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Appropriate imaging for low back pain
- 1. Appropriate imaging for backpain Dr David Lisle Brisbane Private Imaging Royal Brisbane Hospital University of Queensland
- 2. Appropriate imaging forback pain • Imaging modalities • Clinical presentations • Guidelines
- 3. Appropriate imaging forback pain • Imaging modalities – Radiographs (X-rays) – Scintigraphy (bone scan) – CT – MRI • Clinical presentations • Guidelines
- 4. Radiographs What you see • Bony anatomy and alignment • Disc height
- 5. Radiographs What you see • Bony anatomy and alignment • Disc height Disadvantages • Radiation • Nonspecific – OA changes in most adults • Insensitive – No direct visualisation of neural and other nonbony structures
- 6. Bone scan What yousee • Bone pathology – Osteoblastic activity
- 7. Bone scan What yousee • Bone pathology – Osteoblastic activity Disadvantages • Radiation • Very nonspecific • Relatively poor anatomical resolution – (Improved with SPECT; SPECT/CT) – No direct visualisation of neural and other nonbony structures
- 8. CT What you see • Bony anatomy and alignment • Cross sectional view of spinal canal and foramina • Disc, thecal sac, nerve roots
- 9. CT What you see • Bony anatomy and alignment • Cross sectional view of spinal canal and foramina • Disc, thecal sac, nerve roots Disadvantages • Radiation • Nonspecific – Most adults have ‘findings’ • Poor visualisation of individual neural structures and disc anatomy
- 10. Radiation doses Imaging testEffective dose (mSv) CXRs Background exposure Flying hours CXR 0.02 1 3 days 4 Lumbar X-ray 1.5 75 6/12 300 Lumbar CT 2-10 100-500 8/12 - 3 years 400 - 1800 Bone scan 6 300 2 years 1200
- 11. MRI What you see • Bony anatomy and alignment • Bone pathology • Multiplanar view of spinal canal and foramina • Disc: hydration and structure • Neural structures: cord, nerve roots
- 12. MRI What you see • Bony anatomy and alignment • Bone pathology • Multiplanar view of spinal canal and foramina • Disc: hydration and structure • Neural structures: cord, nerve roots Disadvantages • Availability, cost • Pacemakers, claustrophobia • Nonspecific (too sensitive) – Most adults have ‘findings’
- 13. Appropriate imaging forback pain • Imaging modalities • Clinical presentations: classification into 3 broad categories 1. Nonspecific low back pain 2. Back pain associated with radiculopathy 3. Back pain associated with a specific cause requiring prompt evaluation • Guidelines
- 14. Back pain categories 1. Nonspecific (mechanical) low back pain – Acute: < 12 weeks – Chronic: > 12 weeks – Ligament/ muscle strain/ tear – Intervertebral disc degeneration – Osteoarthritis – Facet joints – SI joints – Spondylolysis/ spondylolisthesis
- 15. Back pain categories 2. Back pain associated with radiculopathy a) Unilateral acute nerve root compression (sciatica) – Leg pain >> back pain – Disc herniation b) Unilateral chronic nerve root compression – Disc herniation or spinal stenosis c) Bilateral chronic nerve root compression – Spinal stenosis – DD vascular claudication d) Bilateral acute nerve root compression = ‘cauda equina syndrome’
- 16. Cauda equina syndrome • Bilateral acute nerve root compression – Massive disc protrusion/ sequestration • Sudden onset bilateral leg pain • Saddle anaesthesia • Rapidly progressive or severe neurological deficits – Motor deficits at >1 level – Faecal incontinence – Urinary retention
- 17. Back pain categories 3. Back pain associated with a specific cause requiring prompt evaluation − Cauda equina syndrome − Cancer − Vertebral infection − Vertebral compression fracture − Ankylosing spondylitis
- 18. Back pain categories 3. Back pain associated with a specific cause requiring prompt evaluation − Cauda equina syndrome − Clinical scenario − Cancer − Vertebral infection − Vertebral compression fracture − Ankylosing spondylitis
- 19. Back pain categories 3. Back pain associated with a specific cause requiring prompt evaluation − Cancer − Hx of Ca + new onset LBP − Unexplained weight loss +/- persistent symptoms +/- age > 50 − Vertebral infection − Vertebral compression fracture − Ankylosing spondylitis
- 20. Back pain categories 3. Back pain associated with a specific cause requiring prompt evaluation − Vertebral infection − Fever − iv drug use − Recent infection − Vertebral compression fracture − Ankylosing spondylitis
- 21. Back pain categories 3. Back pain associated with a specific cause requiring prompt evaluation − Vertebral compression fracture − Hx of osteoporosis − Steroid use − Old age +/- minor trauma − Ankylosing spondylitis
- 22. Back pain categories 3. Back pain associated with a specific cause requiring prompt evaluation − Ankylosing spondylitis (seronegative SpA) − Nonmechanical, inflammatory type of back pain: morning stiffness; improved with exercise − Alternating buttock pain − Waking at night − Younger age
- 23. Appropriate imaging forback pain • Imaging modalities • Clinical presentations • Guidelines – Multiple: different countries and associations – Common theme: • Triage into 3 broad categories as described
- 24. LOW BACK PAINGUIDELINES Diagnostic triage 1. Non-specific LBP 2. Radiculopathy 3. Specific LBP • ‘Red flags’ ‘Red Flags’ • Cauda equina syndrome • Known 10 tumour • Weight loss • Severe symptoms, not settling • Fever • Recent infection or Sx • Osteoporosis • Steroid use • Non-mechanical pain • Child*
- 25. Back pain inchildren and adolescents Presentation Associated Sx DD Ix Night pain Fever, malaise Tumour, infection X-ray MRI Acute pain Radiculopathy +ve SLR Disc herniation Spondylosis X-ray MRI Chronic pain Rigid kyphosis Morning stiffness “Scheuermann’s” Inflammatory arthropathy X-ray Pain with extension Sport: eg rowing Hamstring tightness Spondylolysis ‘Stress reaction’ X-ray MRI Pain + recent onset scoliosis Fever, malaise, +ve SLR Idiopathic scoliosis Tumour, infection, syrinx, disc herniation X-ray MRI Am Fam Phys 2007;76:1669-76
- 26. LOW BACK PAINGUIDELINES • American College of Physicians & American Pain Society Recommendations 1. Focused Hx and examination to place patients into 1 of 3 categories 2. No imaging for nonspecific LBP 3. Imaging for LBP + severe or progressive neurological deficits OR risk factors for specific cause 4. Imaging for LBP and radiculopathy if candidates for surgery or epidural injection Ann Intern Med 2007;147:478-491
- 27. Diagnostic work-up Possible causeImaging Additional studies Nonspecific LBP None None Radiculopathy MRI (CT) Cauda equina MRI Cancer MRI for known 10; X-ray for other eg wt loss ESR Vertebral infection MRI ESR, CRP Vertebral compression # X-ray Ankylosing spondylitis X-ray, incl pelvis (MRI) HLA-B27; ESR, CRP Ann Intern Med 2007;147:478-491
- 28. www.imagingpathways.health.wa.gov.au National Institute forClinical Excellence (NICE) UK ACR Appropriateness Criteria
- 29. Ineffectiveness of imagingfor nonspecific LBP • Favourable natural Hx – Most improve by 4 weeks; unaffected by imaging • Nonspecificity: loose association between findings and symptoms – ‘Abnormalities’ or normal aging? • Potential harms: – Radiation – ‘Labelling’ – Incidental findings Ann Intern Med 2011;154:181-190
- 31. • 85 yearold female • Severe acute on chronic mechanical back pain – Can’t sleep – Limited walking to only a few steps • Spontaneous onset • No known trauma Radiograph (X-ray)
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- 38. • 68M • Suddenonset bilateral leg pain and weakness • Urinary retention MRI
- 41. • Dx: Caudaequina syndrome • Cause: massive sequestration • Other causes: – Tumour • Primary of lower cord, nerve, dura, vertebral body • Secondary – Trauma
- 42. Cauda equina syndrome 30M60F 70M T2
- 44. • 62 yearold male • Severe low back pain of rapid onset • Febrile and unwell • 4 weeks ago underwent abdominal surgery for perforated diverticulitis MRI
- 45. T2 T1 T1FScon
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