Imaging work-up of lower
back pain
David Ornan, MD
Assistant Professor, Neuroradiology September 11, 2015
Outline
o
Tools
o
Utility of imaging
oChoosing modality
o
ACR appropriateness criteria
oExamples
Tools
o
Radiography
o Fractureso Degenerative changes o Lytic or sclerotic bone lesions o Hardware
o Dynamic instability o Scoliosis
o
Cross-sectional
o CT/CT myelogram
o High spatial resolution for assessment of bone o Multiplanar capabilities
o MRI
o High contrast resolution for assessment of soft tissues, including discs and ligaments
Tools
Tools
o
CT
Tools
Tools
o
MRI
T2 STIR T1 pre T1 post
Tools
o
Contrast
o Indications
o Infection, inflammation, malignancy o Post-operative spine
o Contraindications o Severe allergy
o Facial edema with dyspnea, laryngeal edema with stridor,
bronchospasm with hypoxia, anaphylaxis
Tools
o
Contrast
o Pre-medication for minor and moderate reactions o Prednisone 50 mg, 13, 7, 1 hr
o Benadryl 50 mg, 1 hr
Utility of imaging
o
Limited in the setting of acute back pain
o
<1% of patients will have serious systemic etiologies
oMost will improve with conservative management
oChou et al, Lancet 2009, meta-analysis
o No significant difference in short and long-term outcomes comparing immediate imaging to conservative management
o
Difficult to correlate symptoms to imaging findings
o Disc herniations seen in 22-67% of asymptomatic adults o Findings often do not correlate with severity of symptoms
o
High likelihood of finding extraspinal incidentals that require
Choosing modality
o
Risk assessment
o
Thorough history and physical exam
o Assume exclude other etiologies outside the spine
o
How concerned am I?
oRed flags
Risk assessment
o
Red flags
o Constitutional symptoms o History of malignancy o Neurologic deficits o Weaknesso Numbness, including “saddle” o Bowel/bladder symptoms o Recent bacterial infection o IV drug use
ACR appropriateness criteria
o6 clinical scenarios
o 1: Uncomplicated acute low back pain or radiculopathy
o 2: Minor trauma, osteoporosis, focal deficit, prolonged duration,
age >70
o 3: Suspicion of cancer, infection, or immunosuppression o 4: Low back pain or radiculopathy, intervention candidate o 5: Prior surgery
o 6: Cauda equina, multifocal deficits
o
Scoring system
o 1-3: Usually not appropriate o 4-6: May be appropriate o 7-9: Usually appropriate
ACR appropriateness criteria
o6 clinical scenarios
o 1: Uncomplicated acute low back pain or radiculopathy o 2: Minor trauma, osteoporosis, focal or progressive deficit,
prolonged duration, age >70
o 3: Suspicion of cancer, infection, or immunosuppression o 4: Low back pain or radiculopathy, intervention candidate o 5: Prior surgery
o 6: Cauda equina, multifocal deficits
o
6 clinical scenarios
o 1: Uncomplicated acute low back pain or radiculopathy o 2: Minor trauma, osteoporosis, focal or progressive deficit,
prolonged duration, age >70
o 3: Suspicion of cancer, infection, or immunosuppression o 4: Low back pain or radiculopathy, intervention candidate o 5: Prior surgery
o 6: Cauda equina, multifocal deficits
ACR appropriateness criteria
MRI
o
6 clinical scenarios
o 1: Uncomplicated acute low back pain or radiculopathy o 2: Minor trauma, osteoporosis, focal or progressive deficit,
prolonged duration, age >70
o 3: Suspicion of cancer, infection, or immunosuppression o 4: Low back pain or radiculopathy, intervention candidate o 5: Prior surgery
o 6: Cauda equina, multifocal deficits
ACR appropriateness criteria
Examples
o Scenario 1: Uncomplicated acute low back pain or radiculopathy o Herniated disc
Examples
o Scenario 1: Annular fissure/Herniated disc
www.spineuniverse.com
Examples
o Scenario 1: Annular fissure/Herniated disc
Examples
Examples
o Scenario 1: Disc protrusion
Examples
Examples
o Scenario 1: Sequestered disc
Examples
o Scenario 2: Minor trauma, osteoporosis, focal or progressive deficit,
prolonged duration, age > 70
o Osteoporotic fracture o Spondylowhointhewhat?
o Spondylosis: Degenerative changes o Spondylolisthesis: Slip
Examples
o Scenario 2: Spondylosis
Examples
Examples
o Scenario 2: Spondylosis
Examples
Examples
o Scenario 2: Spondylosis
Modic type 1 Modic type 2 Modic type 3
Zhang et al., Int J Biol Sci2009; 5(7):647‐658
Examples
Examples
o Scenario 2: Spondylosis
Examples
Examples
o Scenario 2: Osteoporotic fracture
Examples
Examples
o Scenario 3: Suspicion of cancer, infection, or immunosuppression
Examples
Examples
Multiple myeloma
o Scenario 3: Suspicion of cancer, infection, or immunosuppression
Examples
Examples
o Scenario 3: Suspicion of cancer, infection, or immunosuppression
Examples
Examples
o Scenario 4: Low back pain or radiculopathy, intervention candidate
Examples
Examples
o Scenario 4: Low back pain or radiculopathy, intervention candidate
Examples
Examples
o Scenario 4: Low back pain or radiculopathy, intervention candidate
Examples
o Scenario 4: Low back pain or radiculopathy, intervention candidate
Examples
o Scenario 5: Prior surgery o Hardware
o Adjacent level disease
o Recurrent disc versus postoperative scar
Examples
o Scenario 5: Prior surgery o Hardware
Examples
o Scenario 5: Prior surgery o Adjacent level disease
Examples
o Scenario 5: Prior surgery
o Recurrent disc versus postoperative scar
Examples
o Scenario 5: Prior surgery
o Recurrent disc versus postoperative scar
Examples
Examples
o Scenario 6: Cauda equina, multifocal deficits o Epidural lipomatosis
Examples
Examples
o Scenario 6: Cauda equina, multifocal deficits
Examples
o Scenario 6: Cauda equina, multifocal deficits o Sarcoidosis
