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5 Diagnostic Imaging and Pain Management

5 Diagnostic Imaging and Pain Management
The Massachusetts General Hospital Handbook of Pain Management

Diagnostic Imaging and Pain Management

Onassis A. Caneris

I have a little shadow that goes in and out with me,
And what can be the use of him is more than I can see.
He is very, very like me from the heels up to the head;
And I see him jump before me when I jump into my bed.
—Robert Louis Stevenson, 1850–1894

I. Imaging techniques and studies

1. Plain film radiology

2. Fluoroscopy

3. Computed tomography

4. Magnetic resonance imaging

5. Myelography

6. Bone scans and nuclear medicine

7. Discography

8. Positron-emission tomography
II. Headache

1. Primary headache

2. Secondary headache
III. Craniofacial pain syndromes

1. Trigeminal neuralgia

2. Glossopharyngeal neuralgia
IV. Central pain syndromes

1. Thalamic pain syndromes

2. Spinal cord injury
V. Vertebral axis pain

1. Plain x-ray evaluation of low back pain

2. MRI and low back pain

3. Pain after lumbar surgery

4. Arachnoiditis

5. Metastatic disease of the spine

6. Infectious processes of the vertebral spine
VI. Conclusion
Selected Reading

In recent years, there have been tremendous advances in understanding the pathophysiology and mechanisms of pain; concomitantly, there have been enormous advances in diagnostic imaging. Diagnostic imaging is an essential tool for the pain practitioner, who uses it to understand, diagnose, and treat pain. Although plain x-rays remain the mainstay of diagnostic imaging, advanced modalities including computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine studies have proved extremely valuable diagnostic tools for patients with pain. Over the past decade, the use of new technologies has resulted in a 50% increase in healthcare costs. It becomes increasingly important for the pain physician to have a clear understanding of imaging studies and to optimize the use of diagnostic imaging. Consultation with a radiologist or imaging specialist often aids in choosing the most cost-effective test for establishing a diagnosis and in understanding the underlying pathology.
1. Plain film radiology
Plain x-rays (static x-rays) generate two-dimensional (2D) images that primarily display skeletal tissue, but in addition soft tissue anatomy is either seen or inferred. Contemporary x-ray technology generally produces high-quality images with minimal radiation exposure. X-rays are produced as electrons from a cathode are accelerated by electrical current toward an anode target. The x-ray beam is differentially absorbed as it passes through a portion of the patient and then goes on to expose film. Radiopaque contrast materials given orally, locally, intravenously, and intrathecally may be used to aid the study. Most contrast materials used with plain x-rays are iodine-based. Plain x-rays remain the first-line examination for many conditions.
2. Fluoroscopy
The principles of fluoroscopy are the same as those of plain x-rays. The primary difference is that the transmitted radiation is viewed on a fluorescent screen rather than on a static film, and the patient can be imaged in real time. The image is generally amplified by an image intensifier. Fluoroscopy can be used both in diagnostic studies and in assisting with therapeutic treatment.
3. Computed tomography
The prototype CT scanner was developed in the 1960s. Firstgeneration scanners took days to collect data and then hours to reconstruct the images. In the early 1970s, CT scanning for imaging the brain became available. Today’s fourth-generation scanners have significantly improved quality, and the imaging time is significantly shortened. In CT imaging, the x-ray tube produces a beam of energy that passes through a single section of the patient. This beam is then detected by a circular array of detectors on the opposite side. Both the detector and the x-ray source rotate around an axis of the patient and produce exposures at small intervals of rotation. Subsequently, computer reconstruction results in a display of the targeted area. The resolution can be as small as 0.5 mm. Intravenous contrast can be used to enhance the imaging of vascular structures as well as normal tissues.
CT scanning offers the advantage of three-dimensional (3D) images, but they are generally in standard cross-sectional or axial planes. Quantitative CT scanning is particularly useful in measuring bone density for the assessment of osteoporosis. 3D CT also allows postreconstruction images to be rotated at various angles. CT displays soft tissues fairly well and is used for soft tissue imaging if MRI (which provides superior soft tissue contrast) is not available, or if the patient cannot tolerate MRI because of claustrophobia or because it is a more lengthy process.
4. Magnetic resonance imaging
As early as the 1940s and 1950s, nuclear magnetic resonance (NMR) was used to image chemical compounds by exposing them to strong magnetic fields. By the mid 1980s, clinical NMR had become common, and the name was changed to magnetic resonance imaging because of public anxiety engendered by the word nuclear
A significant difference between MRI scanning and CT and x-rays is that MRI uses no ionizing radiation. In MRI, signals are obtained by subjecting the tissues to strong magnetic fields, which influence hydrogen ions in the tissues to align in a certain direction. Tiny radiofrequency signals are emitted as the hydrogen ions “relax” when the magnetic field is removed. The image represents the intensities of the electromagnetic signals emitted from the hydrogen nuclei in the patient. A tissue such as fat, which is rich in hydrogen ions, gives a bright signal, whereas bone gives a void, or essentially no signal. Abnormal tissue generally has more free water and displays different MR characteristics.
The MR signal is a complex function of the concentration of deflected normal hydrogen ions, buildup and relaxation times of the magnetic field (T1 and T2 respectively), flow or motion within the sample, and the MR sequence protocol. Three types of MR sequences are used: spin echo, gradient echo, and inversion recovery. MRI is easily able to provide multiplanar images. Its advantage over CT is its superior contrast of soft tissues, especially neural tissue. The addition of gadolinium as a contrast material aids in defining tumors and inflammatory processes.
5. Myelography
Injection of radiocontrast material into the intrathecal space, followed by imaging using conventional x-ray techniques or CT, provides diagnostic information about potential structural abnormalities affecting the spinal nerves. When noninvasive imaging with either MRI or CT does not provide adequate information, myelography, which was once the gold standard for assessing the spine, remains an option for diagnosing structural spine disease. It is also useful for imaging patients who have had spinal instrumentation, which tends to produce extensive artifact on CT.
Postmyelogram CT imaging is sometimes useful for detecting subtle spinal nerve impingement caused by far-posterior lateral intervertebral disc herniation that has been missed by MRI. Its disadvantages are that it is invasive and, unlike MRI, it utilizes ionizing radiation.
6. Bone scans and nuclear medicine
The field of nuclear medicine followed the discovery of radioactivity in 1896. There are three types of radioactive emissions: positive particles (alpha particles); negative particles (beta particles); and high-penetration gamma radiation. The scintillation events are detected by a scintillation camera and mapped in 2D space. Nuclear medicine uses the tracer principle, which essentially tags certain physiologic substances in the body and measures its distribution and flow or its presence in a target system. A radiopharmaceutical agent is injected into the patient and the radioactive decay is detected by a detection device, for example, a gamma counter.
Bone scans are commonly used to evaluate complaints of skeletal pain. Radiopharmaceuticals labeled with technetium-99m localize areas of increased bone turnover and blood flow that represent increased rates of osteoblastic activity. Bone scans are more sensitive than x-rays in detecting skeletal pathology. One third of patients with pain and known malignant disease with normal x-rays have metastatic lesions on bone scans. The specificity of bone scans is not high, which can sometimes be a problem.
7. Discography
Discography involves injecting the nucleus pulposus of an intervertebral disc with contrast material under fluoroscopic guidance. This can provide objective structural and anatomic information regarding the intervertebral disc. In addition, it can provide subjective information as to whether a particular disc is the source of a patient’s axial lumbar pain.
8. Positron-emission tomography
In positron-emission tomography (PET), positron emissions are detected with a circular array of detectors. The number of decays is displayed to produce an image of specific metabolic processes. PET is an excellent tool for quantification of various metabolic and physiologic changes and processes, making it a functional imaging device. The collection of literature about PET scanning and functional neuroimaging of pain processes is increasing.
Headache is a frequent presentation in both the primary care physician’s office and the pain clinic. The pain specialist must become familiar with the indications for imaging in the assessment of patients with headache. The vast majority of patients who complain of headache and have normal neurologic examinations have a normal CT imaging study.
In a large prospective study of 195 headache patients with normal neurologic examinations, only a minority (9%) had abnormal CT scans (seven had tumor, five had hydrocephalus, three had arteriovenous malformations, two had hemorrhages, and one had cerebral infarction). In a retrospective study of 505 patients with headache without regard to neurologic examination, 35 patients (7%) had abnormal imaging studies. In a study of 350 patients who complained of headache and were prospectively studied with contrast scans, seven patients (2%) had positive scans. Positive pathology included metastasis, sinusitis with epidural abscess, meningiomas, and subdural hemorrhage. In all patients with positive scans, abnormal neurologic exams were present.
An overview of the available data suggests that of 100,000 patients who complain of headache as a sole symptom and have a normal neurologic examination, less than one has a tumor or other significant pathology on cranial imaging studies. It becomes evident that a careful history and neurologic examination are crucial for deciding whether a patient is at risk and whether to order a diagnostic test. Imaging studies ordered without good clinical indication are usually unhelpful and certainly expensive.
1. Primary headache
In patients who present with a history characteristic of primary headache without additional neurologic symptoms and with normal neurologic examinations, it is exceedingly rare to find imaging abnormalities. In a study of 435 patients with symptoms characteristic of classic migraine, contrast-enhanced CT scans were reviewed; one patient was found to have a choroid plexus tumor and no other abnormalities were found. The patient continued to have classic migraines after neurosurgical removal of this tumor, and it was most likely an incidental finding. In a study of 90 patients with “chronic headaches” lasting more than 1 week, CT scanning of all patients found no significant abnormalities. Patients were followed clinically and developed no significant problems.
2. Secondary headache
Several other clinical scenarios warrant discussion. In patients without history of headaches, presenting with the “worst headache of my life,” acute subarachnoid hemorrhage needs to be considered. In such cases, emergent noncontrast CT scanning is the imaging evaluation of choice. Noncontrast CT scanning is extremely sensitive for identifying the presence of acute blood. Additionally, in patients who complain of new headache and fever, lumbar puncture may be indicated. A noncontrast CT scan to exclude a space occupying lesion, which would be a contraindication for lumbar puncture, is indicated before proceeding.
Noncontrast CT scanning is also indicated in acute trauma, because it best identifies acute hemorrhage and lesions of the bone. Contrast CT scanning is indicated when there is clinical suspicion of vascular lesions, neoplastic lesions, or inflammatory conditions. Plain x-rays are not helpful in evaluating headache. In the nonacute setting, MRI scanning has a high degree of sensitivity for intracranial pathology. Diagnostic criteria and imaging for secondary headache are discussed in Chapter 28.
Of patients with newly diagnosed brain tumors, 40% present with a chief complaint of headache. Obstructing the flow of cerebrospinal fluid (CSF), thus increasing intracranial pressure, can produce headaches. Not infrequently, larger parenchymal tumors may initially not produce headache. In patients presenting with headache and focal or lateralizing neurologic symptoms, MRI with contrast material would be the imaging study of choice.
Carotid artery dissection
Symptoms of carotid artery dissection include new-onset unilateral headache with associated anterior cervical pain. Fluctuating hemispheric neurologic deficits as well as Horner’s syndrome may also be present. Carotid dissections are most common in association with trauma; fibromuscular dysplasia may also predispose to carotid dissection. The most common location for dissection is several centimeters above the carotid bifurcation.
Arterial angiography is usually most effective in making the diagnosis, but MRI and magnetic resonance angiography (MRA) may also be helpful, particularly in subsequent follow-up examinations. MRI scanning demonstrates high signal intensity, which usually represents a clot or low arterial flow.
Cerebrovenous and sinus occlusive disease
The most common presenting symptom with either venous or sinus occlusive disease is headache; more than 75% of these patients generally complain of headache. Occlusive disease frequently results in increased intracranial pressure. Cerebral ischemia may also result. Cavernous sinus thrombosis produces severe retroorbital or periorbital pain with proptosis and ophthalmoparesis. Traditional contrast angiography is in most circumstances the imaging study of choice, but traditional angiography is being replaced by MRA and MRI.
Both CT and MRI are appropriate in the evaluation of hydrocephalus. Aqueductal stenosis is seen on imaging studies represented by dilatation of the lateral ventricles and the third ventricle, with a normal appearance of the fourth ventricle; MRI is the imaging study of choice.
In pseudotumor cerebri, imaging studies tend to be normal. Diagnosis is made by examination of the CSF with careful manometry and identification of increased intracranial pressure.
Low Pressure Headache
Postural headaches can be seen as a result of diminished intracranial pressure. These headaches are most commonly seen after lumbar puncture, but they can also be seen after trauma or can occur “spontaneously.” CT and MRI tend to be normal. Isotope cysternography may demonstrate the site of dural leakage of CSF.
Chiari Malformation
Patients with Chiari malformations very frequently present with headache as a primary symptom. Additional neurologic complaints are often associated. MRI is the modality of choice for imaging Chiari malformations. Three types are identified. In type 1, the cerebellar tonsils are displaced caudally into the cervical spinal canal. In type 2, there is additional caudal displacement of the lower cerebellum as well as the brainstem; anatomic abnormalities are seen in the fourth ventricle, and there is associated meningomyelocele. In type 3, either encephalocele or spina bifida is also present.
1. Trigeminal neuralgia
Severe unilateral paroxysmal lancinating pain in the distribution of the trigeminal nerve is characteristic of trigeminal neuralgia. Trigeminal neuralgia is idiopathic. Imaging studies are generally negative. In patients with trigeminal neuropathy and trigeminal neuropathic pain in which atypical features exist, it is important to evaluate for other diagnostic possibilities. MRI is the imaging modality of choice. Occasionally, vascular malformations, aneurysms, and tumors cause trigeminal neuropathy. Multiple sclerosis is sometimes associated with neuropathic facial pain, in which case lesions of increased T2-weighted signal intensity on MRI may be seen in the trigeminal brainstem dorsal root entry zones.
2. Glossopharyngeal neuralgia
The characteristic pain of glossopharyngeal neuralgia is similar to that of trigeminal neuralgia, but it is located unilaterally in the posterior tongue throughout the tonsillar area and sometimes at the auricular area. It also is most frequently idiopathic. In isolated glossopharyngeal neuralgia, imaging studies are rarely positive.In patients with evidence of associated pathology, particularly at the brainstem, MRI with contrast medium is the imaging study of choice.
Central neuropathic pain can result after there has been injury to the primary somatosensory nervous system. Constant burning neuropathic pain is typically seen. Infarction, trauma, and radiation are frequent causes.
1. Thalamic pain syndromes
Injury to the thalamus, specifically the ventral posterolateral nucleus of the thalamus, results in constant burning pain in the contralateral hemi-corpus, including the face, arm, trunk, and leg, although variations in the distribution of pain do exist. This most frequently results from thalamic infarction but can also be the result of hemorrhage, trauma, or space-occupying lesions, including tumor, infection, and abscess. Imaging reveals signal abnormalities in the thalamus contralateral to the pain. A “pseudo-thalamic pain syndrome” can result after injury to the thalamocortical white matter tract. Clinical presentation is the same, but MRI reveals abnormalities in the thalamocortical radiations. In exceptional cases, the MR image is normal but pathology be delineated using functional imaging studies.
2. Spinal cord injury
Injury to the spinal cord at any level can result in a central pain syndrome. Damage to the spinothalamic tract frequently results in central neuropathic pain. Significant central neuropathic pain accompanies spinal cord injury in 25% of patients. Underlying pathology may be trauma, space-occupying lesions including neoplasms, demyelinating process including multiple sclerosis, and syringomyelia. MRI is the imaging modality of choice. In multiple sclerosis, lesions of increased T2-weighted signal intensity are seen in the white matter tracts of the spinal cord. In syringomyelia, MRI reveals a central cavity that shows high signal intensity on T2- weighted images and diminished signal on T1-weighted images.
Low back pain is an extremely common presentation to both the primary care physician and the pain clinic. Underlying pathologic processes affecting the lumbar spine include disc degeneration, degrees of intervertebral disc herniation, osteoarthrosis of the facet joints, fracture of a vertebra, dislocation of a vertebra, spondylolisthesis, and osteoporosis. Degenerative changes causing low back pain may be difficult to distinguish from other common causes, including pain of muscular origin and pain of additional soft tissue origin. Less common alternative causes include intradural and extradural neoplasms, infections, and congenital abnormalities of the spine. The history and physical examination are the basis of the evaluation, but imaging studies may be needed to make a definitive diagnosis.
The primary rationale for radiographic imaging of low back pain is to exclude or define serious pathology. The majority of low back pain originates from soft tissues, and imaging studies are often not helpful. In older patients, imaging studies frequently reveal abnormalities that may or may not be responsible for the patient’s pain syndrome. Plain x-rays can be helpful in diagnosing spondylolysis (pars interarticularis defects, usually at L5 or sometimes L4), ankylosing spondylitis, fractures, and occasionally degenerative disc disease. When neurologic signs or symptoms are present, including those of sciatica, MRI is the imaging modality of choice. MRI without contrast material can detect herniation of lumbar discs with compression of nerve roots causing radicular symptoms.
In patients with a previous history of lumbar surgery, it is imperative to also obtain a contrast-enhanced study, which helps differentiate recurrence of disc herniation from epidural scar tissue; the latter is detected by T1-weighted signal enhancement after administration of contrast. In patients with a clinical complaint of lumbar claudication and suspected spinal stenosis, both CT and MRI are appropriate. CT offers the advantage of superior imaging of bony hypertrophic changes of the lumbar spine.
1. Plain x-ray evaluation of low back pain
Plain x-ray provides an adequate assessment of the configuration and alignment of the lumbar vertebral spine with a high degree of accuracy. There have been a number of natural history and comparative studies evaluating the usefulness of plain x-rays in evaluating low back pain. In a large retrospective study reviewing 1,000 lumbar spine radiographs from patients who complained of low back pain, more than one half of the radiographs were normal. In another study of 780 patients, only 2.4% had unique diagnostic findings on plain radiographs.
Most episodes of low back pain resolve within 7 weeks of onset. It is generally felt that the risks and cost of taking radiographs for all patients at a first presentation of low back pain do not justify the possible small associated benefit. General recommendations for radiographs in patients with low back pain are as follows:

For patients with a first episode of low back pain, present for less than 7 weeks, who have not been treated or who are improving with treatment, no radiographs of the lumbar spine are indicated unless an atypical clinical finding or special psychological or social circumstances exist. Atypical history includes age over 65, history suggesting a high risk for osteoporosis, symptoms of persistent sensory deficit, pain worsening despite treatment, intense pain at rest, fever, chills, unexplained weight loss, and recurrent back pain with no radiographs within the past 2 years. Atypical physical findings include significant motor deficit and unexplained deformity.

For patients with recurrent low back pain, radiographs are not indicated if a previous radiographic study had been done within 2 years.

Patients with a history of a brief, self-limited previous episode of low back pain do not require radiographs within the first 7 weeks of a current episode if they are improving.
In general, anteroposterior and lateral views are the only views that should be done initially. In patients with chronic pain or additional history and physical findings that suggest stenosis or instability, flexion and extension films may be indicated.
2. MRI and low back pain
MRI has a very high sensitivity for detecting pathology of the lumbar spine. A poor correlation exists between the severity of pain symptoms and the extent of morphologic changes seen on MRI studies: a significant percentage of normal individuals without lumbar pain have degenerative changes on MRI (as many as 50% to 60%) and even disc herniation (as many as 20%). Careful attention must be paid to correlating clinical symptoms with radiographic findings; otherwise, imaging findings may be used inappropriately to justify unneeded intervention or treatment.
Age-related morphologic changes occur in the lumbar spine throughout life. There is a decrease in water and glycosaminoglycans in the intervertebral disc, and there is also an increase in collagen. On MRI, this is seen as loss of signal intensity on T2- weighted images, a reduction in the height of vertebral bodies, a reduction in the height of the intervertebral discs, and a reduction in the caliber of the spinal canal. The onset of degenerative processes of the lumbosacral spine seem to be consistently marked by tears of the annulus fibrosis, as well as by MRI and histologic changes of the vertebral bone marrow adjacent to the intervertebral spaces. Facet degeneration rarely occurs in the absence of disc degeneration, and it seems likely that facet osteoarthropathy results from the added stress of increased loading after disc space narrowing has occurred. Multiple studies have found an association between degenerated disc and facet osteoarthritis using imaging criteria.
In patients with radicular symptoms, the clinical evaluation can usually predict the spinal nerve involved. The actual spinal pathology, however, cannot be predicted with clinical evaluation alone, and MRI examination can be of great assistance. A spinal nerve can be compressed by a disc at either the traversing segment by central disc herniation or at the exiting segment by a lateral disc herniation. In these circumstances, imaging is beneficial for defining the site of pathology. Symptomatic patients may have neuroimaging abnormalities at more than one spinal level.
3. Pain after lumbar surgery
In patients who have had previous back surgery and now complain of recurrent radicular pain, the differential diagnosis includes the following:

Incorrect original diagnosis or concomitant disease

Spinal nerve or dorsal root ganglion pathology, including axonal injury or persistent neurapraxic injury

Retained or recurrent intervertebral disc fragment

Epidural fibrosis

Central sensitization

Complex regional pain syndrome
Postoperative fibrosis is a natural consequence of surgical procedures. Numerous reports suggest that fibrosis and adhesions cause compression or tethering of the spinal nerves and their roots, which in turn causes recurrent radicular pain and physical impairment. The literature repeatedly suggests that fibrosis is the major cause of recurrent symptoms when no alternative bony or disc pathology can be found. It has also been suggested that fibrosis may be causal in as much as 25% of all patients with failed back surgery syndrome.
Recurrent radicular pain is defined as pain in a patient who had a successful outcome from the primary surgery at 1 month postoperatively but has had recurrence of radicular pain within 6 months postoperatively. A significant association between the size of the peridural scar and incidence of pain has been demonstrated in this group of patients.
In patients who have had lumbar surgery and present with recurrent radicular pain, it is essential to obtain an MRI scan without and with contrast. This assists in differentiating between a recurrent or retained disc fragment and epidural scarring.
The criteria used to identify epidural fibrosis by MRI include the following:

Epidural scar is isointense to hypointense relative to the intervertebral disc on T1-weighted images on an MRI scan.

Peridural scar tends to form in a curvilinear pattern surrounding the dural tube, with homogenous intensity.

Traction of the dural tube toward the side of the soft tissue is more characteristic of scar.

Scar tissue is seen to consistently enhance immediately after the injection of contrast material, regardless of its location.
The criteria used to identify recurrent herniated disc by MRI include the following:

Recurrent herniated disc material is isointense to the intervertebral disc on T1-weighted images. There tends to be a more variable appearance on T2-weighted images.

Recurrent herniations tend to have a polypoid configuration with a smooth outer margin.

Recurrent disc material does not enhance within the first 10 to 20 minutes after administration of contrast material.
4. Arachnoiditis
Arachnoiditis, which is distinct from epidural scar formation, involves inflammatory and scar tissue within the dura surrounding the spinal nerves. The MRI characteristics of arachnoiditis show three different possible patterns. The first is centrally clumped spinal nerve roots in the thecal sac seen on T1-weighted images; the second is peripheral adhesions of roots to the thecal sac; the third is an increased soft tissue signal within the thecal sac below the conus. Arachnoiditis typically presents as polyradicular lower extremity pain.
5. Metastatic disease of the spine
Severe back pain is a common presentation of metastatic disease of the lumbar spine. The most common tumors that metastasize to bone and thus the lumbar spine are lung, prostate, and breast. Multiple myeloma and breast cancer typically are osteolytic, whereas prostate tends to cause osteosclerotic changes. Bone scans are very sensitive for detecting metastatic involvement of the lumbar spine. The correlation between the severity of bone scan and the intensity of pain is generally poor.
When spinal cord compression resulting from epidural metastatic disease is suspected, MRI is the imaging modality of choice and contrast enhancement is recommended. Back pain is a common presentation of spinal cord compression. When significant reduction of vertebral body height is seen, concomitant epidural involvement is common. Disruption of the pedicle on imaging suggests metastatic disease and, when seen on a plain radiograph, warrants thorough investigation.
6. Infectious processes of the vertebral spine
Plain x-rays can be utilized to assess osteomyelitis. Characteristic changes include loss of end-plate definition, associated soft tissue swelling, destruction of vertebral bodies, and loss of intervertebral disc height. MRI detects involvement of the disc space. Occasionally, MRI is negative and radionucleotide imaging studies can be helpful in establishing the diagnosis. The characteristics of osteomyelitis as seen on MRI include decreased signal intensity, a loss of delineation and demarcation of the vertebral end plate on T1- weighted images; and increased signal intensity in the intervertebral disc on T2-weighted images.
Imaging studies are indispensable tools for the pain physician, who must use them not only as appropriate diagnostic tools but also in a cost-effective manner. Consultation with the department of radiology may be helpful when a diagnosis is uncertain.

Atlas SW, ed. Magnetic resonance imaging of the brain and spine. New York: Raven Press, 1996.

Modic MT, Masaryk TJ, Ross JS, eds. Magnetic resonance imaging of the spine. Chicago: Year Book Medical, 1989.

Osborn AG. Diagnostic neuroradiology. St Louis: Mosby. 1994.


One comment on “5 Diagnostic Imaging and Pain Management

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