Imaging of Low Back Pain - PowerPoint Presentation

Slide1

Imaging of Low Back Pain

Dinesh Rao MD

Assistant Professor

Department of Radiology

Neuroradiology and Musculoskeletal Radiology

University of Florida College of Medicine - JacksonvilleSlide2

Disclosures

I have no disclosuresSlide3

Overview

Types of Low Back Pain (LBP)

Modalities of Imaging

Risks of Inappropriate Imaging

Review MRI/CT findings in patients with LBP with neurological symptomsSlide4

Low Back pain – 3 Types

Uncomplicated low back pain

Low back pain associated with neurological symptoms

Low back pain with “red flags”

Trauma, infection, tumor, acute neurological symptomsSlide5

Modalities of Imaging

Plain Film:

"

…

the value of a lumbar spine radiograph is to establish the presence of a spine.”

–

Michael Modic MDSlide6

Modalities of Imaging

CT

W

orkhorse

for

trauma

CT myelogram

P

roblem

solving (tumor, etc

.)

Surgical planningSlide7

Modalities of Imaging

MRI

–

for neurological symptoms

Myelopathy

–

spinal cord disease

Neurogenic claudication

–

canal stenosis below conus

Radiculopathy

–

after failed conservative treatment if patient is considering surgery or pain interventionSlide8

Uncomplicated Low Back Pain

Poorly understood, multifactorial

In young adults, likely related to weak core muscles, weight, bad posture, muscle strain

1

Usually self limiting with conservative treatment

1 Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363–370Slide9

MRI for LBP is Inappropriate

Fewer than 1% of patients in primary care setting have “red flags”

1

Up to 38% of lu

m

bar MRI not indicated

2

Deyo

RA, Weinstein JN. Low back pain. N Engl J Med 2001;

344:363–370

Swedlow A, Johnson G, Smithline N, Milstein A. Increased costs and rates of use in the California workers’ compensation system as a result of self-referral by physicians.

N Engl J Med

. 1992;327:1502–6.Slide10

Risks of Inappropriate Imaging

Costs

Much higher costs with early imaging

Direct costs of scan

Up to 10x as much cost compared to conservative management and testing.

3

No difference in outcome between early MRI and usual care

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3.

Joines JD, McNutt RA, Carey TS, et al. Finding cancer in primary care outpatients with low back pain: a comparison of diagnostic strategies. J Gen Intern Med 2001; 16:14–23

4.

Deyo RA, Mirza SK, Turner JA, et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009;

22:62–68Slide11

Risks of Inappropriate Imaging

Increased rate of surgery

Lumbar MRI leads to more surgery without better outcome

2 times

more likely to have

surgery with plain film

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8 times more likely to have surgery with MRI

6

5.

Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289;2810-2818.

6.

Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52:900-907.Slide12

Risks of Inappropriate Imaging

False positives

–

57% of patients without back pain have a herniated disk

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“Many imaging based degenerative features are likely part of normal aging and unassociated with pain.”

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Degenerative changes correlate poorly with pain and disability

1

7.

Modic, M. T., Obuchowski, N. A., Ross, J. S., Brant-Zawadzki, M. N., Grooff, P. N., Mazanec, D. J., & Benzel, E. C. (2005). Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. 

Radiology

, 

237

(2), 597-604

.

8.

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR. 2015

Apr;26(4):811-6

.

1.

Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363–370Slide13

Risks of Inappropriate Imaging

Patient Labelling

–

patients become less happy with their

life

9

Longer work

disability and higher treatment costs

Increased fear and avoidance of

activities

10

9.

Sloan TJ, Walsh DA. Explanatory and diagnostic labels and perceived prognosis in chronic low back pain. 

Spine

 2010;35:E1120–5.

10.

Webster, BS, Bauer AZ, Choi YS. Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain. SPINE 2013 Volume 38, (22) 1939-1946 Slide14

LBP with Neurological Symptoms

Radiculopathy

Usually recover within a few weeks

Imaging useful for surgical or pain intervention in cases refractory to conservative treatment.

Neurogenic Claudication

–

chronic spinal stenosis

Cauda Equina

–

acute injury/stenosis

MyelopathySlide15

RadiculopathySlide16
Slide17

1 month post opSlide18

1 year post opSlide19

Neurogenic ClaudicationSlide20

MyelopathySlide21

Low Back Pain with Red Flags

Trauma

Infection

Immunosuppresion

Suspicion/history of malignancy

AnticoagulationSlide22

Type 1 DJD

Radiologykey.comSlide23

Discitis/Osteomyelitis (bacterial)Slide24

Discitis/Osteomyelitis (atypical)Slide25

HemorrhageSlide26

TraumaSlide27

TumorSlide28

Summary

Plain film not useful

CT for trauma or specialized issue

MRI

“red flags”

Neurological symptoms possibly requiring surgery