LBP - Diagnostic Radiology UPR


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LBP - Diagnostic Radiology UPR

  1. 1. Appropriateness Criteria in the evaluation of back pain<br />Edgar Colón Negrón, MD<br />Angel GómezCintrón, MD, MPH<br />Diagnostic Radiology<br />UPR-RCM<br />
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  11. 11. Introduction<br />Acute low back pain is the leading cause of disability for persons younger than 45 in the US<br />High prevalence and high cost in dealing with this problem<br />After multiple studies it is clear that uncomplicated LBP is a benign self-limited condition that does not warrant any imaging studies<br />Vast majority of patients are back to their usual activities in 30 days<br />The challenge for the clinician is to distinguish who should be evaluated to exclude a more serious problem<br />
  12. 12. Indicationsforradiographicevaluationofthespine<br />Red Flags:<br />Significant trauma, ormilderifage >50<br />Unexplainedweightloss<br />Unexplainedfever<br />Immunosuppression<br />HistoryofCancer<br />IV Drug use<br />Osteoporosis, prolonged use ofsteroids<br />Age > 70<br />Focal neurologicdeficitordisablingsymptoms<br />Durationlongerthan 6 weeks<br />
  13. 13. Imaging Modalities<br />Plain films<br />Bone scintigraphy<br />CT<br />MRI<br />Myelography<br />
  14. 14. Plain films<br />Inexpensive<br />Available<br />Screening ( trauma )<br />Assessment of subluxation and alignment<br />
  15. 15. Normal AP, Lat, Obl and Swimmer’s view of cervical spine<br />Look for alignment, vertebral body shape, posterior elements and prever<br />tebral soft tissues. Examination must include C7. Oblique views for<br />evaluation of uncovertebral joints, neural foramina stenosis and facet <br />alignment<br />
  16. 16. Legend:<br />1, v. body<br />2, transverse process <br />3, posterior arch atlas<br />4, 5 facet joints<br />6, lamina<br />7, spinous process<br />8, uncinate process<br />10, disc space<br />11, articular facet joint<br />12, left neural foramina<br />14, pars interarticularis<br />15, pedicle<br />
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  18. 18. Indicationsforradiographicevaluationofthespine<br />Red Flags:<br />Significant trauma, ormilderifage >50<br />Unexplainedweightloss<br />Unexplainedfever<br />Immunosuppression<br />HistoryofCancer<br />IV Drug use<br />Osteoporosis, prolonged use ofsteroids<br />Age > 70<br />Focal neurologicdeficitordisablingsymptoms<br />Durationlongerthan 6 weeks<br />
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  20. 20. IsotopeBone Scan<br />Moderatelysensitiveforthepresenceoftumors, infectionoroccult fractures; notspecific<br />Bonescintigraphywith SPECT followedwith CT is more sensitive in the diagnosis ofspondylolysisthan MR<br />SPECT may localizethesourceofpain in patientswith articular facet OA<br />
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  22. 22. CT of the spine<br />Superior bone detail, not as useful as MR in depicting disc protrusions<br />CT is useful in depicting spondylolysis<br />Poor visualization of the cord, intrathecal contrast needed.<br />Great technique for the assessment of pseudoarthosis, scoliosis, post surgical evaluation of bone graft integrity, surgical fusion and instrumentation <br />
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  31. 31. MRI<br />Examination of choice in complicated LBP<br />Multidisciplinary agreement on terminology facilitates reporting of MR findings<br />No radiation<br />Excellent contrast resolution<br />Multiplanarcapabilities<br />Great visualization of the spinal cord<br />Higher soft tissue contrast than CT<br />
  32. 32. MR in low back pain<br />Acute back painwith radiculopathy suggeststhepresenceofdemonstrablenerverootcompressionon MR<br />MR findingsofModicendplatechanges, anterolisthesis or disk extrusion are more stronglyassociatedwithlow back painthan disk changeswithoutendplatechanges<br />Particularlyefficacious in thedetectionof red flags diagnosis<br />Post operativepatientsenhanced MR allowsdistinctionbetweendiscandscartissue<br />
  33. 33. T1 (left) and T2 (right) weighted <br />images of a normal dorsal spine<br />
  34. 34. T2 weighted images of<br />the lumbar spine. <br />Extreme parasagital <br />views demonstrating<br />root foraminas<br />dorsal root ganglion<br />
  35. 35. T2<br />T1<br />Normal Lumbar <br />Spine<br />
  36. 36. CT vs MRI<br />
  37. 37. Imaging in the diagnosis of spinal diseases<br />
  38. 38. Degenerative diseases and back pain; epidemiologic facts<br />Affects 5% of the adult population per year with a lifetime incidence of 70%-80%<br />90% of patients recover within 3 months<br />286,000 surgeries per year <br />The estimated cost of this entity to the society is between 16 – 60B, with 10B in direct medical care alone<br />2B in MRI alone<br />Modic MT, MRI Clinics of North Amer, Aug 1999<br />
  39. 39. Spinal Degeneration<br />Normal consequence of the aging process, that can be predisposed or accelerated by developmental and acquired factors<br />Two major degenerations;<br />Osteochondral which affects the intervertebral disc ( synchondral articulation)<br />Osteoarthritic affecting the synovial joints (uncovertebral joints in the cervical spine and the facet joints)<br />
  40. 40. Sagital fluid sensitive<br />Pulse sequences<br />Multisegmental degenerative <br />osteochondral changes<br />Normal sagital fluid sensitive<br />Pulse sequence<br />
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  42. 42. T2<br />T1<br />annular fissure<br />
  43. 43. Spinal canal stenosis<br />
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  45. 45. Degenerative osteoarthritic changes to the right uncovertebral<br />joint of the cervical spine with nerve root foramina <br />narrowing<br />
  46. 46. Annular displacement<br />
  47. 47. Displacement of the nucleus pulposus (disc herniations)<br />Due to degeneration of the annular fibers<br />Displacement can be superior, inferior or most commonly posterior<br />Definition<br />Protrusion: within the annulus, annular fissure<br />Extrusion: beyond the annulus but contained by the PLL<br />Sequestrum = free fragment<br />
  48. 48. A-C normal variants, D protruded , E extruded, F and G free fragments<br />
  49. 49. Degenerative osteochondral<br />changes in the with resultant <br />end plate herniations<br /> (Schmorl’s nodes)<br />
  50. 50. Protruded disc<br />
  51. 51. T1<br />T2 <br />small annular fissures<br />
  52. 52. Central extruded disc limited by the posterior <br />Longitudinal ligament<br />
  53. 53. Free fragment<br />
  54. 54. Correlation of symptoms<br />The three most important for localization and causal differential are:<br />Pain<br />Sensory changes<br />Weakness<br />
  55. 55. Patients more likely to have a favorable outcome <br />from surgery should have;<br /> - A clear history of sciatica<br /> - Straight leg raising of less than 30<br /> - Objective neurologic signs<br /> - Imaging evidence of a disc herniation<br /> that corresponds with the anatomical <br /> area of concern<br />
  56. 56. Poor surgical outcome is likely when treating for;<br /><ul><li> Disc disruption syndrome
  57. 57. Degenerative segmental instability
  58. 58. Bulging discs
  59. 59. Pain alone</li></li></ul><li>When to use contrast?<br />Post operative spine, failed back syndrome<br />Evaluation of infection<br />Metastatic disease<br />R/O intramedullary lesion<br />
  60. 60. Axial T1WI pre and post gadolinium injection demonstrating <br />scar at surgical site<br />Contrast enhancement is needed for all post op patients.<br />
  61. 61. RelativeRadiationLevel<br />“Thereispotentialforadversehealtheffectsassociatedwithradiationexposure, thereforeitisanimportant factor toconsiderwhenorderingimagingstudies.”<br />RRL isusedtoestimatepopulation total radiationriskassociatedwithanimagingprocedure.<br />
  62. 62. The bottom line<br />Imaging correlates with outcome only when combined with clinical data<br />Most patients with low back pain will go into clinical response and may not need imaging procedures unless a red flag is raised<br />Knowing of the red flags is important in order to perform the most appropriate imaging procedure, when needed<br />Back pain will continue to be an important clinical topic in the near future due to its economic implications. <br />
  63. 63. RemembertheRED FLAGS<br />Significant trauma, ormilderifage >50<br />Unexplainedweightloss<br />Unexplainedfever<br />Immunosuppression<br />HistoryofCancer<br />IV Drug use<br />Osteoporosis, prolonged use ofsteroids<br />Age > 70<br />Focal neruologicdeficitordisablingsymptoms<br />Durationlongerthan 6 weeks<br />
  64. 64. Reference<br />ACR AppropriatenessCriteria ©<br /><br />