Backache Imaging Presentation        Hieder A`ala            601       MUST University
Wasted time?   Radiology departments do lots of imaging    for low back pain.   X-rays, CT, MRI etc.   How much makes a...
Causes of back pain andsciatica   Paraspinal muscles            Spondylosis    and ligaments                     Spinal...
Acute Back Pain   2nd most common complaint to primary    care physician   >75% of adults will suffer it at some    time...
Back pain imaging — falsepositives   Most adults over 40 will have    degenerative changes on x-rays   MRI shows disc pa...
When to image in patients with        acute back pain?   Most authorities suggest conservative    treatment for 4-6 weeks...
“Red flags” for early imaging   Severe progressive neurological deficit   Fracture?       Major trauma or minor trauma ...
Imaging options   Radiography   CT       Better for fine bone detail, arthritis       As good as MRI for acute disc di...
Radiography   AP and lateral films   Oblique films   Flexion / extension films
Radiography   Diagnoses that can be made on AP and    lateral:       Spondylolisthesis       Compression fracture     ...
Discitis
Radiography   Diagnosis    best made on    oblique films:       Spondylolysis                          Facet joints    ...
Radiography    Diagnosis made with flexion / extension     films:        instability
Spondylolysis   Stress fracture through pars interarticularis   If bilateral, can cause spondylolisthesis    Sagittal re...
Cross Sectional Imaging: CT and MRI    Why?   Confirm extent of degenerative disease and    spinal stenosis.   Search fo...
Anatomy (see hieder lecture on radiological anatomy ) T1                      T2                                          ...
Anatomy                            Nucleus                            pulposisNerve root                                Ne...
Disc disease   After age 40, most adults have at least    some desiccation and loss of height of    lumber discs:       ...
Intervertebral disc anatomy      Nucleus      pulposus    Annular fibers                     T2
Glossary of disc pathology        terms   Herniation: nonspecific term subject to    misinterpretation.       Not recomm...
Glossary of disc pathologyterms   Extrusion: nucleus material pushes out    beyond posterior longitudinal ligament but   ...
Glossary of disc pathologyterms   Localizing terms:       Central       Paracentral       Foraminal       Lateral
Annular disc bulge                                        Compressed 8 :1                Disc bulges diffusely       Page:...
Broad based disc protrusion                                                              Compre                           ...
Paramedian disc protrusion         Normal right L5 root   Displaced left L5 root     This should correlate with a left    ...
Right paramedian disc protrusionSag T1   Sag T2      Axial T2
Foraminal Disc Extrusion Normalforamina           Foraminal Fat Obliterated
Even large disc extrusions will   resolve spontaneously      Large extruded disc   Several months later
Spondylosis   Degenerative disease       Disc desiccation, bulges and protrusions       Ligamentum flavum hypertrophy  ...
Spaces for nerve roots                                    Cauda equina roots in spinal canal  Neural foramen              ...
Facet joint arthritis
Spinal stenosis   Symptoms       Neurogenic claudication       Pain relieved with sitting, bending forward       Progr...
Spinal stenosis   Contributing factors:       Disc bulges and protrusions       Facet arthropathy       Ligamentum fla...
Spondylosis   (Degenerative Disease) Sag T2             Axial T2            Axial CTAnnular disc bulge and facet arthropat...
Spondylosis causing spinal                stenosis                                                                        ...
What does that report mean?   Facet disease:       Common in older patients       May cause pain radiating to hip, simu...
What does that report mean?   Look for key words and descriptions:       “spinal stenosis”, “foraminal stenosis”       ...
What to order: MRI or CT   MRI generally preferred   Contraindications to MRI? — CT is an    acceptable substitute for d...
Spinal and Epidural Infection   High risk populations:       Immunocompromised                      AIDS              ...
Bacterial discitis                     T1 Axial With GDT1 Sag   T2 Sag
Tuberculous spondylitis with       epidural abscess             Enhancing             vertebral body             Non-enhan...
IV drug user– paraspinalabscessT1 unenhanced                   T1 enhanced                T2 unenhanced
Compression fracture:Benign or malignant?   Often difficult to distinguish cause of    acute compression fracture       ...
Compression fracture:Acute or chronic?   Many patients have unsuspected old    compression fractures:   Cheapest evaluat...
Compression Fracture—new or           old? •     New     •   Hypointense T1     •   Hyperintense T2        Easily missed i...
Metastatic disease     On T1 weighted      images, discs should      be darker than      marrow tissue     Tumor brighte...
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Backache imaging presentation

  1. 1. Backache Imaging Presentation Hieder A`ala 601 MUST University
  2. 2. Wasted time? Radiology departments do lots of imaging for low back pain. X-rays, CT, MRI etc. How much makes a difference? Studies show advanced imaging in acute back pain and sciatica doesn’t change outcomes, but improves diagnostic confidence.
  3. 3. Causes of back pain andsciatica Paraspinal muscles  Spondylosis and ligaments  Spinal stenosis Synovial joints:  Foraminal stenosis  Facet and sacroiliac  Bone disease joints  Tumor Disc disease  Fracture  Tear of annulus  Infection fibrosis  Epidural abscess  Specific nerve root  discitis impingements
  4. 4. Acute Back Pain 2nd most common complaint to primary care physician >75% of adults will suffer it at some time. 90% will resolve without intervention (or imaging), most without a specific dx. Among patients with sciatica, only <10% will need surgery. Whom to image?
  5. 5. Back pain imaging — falsepositives Most adults over 40 will have degenerative changes on x-rays MRI shows disc pathology in the majority of adults Many asymptomatic people have disc bulges and protrusions. So, imaging is likely to result in an abnormal report. But correlation between radiographic findings and clinical symptoms is poor. When to image?
  6. 6. When to image in patients with acute back pain? Most authorities suggest conservative treatment for 4-6 weeks unless there are “red flags”:  Look for historical and physical findings that raise clinical question of infection, tumor, or serious neurological impairment  Even positive findings of degenerative disease like disc extrusions and spinal stenosis are not urgent and will be treated conservatively at first.
  7. 7. “Red flags” for early imaging Severe progressive neurological deficit Fracture?  Major trauma or minor trauma in osteoporotic pt. Tumor?  History of cancer, weight loss  Pain worse at night or when supine Infection?  Recent bacterial infection, immune supression, fever, IVDA
  8. 8. Imaging options Radiography CT  Better for fine bone detail, arthritis  As good as MRI for acute disc disease  Myelography as adjunct MRI  Very good for disc, paraspinal pathology, stenosis  Infection  Marrow disorders  Contrast for infection, post-op, tumor Bone scan  Not for primary imaging in most cases Discography
  9. 9. Radiography AP and lateral films Oblique films Flexion / extension films
  10. 10. Radiography Diagnoses that can be made on AP and lateral:  Spondylolisthesis  Compression fracture  SI joint disease  Disc degeneration  Facet arthritis  Tumor  Infection in disc space
  11. 11. Discitis
  12. 12. Radiography Diagnosis best made on oblique films:  Spondylolysis Facet joints  Facet arthritis  Foraminal stenosis (cervical spine)
  13. 13. Radiography  Diagnosis made with flexion / extension films:  instability
  14. 14. Spondylolysis Stress fracture through pars interarticularis If bilateral, can cause spondylolisthesis Sagittal reformatted CT spondylolysis spondylolisthesis
  15. 15. Cross Sectional Imaging: CT and MRI Why? Confirm extent of degenerative disease and spinal stenosis. Search for confirmatory findings in patient with a specific radiculopathy if surgery is contemplated. Occult back pain not responding to conservative treatment Rule out tumor or infection in appropriate patients
  16. 16. Anatomy (see hieder lecture on radiological anatomy ) T1 T2 Conus medullaris Cauda equina
  17. 17. Anatomy Nucleus pulposisNerve root Nerve rootin foramen in foramen disc Facet joint Ligamentum flavum
  18. 18. Disc disease After age 40, most adults have at least some desiccation and loss of height of lumber discs:  Low signal on T2 images.  Posterior or diffuse bulges and protrusions are common.  Jelly-like nuclear material leaks out through tear in annular fibers.
  19. 19. Intervertebral disc anatomy Nucleus pulposus Annular fibers T2
  20. 20. Glossary of disc pathology terms Herniation: nonspecific term subject to misinterpretation.  Not recommended. Bulge: diffuse enlargement of disc area  Very common  Usually not clinically important  May contribute to spinal stenosis Protrusion: nucleus pulposus pushes focally through fibers of annulus fibrosis  Base wider than apex  May focally impinge on nerve or thecal sac
  21. 21. Glossary of disc pathologyterms Extrusion: nucleus material pushes out beyond posterior longitudinal ligament but remains in contact with disc space  Apex wider than base  Likely to impinge on nerve roots Sequestration: Disc fragment isolated from parent disc
  22. 22. Glossary of disc pathologyterms Localizing terms:  Central  Paracentral  Foraminal  Lateral
  23. 23. Annular disc bulge Compressed 8 :1 Disc bulges diffusely Page: 54 of 100 IM: 54 SE: 3
  24. 24. Broad based disc protrusion Compre Page: 2 of 18 IM: cm cm Compressed 7 :1 Compressed 7 :1 Compressedf 11 Page: 6IM:11SE: 201 of 6 IM: 6 SE: 301 cm cm cm cm
  25. 25. Paramedian disc protrusion Normal right L5 root Displaced left L5 root This should correlate with a left L5 radiculopathy.
  26. 26. Right paramedian disc protrusionSag T1 Sag T2 Axial T2
  27. 27. Foraminal Disc Extrusion Normalforamina Foraminal Fat Obliterated
  28. 28. Even large disc extrusions will resolve spontaneously Large extruded disc Several months later
  29. 29. Spondylosis Degenerative disease  Disc desiccation, bulges and protrusions  Ligamentum flavum hypertrophy  Facet arthritis and hypertrophy  Degenerative spondylolisthesis (seen in 7% of asx patients)  Osteophytes All combine to cause stenosis of spaces that nerve roots pass through:  Canal, lateral recess, neural foramen
  30. 30. Spaces for nerve roots Cauda equina roots in spinal canal Neural foramen Nerve root in lateral recess Compr Comp Page: 13 of 18 IM cm cm
  31. 31. Facet joint arthritis
  32. 32. Spinal stenosis Symptoms  Neurogenic claudication  Pain relieved with sitting, bending forward  Progressive pain  +/- radiculopathy, cauda equina syndrome  +/- low back pain No specific measurement to define it in the lumber spine. Many improved with nonsurgical therapy
  33. 33. Spinal stenosis Contributing factors:  Disc bulges and protrusions  Facet arthropathy  Ligamentum flavum hypertrophy  Posterior vertebral body osteophytes  Anterior and lateral osteophytes generally not important  Spondylolisthesis  Not spondylolysis alone
  34. 34. Spondylosis (Degenerative Disease) Sag T2 Axial T2 Axial CTAnnular disc bulge and facet arthropathy cause spinal stenosis
  35. 35. Spondylosis causing spinal stenosis Compressed 5 :1 Compressed 5 :1 Page: 11 of 18 IM: 11 SE: 5 cm cm Page : 8 of 18 18 IM: 8 SE: 5 cm cm Compressed 5 :1Page: 6 of 11 IM: 6 SE: 3 cm cm Compressed 5 :1 Page: 13 of 18 13 IM: 13 SE: 5 cm
  36. 36. What does that report mean? Facet disease:  Common in older patients  May cause pain radiating to hip, simulating sciatica  Predisposes to dynamic instability  Contributes to spinal and foraminal stenosis Mild disc bulges or protrusions  Very common incidental findings  Focal sciatica  Spinal stenosis only if large or in combination with other factors (formerly asx stenosed canal)  Usually not significant unless good correlation with sx.
  37. 37. What does that report mean? Look for key words and descriptions:  “spinal stenosis”, “foraminal stenosis”  Nerve root “displacement”, “compression” or “impingement” (see lecture of nomenclature) Is a specific root involved? Does it correlate with symptoms?
  38. 38. What to order: MRI or CT MRI generally preferred Contraindications to MRI? — CT is an acceptable substitute for disc and bony disease, but poor for infection or intrathecal tumor. MRI — IV contrast only for:  Suspected infection  Suspected tumor  Post-operative spine  Recurrent disc vs. scar tissue
  39. 39. Spinal and Epidural Infection High risk populations:  Immunocompromised  AIDS  Transplant  Chemotherapy  Endocarditis or sepsis  Postoperative patients especially with hardware (instrumentations) Tuberculosis: not necessarily immune compromised
  40. 40. Bacterial discitis T1 Axial With GDT1 Sag T2 Sag
  41. 41. Tuberculous spondylitis with epidural abscess Enhancing vertebral body Non-enhancing fluid in disc space and epidural spaceT1 with Gd T2
  42. 42. IV drug user– paraspinalabscessT1 unenhanced T1 enhanced T2 unenhanced
  43. 43. Compression fracture:Benign or malignant? Often difficult to distinguish cause of acute compression fracture  History of osteoporosis?  Osteoporosis may indicate multiple myeloma in patient without risk factors.  History of primary tumor?  MRI good for survey of marrow at other levels to look for other metastases  Bone scan may serve same function
  44. 44. Compression fracture:Acute or chronic? Many patients have unsuspected old compression fractures: Cheapest evaluation: check old films! Bone scan can prove a fracture is old  May remain positive for up to two years  In elderly, may not be positive in first day MRI can detect acute marrow edema
  45. 45. Compression Fracture—new or old? • New • Hypointense T1 • Hyperintense T2 Easily missed if only T2 Sequence used • Chronic • Same marrow signal as other vertebral bodies on all pulse sequences T1 T2
  46. 46. Metastatic disease  On T1 weighted images, discs should be darker than marrow tissue  Tumor brighter on T2 weighted images, enhances with contrast  Exception—sclerotic prostate metastases
  47. 47. Thank you
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