LBP - Diagnostic Radiology UPR
description
Transcript of LBP - Diagnostic Radiology UPR
![Page 1: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/1.jpg)
Appropriateness Criteria in the evaluation of back pain
Edgar Colón Negrón, MD
Angel Gómez Cintrón, MD, MPH
Diagnostic Radiology
UPR-RCM
![Page 2: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/2.jpg)
www.acr.org
![Page 3: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/3.jpg)
![Page 4: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/4.jpg)
![Page 5: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/5.jpg)
UNIVERSITY OF PUERTO RICO · SCHOOL OF MEDICINE · DIAGNOSTIC RADIOLOGY
![Page 6: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/6.jpg)
![Page 7: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/7.jpg)
![Page 8: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/8.jpg)
![Page 9: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/9.jpg)
![Page 10: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/10.jpg)
![Page 11: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/11.jpg)
Introduction• Acute low back pain is the leading cause of
disability for persons younger than 45 in the US• High prevalence and high cost in dealing with this
problem• After multiple studies it is clear that uncomplicated
LBP is a benign self-limited condition that does not warrant any imaging studies
• Vast majority of patients are back to their usual activities in 30 days
• The challenge for the clinician is to distinguish who should be evaluated to exclude a more serious problem
![Page 12: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/12.jpg)
Indications for radiographic evaluation of the spine
• Red Flags:
– Significant trauma, or milder if age >50– Unexplained weight loss– Unexplained fever– Immunosuppression– History of Cancer– IV Drug use– Osteoporosis, prolonged use of steroids– Age > 70– Focal neurologic deficit or disabling symptoms– Duration longer than 6 weeks
![Page 13: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/13.jpg)
Imaging Modalities
• Plain films• Bone scintigraphy• CT• MRI• Myelography
![Page 14: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/14.jpg)
Plain films
• Inexpensive• Available• Screening ( trauma )• Assessment of subluxation and alignment
![Page 15: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/15.jpg)
Normal AP, Lat, Obl and Swimmer’s view of cervical spine
Look for alignment, vertebral body shape, posterior elements and prevertebral soft tissues. Examination must include C7. Oblique views forevaluation of uncovertebral joints, neural foramina stenosis and facet alignment
![Page 16: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/16.jpg)
Legend:1, v. body2, transverse process 3, posterior arch atlas4, 5 facet joints6, lamina7, spinous process8, uncinate process10, disc space11, articular facet joint12, left neural foramina14, pars interarticularis15, pedicle
![Page 17: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/17.jpg)
![Page 18: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/18.jpg)
Indications for radiographic evaluation of the spine
• Red Flags:– Significant trauma, or milder if age >50– Unexplained weight loss– Unexplained fever– Immunosuppression– History of Cancer– IV Drug use– Osteoporosis, prolonged use of steroids– Age > 70– Focal neurologic deficit or disabling symptoms– Duration longer than 6 weeks
![Page 19: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/19.jpg)
![Page 20: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/20.jpg)
Isotope Bone Scan
• Moderately sensitive for the presence of tumors, infection or occult fractures; not specific
• Bone scintigraphy with SPECT followed with CT is more sensitive in the diagnosis of spondylolysis than MR
• SPECT may localize the source of pain in patients with articular facet OA
![Page 21: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/21.jpg)
![Page 22: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/22.jpg)
CT of the spine
• Superior bone detail, not as useful as MR in depicting disc protrusions
• CT is useful in depicting spondylolysis• Poor visualization of the cord, intrathecal
contrast needed.• Great technique for the assessment of
pseudoarthosis, scoliosis, post surgical evaluation of bone graft integrity, surgical fusion and instrumentation
![Page 23: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/23.jpg)
![Page 24: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/24.jpg)
![Page 25: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/25.jpg)
![Page 26: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/26.jpg)
![Page 27: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/27.jpg)
![Page 28: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/28.jpg)
![Page 29: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/29.jpg)
![Page 30: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/30.jpg)
![Page 31: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/31.jpg)
MRI
• Examination of choice in complicated LBP• Multidisciplinary agreement on terminology
facilitates reporting of MR findings• No radiation• Excellent contrast resolution• Multiplanar capabilities• Great visualization of the spinal cord
– Higher soft tissue contrast than CT
![Page 32: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/32.jpg)
MR in low back pain
• Acute back pain with radiculopathy suggests the presence of demonstrable nerve root compression on MR
• MR findings of Modic endplate changes, anterolisthesis or disk extrusion are more strongly associated with low back pain than disk changes without endplate changes
• Particularly efficacious in the detection of red flags diagnosis
• Post operative patients enhanced MR allows distinction between disc and scar tissue
![Page 33: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/33.jpg)
T1 (left) and T2 (right) weighted images of a normal dorsal spine
![Page 34: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/34.jpg)
T2 weighted images ofthe lumbar spine. Extreme parasagital views demonstratingroot foraminas
dorsal root ganglion
![Page 35: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/35.jpg)
T2 T1
Normal Lumbar Spine
![Page 36: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/36.jpg)
CT vs MRI
![Page 37: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/37.jpg)
Imaging in the diagnosis of spinal diseases
![Page 38: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/38.jpg)
Degenerative diseases and back pain; epidemiologic facts
• Affects 5% of the adult population per year with a lifetime incidence of 70%-80%
• 90% of patients recover within 3 months• 286,000 surgeries per year • The estimated cost of this entity to the society is
between 16 – 60B, with 10B in direct medical care alone
• 2B in MRI alone
Modic MT, MRI Clinics of North Amer, Aug 1999
![Page 39: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/39.jpg)
Spinal Degeneration
• Normal consequence of the aging process, that can be predisposed or accelerated by developmental and acquired factors
• Two major degenerations;– Osteochondral which affects the intervertebral
disc ( synchondral articulation)– Osteoarthritic affecting the synovial joints
(uncovertebral joints in the cervical spine and the facet joints)
![Page 40: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/40.jpg)
Multisegmental degenerative osteochondral changes
Sagital fluid sensitivePulse sequences
Normal sagital fluid sensitivePulse sequence
![Page 41: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/41.jpg)
![Page 42: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/42.jpg)
T2 T1
annular fissure
![Page 43: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/43.jpg)
Spinal canal stenosis
![Page 44: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/44.jpg)
![Page 45: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/45.jpg)
Degenerative osteoarthritic changes to the right uncovertebral joint of the cervical spine with nerve root foramina narrowing
![Page 46: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/46.jpg)
Annular displacement
![Page 47: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/47.jpg)
Displacement of the nucleus pulposus (disc herniations)
• Due to degeneration of the annular fibers• Displacement can be superior, inferior or
most commonly posterior• Definition
– Protrusion: within the annulus, annular fissure– Extrusion: beyond the annulus but contained by
the PLL– Sequestrum = free fragment
![Page 48: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/48.jpg)
A-C normal variants, D protruded , E extruded, F and G free fragments
![Page 49: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/49.jpg)
Degenerative osteochondral changes in the with resultant
end plate herniations (Schmorl’s nodes)
![Page 50: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/50.jpg)
Protruded disc
![Page 51: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/51.jpg)
T2 T1
small annular fissures
![Page 52: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/52.jpg)
Central extruded disc limited by the posterior Longitudinal ligament
![Page 53: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/53.jpg)
Free fragment
![Page 54: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/54.jpg)
Correlation of symptoms
• The three most important for localization and causal differential are:– Pain– Sensory changes– Weakness
![Page 55: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/55.jpg)
Patients more likely to have a favorable outcome from surgery should have;
- A clear history of sciatica- Straight leg raising of less than 30- Objective neurologic signs- Imaging evidence of a disc herniation
that corresponds with the anatomical area of concern
![Page 56: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/56.jpg)
Poor surgical outcome is likely when treating for;- Disc disruption syndrome- Degenerative segmental instability- Bulging discs- Pain alone
![Page 57: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/57.jpg)
When to use contrast?
• Post operative spine, failed back syndrome• Evaluation of infection• Metastatic disease• R/O intramedullary lesion
![Page 58: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/58.jpg)
Axial T1WI pre and post gadolinium injection demonstrating scar at surgical site
Contrast enhancement is needed for all post op patients.
![Page 59: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/59.jpg)
Relative Radiation Level
• “There is potential for adverse health effects associated with radiation exposure, therefore it is an important factor to consider when ordering imaging studies.”
• RRL is used to estimate population total radiation risk associated with an imaging procedure.
![Page 60: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/60.jpg)
The bottom line
• Imaging correlates with outcome only when combined with clinical data
• Most patients with low back pain will go into clinical response and may not need imaging procedures unless a red flag is raised
• Knowing of the red flags is important in order to perform the most appropriate imaging procedure, when needed
• Back pain will continue to be an important clinical topic in the near future due to its economic implications.
![Page 61: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/61.jpg)
Remember the RED FLAGS
– Significant trauma, or milder if age >50– Unexplained weight loss– Unexplained fever– Immunosuppression– History of Cancer– IV Drug use– Osteoporosis, prolonged use of steroids– Age > 70– Focal neruologic deficit or disabling symptoms– Duration longer than 6 weeks
![Page 62: LBP - Diagnostic Radiology UPR](https://reader031.fdocuments.net/reader031/viewer/2022013104/547c72dfb4af9fdb728b469d/html5/thumbnails/62.jpg)
Reference
• ACR Appropriateness Criteria ©
•acr.org