Lumbar magnetic resonance imaging findings in patients with and without Waddell Signs

Background Context Waddell Signs (WS), introduced as a method to establish patients with substantial psychosocial components to their low back pain, carry a negative association despite no literature evaluating whether physical disease is associated with them. Purpose To compare lumbar magnetic resonance imaging (MRI) findings between the patients with and without WS. Study Design Retrospective cohort study based on prospectively collected data. Patient Sample Thirty patients aged 35 to 55 years with an Oswestry Disability Index (ODI) score >50 randomly selected such that there was an even distribution of patients based on the number of WS. Outcome Measures ODI and Short Form-12 scores, number of WS, presence and severity of spinal pathology. Methods MRIs were reviewed by three spine specialists blinded to clinical exam findings, number of WS, and patient identity. Type and severity of pathology and presence of surgical and non-surgical lesions were assessed, and findings were rank ordered based on the overall impression of the pathology. There was no external funding or potential conflicts of interest for this study. Results There were significantly more individual pathologic findings in patients without WS (p=.02). However, there was no difference in the severity of pathology based on WS (p=.46). Furthermore, the rank ordering based on overall impression of severity showed no difference between the patients with and without WS (p=.20). Although 100% of the patients without WS showed pathologic findings on MRI, 70% of WS patients also had significant pathology on MRI. The prevalence of spondylolisthesis, stenosis, and disc herniation was similar (p=.41, p=.22, and p=.43, respectively). The prevalence and mean number of lesion amenable to surgery did not differ based on presence of WS (p=.21 and p=.18, respectively). Conclusions Patients with WS present a difficult diagnostic challenge for the physician as their organic symptoms are often coexistent with emotional fear avoidance behavior. Although there is more overall pathology in patients without WS, a significant number of these patients appear to have comparable spinal pathology with equivalent severity, which may be contributing to patients' symptoms and disability. Presence of these non-organic symptoms often makes us doubt these patients. However, as part of effective treatment, physicians should better understand both the physical and psychological components of patient disability.