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Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis
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  • Published on:
    Response to Best test for diagnosing PEBSI

    Dear Dr Obedkova

    Thank you for your e-letter of 5th April 2021 regarding our publication ‘Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis. BMJ Open Sport & Exercise Medicine 2020;0:e000764. doi:10.1136/ bmjsem-2020-000764’. We welcome your comments and interest in this research as it further highlights the importance of evidence based safe and ethical practice. Our own interest and rationale for this review stems from extensive working with young adults and adolescents involved in elite sport with low back pain.

    We take on board your comments, although where good evidence to support one modality over another is lacking, the merits of different approaches concerning risk v benefit must be central to clinical decision making. In this instance, evidence based practice in the UK overwhelmingly supports the use of MRI as the first line investigation; recognising SPECT/CT involves ionising radiation, and that a safe alternative exists with MRI. When undertaken and interpreted correctly, MRI permits the sensitive detection of posterior element bone stress injury in the vast majority of cases and should therefore be used as the first line investigation. SPECT/CT should therefore be reserved for those small minority of cases where (following MRI) diagnostic doubt remains, where there are underlying complexities (such as previous same-level stress injuries)...

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    Conflict of Interest:
    None declared.
  • Published on:
    Best test for diagnosing PEBSI.
    • Irina Obedkova, Nuclear Medicine Medical Resident Puerta de Hierro University Hospital , Madrid

    Dear colleagues, I have read with a great interest this systematic review “Esh R, Grødahl LHJ, Kerslake R, et al. Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis”[1] and would like to make some comments. Further research, as authors concluded, are always desired and I wish there are appropriate studies in the next future to decide if MRI could be a modality of choice for diagnosing PEBSI and not SPECT/CT as it is by now. But the referred articles from this review do not support this assertion for the following reasons.
    First, there are just 2 articles from 4 included in this review compared MRI and SPECT/CT and just in 1 of them (Juvenil spondilolysis: a comparative analysis of CT, SPECT and MRI) the results of both techniques were concordant, although the main causes of discrepancy were between MRI and SPECT/CT for diagnoses of stress reaction in absence of overt fracture and distinguishing incomplete fracture from intact pars of complete defects (22 patients and 40 pars defect) [2].
    Second, in the 2nd article the authors mention that sensitivity and specificity of MRI was 80 and 100% respectively skipping the SPECT/CT results and author’s conclusion that in the original article was following: “These results suggest that there is a high rate of active spondylolysis in active athletes with low back pain. MRI is inferior to bone scintigraphy (with SPECT)/c...

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    Conflict of Interest:
    None declared.