Typical lifetime total cancer risk as a function of age at exposure and sex HPA-CRCE-028

18. BEIR VII June 2005

19. MSK Appendicular • Axial-plain x-ray first. Better for ossification, foreign bodies, loose bodies, essential in primary tumour assessment • X-ray may guide whether you want to undertake MR or refer • Lumps and Bumps- ?nothing or ultrasound.

20. Shoulders • X-ray-useful for most conditions • Ultrasound- tendinopathy, injection, bursitis • Specialist referral if for dislocation

21. Knee • X-ray- severe degenerative change, don’t need MR • Age >50 very unlikely to warrant MR, unless ?fracture, infection, severe ligamentous injury or synovitis. Specialist referral/locomotive service. • Don’t repair menisci after age 40

23. Knee Ultrasound • Injection • Patellar and quadriceps tendon • ?Popliteal cyst • Pes Anserinus Bursa • Chronic MCL pain (stripping) • Iliotibial Band Friction • Muscle tears (aspiration)

24. Acute Trauma Knee • In the young patient serious concern regarding mensical tear or ligamentous injury consider referring urgently to sports clinic (Tues and Fri 020 8510 7835) . Small tear may increase in size if not treated urgently. • Older patients more likely to be treated conservatively

26. Ankle • X-Ray: trauma, degenerative change, inflammation • Ligamentous injuries may be initially treated conservatively, so don’t necessarily need definitive diagnosis. • MR if worried re fracture which has not been identified on x-ray. Should be able to weight bear without pain 1 month into rehab • Tender over talar dome ?OCD

28. Muscle tears in calf- if collection needs aspiration to facilitate healing • Fractures different rehab, especially if sports person • Late referral/diagnosis can immensely prolong rehab

29. Back Pain

30. Back Pain • Back pain affects most adults at some time, ? 20% of these consult their GP • 85-98% Non specific back pain • 70% back to work in 1 week, 90% within 2 months • Radicular Pain • Red Flags • Not MSK in origin (renal, GI, aorta, gynae)

31. Red Flags • Symptoms of Cauda Equina (sphincters, gait saddle anaesthesia) • Motor Loss • Elevated plasma viscosity • Systemic symptoms (weight loss, pyrexia) • Increased risk of TB or recent sepsis • Non mechanical back pain • Thoracic Pain (2/3rds mets in thoracic region) • Age <16 (cancer), 16-20 (seroneg arthropathy) or new pain >50 (cancer) • Previous cancer

32. X-Rays • Trauma or osteoporotic fracture • Don’t relay on findings. Any Red Flags consider specialist referral or MR; need 50% bone loss to see a lesion on x-ray. Path tests. • Seronegative arthritis will see late changes, again can’t exclude. Does not assess activity.

33. Stratification with STarT Back • Low Risk: self management with GP support • Medium risk: physio referral, exercise, manual therapy, TENS • High Risk: biopsychosocial assessment and management plan Maps of Medicine April 2013

34. Lower Back Pain • Utilise Locomotive Service if 4 weeks of intractable back pain • 6 weeks of conservative active management and still pain undertake MR

35. Specialist Referral • Radicular Pain- shooting or lancing pain with tingling, burning numbness in distribution of a nerve root • Severe Radicular Pain: disabling pain, intrusive, stops patient going to work • Neurological Deficit

36. NICE Guidance 2008 • Physical activity and exercise • Manual therapy [1] • Invasive procedures • Combined physical and psychological treatment programme • Consider referral for a combined physical and psychological treatment programme • Assessment and imaging • Do not offer X-ray of the lumbar spine for the management of non-specific low back pain. • Only offer an MRI scan for non-specific low back pain within the context of a referral for an opinion on spinal fusion (see section 1.9). • Referral for surgery • Consider referral for an opinion on spinal fusion for people who: have completed an optimal package of care, including a combined physical and psychological treatment programme (see section 1.7) and still have severe non-specific low back pain for which they would consider surgery.

37. Reassurance? • Patients may develop a sense of ‘less well being’ when the extent of their spine disease is revealed • Around 1/3rd of radiculopathy symptomatic discs will regress at 6 weeks • Increased frequency of lumbar spine MR associated with higher rates of spinal surgery without clear differences in patient outcomes • Radiology 2005;237:597-604 • Mapsofmedicine.com

38. Lumbar Canal Stenosis • No correlation between imaging appearances and the level of disability • MR used to guide surgery levels • Eur Spine J. 2008 May; 17(5): 679–685.

39. Neck Pain • Common condition, up to 70% adults • Acute torticollis • Whiplash • Non-specific neck pain • Cervical radiculopathy • Others • Red flags

40. Red Flags • Trauma X-Ray • Inability to rotate the neck 45 degrees • Focal neurological deficit/ weakness • Dangerous mechanism of injury • Myelopathy • Cancer, infection etc

41. X-Ray • Indicated in trauma. • Red Flags, but don’t use to exclude • Rheumatoid Arthritis and seronegative arthropathies

42. MRI • Red flags • Consider if failure to respond to treatments over (?)12 weeks • Radiculopathy- or refer?

43. Informally run for several years Should follow ELIC protocol Not a substitute for referral to haematuria clinic Do requests for CT KUB meet the agreed protocol? What is the positive rate for renal colic CT KUB

44. CT KUB • 46 CT KUB over the period Dec 2012 to May 2013 • Request details and reports evaluated • 30 pts haematuria, 1 no haematuria, 15 not stated • 2 patients macroscopic haematuria, 13 micro, not stated 31 • Temperature only mentioned in 1 • 10 no side of pain mentioned • 6 (13%) positive for renal colic, 9 (20%) renal calcifications, no significant other findings • 2009 Audit ED referrals 48.5% renal colic, 9.5% significant other findings