Low Back Pain Low Back Pain:

Approach to Imaging and Diagnosis Jacque Jumper, MD Clinical Instructor and Fellow University of California-San Francisco January 27, 2004 Importance
Affects 2/3 of adults Second most common reason for physician visit Most common and expensive reason for work disability

Low Back Pain

Challenges
Definitive diagnosis difficult
not made in 85%

Low Back Pain

Distinguishing benign, self-limited disease (95%) from serious disease (5%) Determining when imaging studies are needed Reassuring the patient

Clinical Approach Imaging Approach Potential Etiologies Specific Cases

LBP: Clinical Approach

Questions
1. Systemic Disease? 2. Psychosocial stressors? 3. Neurologic Compromise?

LBP: Clinical Approach

History: Underlying Disease
age recent trauma cancer / arthritis weight loss IV drug use chronic infection time and duration of pain response to previous therapy

Usually, a careful history and physical can answer the questions

LBP: Clinical Approach

History: Psychosocial Stressors
Depression Substance abuse Job dissatisfaction Disability compensation

LBP: Clinical Approach

History: Neurologic Compromise
sciatica / pseudoclaudication numbness / paresthesia bowel / bladder dysfunction leg weakness provocative maneuvers

LBP: Clinical Approach

Physical:
Fever Tenderness Positive straight leg raising test Loss of reflexes Weakness Sensory changes

LBP: Clinical Approach

Three Categories:
1. Back Pain Only (93%)
musculoligamentous, fracture, spondylosis, infection, tumor, non back related

2. Sciatica (4%)
a. Radiculopathy only b. Associated symptoms: bowel, bladder, saddle anesthesia (cauda equina syndrome)

3. Spinal Stenosis (3%)

LBP: Clinical Approach

Algorithm
Low Back Pain Back Pain Only 93% Sciatica 4% Possible Stenosis 3%

LBP: Clinical Approach

Back Pain Only
Simple Back Pain
Trial of NSAIDS and muscle relaxants for six weeks
most improve (90% in 3 days)

Complicated Back Pain

Risk factors (2+) of age > 50, known malignancy, infection, trauma, IVDA Erythrocyte Sedimentation Rate (ESR) > 20 MRI or CT indicated

LBP: Clinical Approach

Algorithm
Back Pain Only Simple Back Pain
Age < 50 No systemic dz, neurologic deficit Conservative Therapy for 6 weeks Improved Not Improved

LBP: Clinical Approach

Sciatica
sharp radiating pain often associated with numbness or paresthesia weakness and loss of reflexes
L4: knee jerk L5: dorsiflexion, medial sensation S1: plantarflexion, ankle reflex, lateral sensation

Complicated Back Pain

Age > 50 Fever, wt loss, cancer, IVDA, LAD Erythrocyte Sedimentation Rate 2+ risk factors or ESR > 20: Plain Films MRI or CT

aggravated by coughing, sneezing, Valsalva most common cause is herniated disc (HNP)
L4/5, L5/S1 most common

Stop

LBP: Clinical Approach

Sciatica
most common cause is herniated disc (HNP)
L4/5, L5/S1 most common Ages 30-55 years Common finding in asymptomatic Treat nonsurgically for at least six weeks
unless bowel/bladder or saddle anesthesia

LBP: Clinical Approach

Cauda Equina Syndrome
surgical emergency urinary retention, saddle anesthesia, reduced sphincter tone, bilateral sciatica immediate referral for MRI or CT surgical consultation

LBP: Clinical Approach

Algorithm
Sciatica Radiculopathy No Bladder Involvement 99% Conservative Care Urgent Situations Urinary Retention Saddle Anesthesia Urgent Consultation CT or MRI Surgery

LBP: Clinical Approach

Spinal Stenosis

Improved Stop

Not Improved CT or MRI

disease of older adults caused by bone (facets, osteophytes) or soft tissue (bulging disc, ligamentum flavum enlargement) neurogenic claudication, numbness, tingling pain improved when seated or spine is flexed trial of conservative, nonsurgical treatment if intolerable, MRI/CT and possible laminectomy

LBP: Clinical Approach

Algorithm
Possible Stenosis Relieved by sitting Tolerable Symptoms No Neurologic Deficit Treat Symptoms Improved Stop Not Improved Intolerable Symptoms Neurologic Deficit MRI, CT Consider Laminectomy

LBP: Imaging Approach

Imaging Studies:
discouraged early on
majority of LBP patients improve with conservative therapy disc disease and DJD are frequently seen in asymptomatic patients

reserved for those who failed conservative therapy or suspicion for underlying disease

Imaging studies should not replace a good clinical evaluation!

LBP: Imaging Approach

Imaging Studies
Plain radiography Bone Scanning CT (+/- myelography) MRI

LBP: Imaging Approach

Plain Radiography
Standard AP and lat views Flexion/Extension: evaluate instability Oblique: evaluate for spondylolysis
Sacroiliac joints

Relatively insensitive for most disease processes Ionizing radiation Incidental findings

AP

Lateral

History of L5/S1 disc arthroplasty

flexion

extension

LBP: Imaging Approach

Bone Scan
IV radionuclide adheres to metabolically active bone used to detect metastasis, infection, radiographically occult fractures images whole body
good when location of tumor/infection not well defined small advantage over MRI where a local area is imaged oblique
MRI can detect infections, tumors that bone scan cannot

Radionuclide Bone Scan

LBP: Imaging Approach

CT
excellent for defining bony anatomy poor delineation of soft tissues, especially within the spinal canal
improved with myelography

uses ionizing radiation 2.5 mm axial images parallel to disc space sagittal and coronal reformations
ant post
Known prostate ca

Normal CT myelogram Sagittal Reformations

Coronal Reformations

LBP: Imaging Approach

MRI
superb soft tissue resolution better visualization of canal and marrow no ionizing radiation benign vs malignant compression fx post-op scar vs recurrent disc

LBP: Imaging Approach

MRI: protocol
0.3-1.5T magnetic field strength T1 sagittal T2 sagittal T1 axial T2 axial gadolinium if history of malignancy, suspicion for infection or prior surgery

LBP: Imaging Approach

MRI
T1:
high signal
fat protein some forms of blood contrast / gadolinium

T2:
high signal
CSF high water content

MRI Lumbar Spine

LBP: Imaging Approach

MRI: Contraindications
Absolute
ferromagnetic aneurysm clips cardiac pacemaker orbital metallic foreign body cochlear implant

Relative
first trimester pregnancy transcutaneous nerve stimulator severe claustrophobia

T1

T2

LBP: Imaging Approach

Reimbursements:
Plain Radiography: $38 CT: $291 MRI: $562 Bone Scan: $212
with SPECT: $285

Part II
Cases

Normal L-spine MRI

Vertebral Bodies
signal alignment
Ligamentum Flavum

Discs
anulus fibrosis nucleus pulposis

Facets and Ligaments Neuroforamina Central Canal / Conus Surrounding Tissues

Normal Canal

Normal MRI L-spine

T1

T1

T2

T2 Normal MRI L-spine

Disc Pathology
Diffuse Disc Bulge
Circumferential extension of disc beyond margins of endplates >50% of disc circumference < 3 mm Usually associated with DDD NOT considered a form of herniation

Diffuse Disc Bulge

Disc Pathology
Diffuse Disc Bulge

Anular Tear (Fissure)

Separations or breaks between fibers of anulus fibrosis Does not imply trauma Usually asymptomatic, but can be a source of pain High signal in the anulus Usually occurs posteriorly where the anulus is weakest

L4/5

Disc Pathology
Protrusion
Type of disc herniation Present if the greatest distance in any plane, between the edges of the disc material behond the disc space is less that the distance between the edges of the base, in the same plane Focal (<25%) or Broad Based (25-50%)

Anular Tear with Disc Protrusion

Anular Tear w/ Fatty Filum

Anular Tear w/ protrusion

Grade 3 Anular Tear

Disc Pathology
Disc Extrusion
Type of disc herniation Present if the greatest diameter of the herniated disc in any plane is greater than the distance between the edges of the base in the same plane Migration: displacement of disc material away from the parent disc Sequestered: no continuity with parent disc

29 year old male with LBP for 6 months radiating into L leg

Disc Extrusion

Disc extrusion

Disc Extrusion with Migration Disc Extrusion with Migration

Disc Extrusion with Migration Disc Extrusion with Migration

Recurrent Disc After Surgery

Recurrent Disc After Surgery

L4/5

Disc Pathology
Recurrent Disc After Surgery

Foraminal Disc Herniation

Disc material extending into neural foramen Up to 10% of disc herniations Usually more symptomatic than other disc herniations
L5/S1 confined space of the neural foramen obliterates the perineural fat

Foraminal Disc Herniation

Foraminal Disc Herniation

L4/5

Foraminal Disc Herniation

Foraminal Disc Herniation

Rt

Foraminal Disc Herniation

Disc Pathology

Intravertebral Disc Herniation

Schmorls node Disc extends vertically into the vertebral body through a weakness in the endplate Rarely symptomatic

L5/S1

Intravertebral Disc Herniation

Intravertebral Disc Herniation

L2/3

L4/5

Spinal Stenosis
Intravertebral Disc Herniation

Spondylosis Narrowing of spinal canal, neural foramina and lateral recesses Effaced fat and CSF spaces Secondary to multifactorial degenerative changes
facet arthropathy ligamentum flavum enlargement disc osteophyte complexes congenitally short pedicles

L4/5

Facet Arthropathy
Facet Arthropathy

Facets are synovial joints

prone to osteoarthritis osseous overgrowth can result in:
neural foraminal narrowing central canal stenosis Thickened Ligamentum Flavum

Associated with facet synovial cysts and degenerative disc disease

Spinal Stenosis

Spinal Stenosis

Spinal Stenosis

Pony tail effect

Spinal Stenosis

Cauda Equina Syndrome

Compression of cauda equina
Surgical emergency Urinary retention, saddle anesthesia, reduced sphincter tone, bilateral sciatica Immediate referral for MRI or CT Surgical consultation

Compression can be from degenerative changes, trauma, infection, tumor or hematoma

Cauda Equina Syndrome

Cauda Equina Syndrome

T12/L1

Epidural Lipomatosis Epidural Lipomatosis

Facet Synovial Cyst

Thickened synovium Contiguous with degenerated facets Filled with synovial fluid / hemorrhage Can cause compression of the thecal sac and canal stenosis Laminectomy with resection of cyst has high success rate

Facet Disease

Disc Extrusion and Facet Synovial Cysts

Disc Extrusion and Facet Synovial Cysts

Facet Synovial Cyst

Facet Synovial Cyst causing Canal Stenosis

L4/5

89 year old female Low back and R leg pain

Epidural Nerve Block

Discitis/Osteomyelitis
Infection of the vertebral bodies and intervening disc Plain films negative for 2-8 weeks after onset of symptoms MRI is imaging modality of choice
L5-S1

endplate edema T2 hyperintense and enhancing discs epidural abscess paraspinous abscess

Discitis/Osteomyelitis

Discitis/Osteomyelitis

Discitis/Osteomyelitis

Epidural Abscess and (Epi)Dermoid

H/O gastroenteritis, back pain and refusal to walk

Discitis/Osteomyelitis Discitis/Osteomyelitis

Epidural Abscess

Metastatic Disease
Spine metastasis found in 5-10% of cancer patients May cause pathologic fracture, cord compression Malignant v. Benign Compression fx
may be difficult to distinguish if acute look for other signs such as paraspinous soft tissue, marrow signal, extension into posterior elements, multiple lesions

Metastasis

Metastasis

Metastatic Disea

Blastic Metastasis

Extradural and Intradural Metastasis

Osteoporotic Compression Fracture Benign Compression Fracture

Osteoporotic Compression Fracture Lymphoma

Vertebral Hemangioma
Benign vascular and fatty tumor
incidental finding asymptomatic 10-12% of adult population

Vertebral Hemangioma

Hyperintense on T1 and T2WI Well circumscribed Coarse trabecula Occasionally, they will be aggressive If aggressive, can be confused with mets

Vertebral Hemangioma

Vertebral Hemangioma

Schwannoma
Benign nerve sheath tumor Can mimic disc herniation
pain is most common presentation

Dumbbell shaped tumor T2 hyperintense Intense enhancement May be cystic

Schwannoma

Spondylolysis with Spondylolisthisis

Defect in pars interarticularis
thought to be from chronic repetitive trauma associated with anterior slippage (anterolisthisis)
treated conservatively if slip is <50% posterior fusion if slippage >50%

Canal appears elongated at level of lysis and slip

Spondylolisthisis

Spondylolysis

Spondylolisthisis

Spondylolysis

Spondylolysis

Spondylolisthisis Spondylolysis

Spondylolysis Spondylolysis / Spondylolisthisis

Surrounding Soft Tissues

Retroperitoneal pathology can be responsible for back pain!
AAA Renal mass Ureteral Stone Pancreatitis Cholelithiasis Uterine Fibroids UTI Abdominal Aortic Aneurysm

T1

T2

CT

MR Neurogram
Exquisite evaluation of peripheral nerves Useful for evaluating pathologies of brachial or lumbosacral plexus
inflammation avulsion radiation plexopathy

MR Neurogram

STIR, T1 and sometimes gad images in sagittal, coronal and axial planes
L L5 radiculopathy

MR Neurogram

MR Neurogram

Suspicion of R piriformis syndrome

Suspicion of R piriformis syndrome

References
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