6/14/2018 BACK PAIN SPINE IMAGING WHEN TO REFER. 45 yr old male. Neck pain with radiating arm pain for 6 months. Weakness left arm

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Agatha Bridges
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1 BACK PAIN SPINE IMAGING WHEN TO REFER Venkat Ganapathy FRCS (C), FAAOS, CCFP, Director Orthopedic Spine Surgery, UT COM Assistant Prof. Orthopedics Surgery, UT COM 45 yr old male Neck pain with radiating arm pain for 6 months Weakness left arm Work up showed C3-C4 and C4-5 large disc herniation Failed non surgical treatment Underwent C3-4 and C4-5 ACDF Complete resolution of arm pain 1

buttock and leg pain Leg heaviness, weakness, difficulty walking (<1 block) MRI-L3-4 and L4-5 spinal

2 26 yr old male Severe off and on back and leg pain for 2 years Weakness leg, tingling and numbness left S1 Positive SLR MRI-posterolateral disc herniation Failed non op treatment 72 yr old lady Back pain, bilateral buttock and leg pain Leg heaviness, weakness, difficulty walking (<1 block) MRI-L3-4 and L4-5 spinal stenosis Failed non surgical treatment MIS lumbar laminectomy Post op improved walking and resolution of radiculopathy 2

85 yr old lady came in to ER due to severe back

with slip 2 level MIS interbody fusion with

3 85 yr old lady came in to ER due to severe back and leg pain Failed PT and injection, unable to ambulate Xrays-L4-L5 spondylolisthesis MRI-L3-L4 foraminal disc and L4-5L5 severe spinal stenosis with slip 2 level MIS interbody fusion with decompression Post op improvement of leg pain and walks with cane 3

4 42 yr old gentleman Unable to swallow, difficulty breathing, change in voice Neck pain and bilateral shoulder pain Unable to elevate head with poor gaze Progressive worsening Clinically myelopathic 4

5 5

40 year old male Severe bilateral radiculopathy Urinary

residual abnormal Acute cauda equina Emergent decompression

degenerative scoliosis Failed non operative treatment Poor

6 40 year old male Severe bilateral radiculopathy Urinary retention on presentation Abnormal rectal exam Post void residual abnormal Acute cauda equina Emergent decompression Presentation 58 yr old gentleman Severe back and leg pain Adult degenerative scoliosis Failed non operative treatment Poor quality of life Walking with cane MRI-severe canal stenosis (L3-L5) and foraminal stenosis, 6

7 7

35 yr old Adolescent idiopathic scoliosis 6

infections related to them Extensive hardware

injections Evaluation showed screw in the

SI joint findings Complete relief with SI

joint screw was broken, removed and SI fused

8 35 yr old Adolescent idiopathic scoliosis 6 surgeries so far including multiple infections related to them Extensive hardware Chronic back pain Failed PT, pain management, injections Evaluation showed screw in the left SI joint Right SI screw broken Positive SI joint findings Complete relief with SI joint injection Intra operatively the left SI joint screw was broken, removed and SI fused in an MIS technique Compete pain relief at 6 weeks post op 8

28 yr old with severe back pain for several months Previous multiple ER visits for

bilateral lower extremity pain and weakness MRI showed discitis and osteomyelitis

Multiple ER visits for thoracic back pain Subsequently paraplegic on ER visit with

9 28 yr old with severe back pain for several months Previous multiple ER visits for back pain with negative radiographs On last presentation to ER-severe back pain, bilateral lower extremity pain and weakness MRI showed discitis and osteomyelitis Needed surgical decompression (due to neuro deficits) Post op antibiotics 16 yr old Multiple ER visits for thoracic back pain Subsequently paraplegic on ER visit with urinary retention Myelopathic MRI work up thoracic lymphoma Emergency thoracic decompression 9

Neurological improvement in 24 hrs Normal bladder function in 48 hrs Radiation 2 weeks post op after wound completely healed Disease burden Low back pain 2% of

treating LBP in the USA ranges from $20 to $50 billion dollars, in addition to $28 billion in lost productivity Arthritis ($80.

10 Neurological improvement in 24 hrs Normal bladder function in 48 hrs Radiation 2 weeks post op after wound completely healed Disease burden Low back pain 2% of all physician visits 2005 the total expenditure for the treatment of back and neck disorders was approximately $86 billion The estimated annual direct cost of treating LBP in the USA ranges from $20 to $50 billion dollars, in addition to $28 billion in lost productivity Arthritis ($80.3 billion), cancer ($89 billion), diabetes ($98.1 billion), and heart disease and stroke ($257.6 billion) Classification Back pain Acute (< 4 weeks) Sub acute (4-12 weeks) Chronic (>12 weeks) 10

Axial neck pain Pain occurring in the cervical, occipital, or posterior scapular areas but not radiating into the upper extremities Risk factors: females; repetitive movements, heavy lifting, smoking

11 Axial neck pain Pain occurring in the cervical, occipital, or posterior scapular areas but not radiating into the upper extremities Risk factors: females; repetitive movements, heavy lifting, smoking Pain and stiffness in neck with no arm pain and no neuro symptoms, Explore red flags: malignancy, trauma, infection, immunosuppression or acute neurologic changes Known rheumatoid arthritis or Down syndrome?-investigate further Pain generators: Cervical disks, facet joints, joint capsules, muscles, tendons, and neurologic structures have all been implicated Evaluation Evaluating x-rays Comprehensive neck exam, check shoulder, r/o thoracic outlet (adson/wright tests), Usually normal neuro exam, cervical tenderness Flexion pain-discogenic/muscular; Extension-facet Evaluation mainly with history and physical. Standing cervical AP and lateral rays if no resolution after 4-6 weeks; image (MRI) earlier if suspicious for red flags Usually resolves in 6 weeks, non surgical management mainstay MRI Management Vertebral body lesions Look for disc hydration (best time when I discuss smoking cessation) Disc bulge/herniation Impingement on neural elements Spinal cord signal change Brief period of relative rest (~24 to max 48 hrs) Quit smoking Optimize mental health & sleep Activity modification (avoid pain provoking activity) Limited course of medications-nsaids etc. Physical therapy/acupuncture-dry needling/chiropractor care Local modalities: Heat, ice, massage, ultrasonography, and transcutaneous electrical nerve stimulation Injections: Cervical epidural, selective nerve root blocks, facet injections Failed non surgical treatment: Anterior cervical discectomy & fusion (for the right patient with realistic goals) 11

ACDF Cervical radiculopathy Exam Radiating arm pain, tingling,

often in the C5-C6, and C7 distributions.

pathology (pancoast tumor rare) Complete neck, shoulder exam (r/o

entrapment exam Positive Spurlings sign Check for thoracic outlet

Imaging Xrays-AP, Lat, Oblique-alignment, degenerative disk disease

Oblique images reveal the foramen MRI-best for disc, cord & soft

12 ACDF Cervical radiculopathy Exam Radiating arm pain, tingling, burning, in dermatomal distribution, weakness, and numbness Most often in the C5-C6, and C7 distributions. Differentiate from shoulder pain referred to neck Beware of lung pathology (pancoast tumor rare) Complete neck, shoulder exam (r/o TOS) Comprehensive neurological exam r/o Peripheral nerve entrapment exam Positive Spurlings sign Check for thoracic outlet syndrome Check for peripheral nerve entrapment Investigations Imaging Xrays-AP, Lat, Oblique-alignment, degenerative disk disease and disk space narrowing on the laterals. Oblique images reveal the foramen MRI-best for disc, cord & soft tissue patho-anatomy CT-not commonly done, best for bony anatomy Myelography-not commonly done, use if contraindications for MRI, risky (dye, invasive) 12

Management Surgical indications Brief period of relative rest

Activity modification (avoid pain provoking activity) Limited

Traction in flexion, Physical therapy/dry needling/chiropractor

electrical nerve stimulation Cervical epidural, selective root

$intervention Persistent or recurrent arm pain refractory to at$ neurologic deficits or static neurologic deficits with

physical examination findings Surgical options Anterior Cervical

13 Management Surgical indications Brief period of relative rest (~24 to max 48 hrs) Quit smoking Optimize mental health & sleep Activity modification (avoid pain provoking activity) Limited course of medications-nsaids etc. Traction in flexion, Physical therapy/dry needling/chiropractor Heat, ice, massage, ultrasonography, and transcutaneous electrical nerve stimulation Cervical epidural, selective root block injections Failed non surgical treatment: Surgical intervention Persistent or recurrent arm pain refractory to at least 3 months of nonsurgical treatment with progressive neurologic deficits or static neurologic deficits with significant arm pain; and imaging studies correlated with the physical examination findings Surgical options Anterior Cervical Discectomy & Fusion (ACDF) Anterior Cervical Corpectomy & Fusion (ACCF) Lamino-foraminotomy Cervical disc arthroplasty Cervical disc arthroplasty 13

Cervical myelopathy Causes: spondylosis/congenital/degenerative/opll/infection/tumor

fine motor tasks, and diffuse numbness, tendency to drop objects, difficulty in

gait with spasticity, ataxia, or weakness, electric shock-like sensations that travel

Lhermitte sign) Bowel and bladder dysfunction UMN signs-hyperreflexia, clonus,

test Imaging Treatment No true non surgical treatment * Asymptomatic cord compression

wise progression Surgical goal is to increase space available for cord and put put a

look for cord signal changes in T1 and T2 (myelomalacia poor prognosis) 2.

14 Cervical myelopathy Causes: spondylosis/congenital/degenerative/opll/infection/tumor causing cervical spinal cord compression Hand clumsiness, difficulty in performing fine motor tasks, and diffuse numbness, tendency to drop objects, difficulty in buttoning a shirt, and inability to differentiate objects by palpation, Wide-based gait with spasticity, ataxia, or weakness, electric shock-like sensations that travel down the spine or extremities when the neck is in certain provocative positions (the Lhermitte sign) Bowel and bladder dysfunction UMN signs-hyperreflexia, clonus, Hoffmans, inverted BR reflex, finger escape sign, Babinski, 10-second grip-and-release test Imaging Treatment No true non surgical treatment * Asymptomatic cord compression may never become symptomatic-so watch closely If symptomatic, natural course is step wise progression Surgical goal is to increase space available for cord and put put a stop to the progression 1. look for cord signal changes in T1 and T2 (myelomalacia poor prognosis) 2. ratio of the smallest sagittal cord diameter to the largest transverse diameter at one level (< 0.4 is an indicator of a poor prognosis) Surgical options-depend on cervical alignment, no: of levels and site of pathology ACDF/Corpectomy and fusion/cervical arthroplasty/posterior cervical decompression and fusion or laminoplasty Cervical Laminectomy 14

Cervical Laminoplasty Clinical Presentation Evaluation Less common, most occur below T8, (lack of ribs support) Risk factors:

asymptomatic, most resolving over time Thoracic pain wraps around the chest or abdomen in a dermatomal distribution, Signs of

cauda compression than a thoracic disk herniation.

disc (dural usually adherent in these cases) Electromyography can confirm nerve root involvement, and somatosensory and motor-evoked

Injections at the level of the suspected nerve root can be both diagnostic and therapeutic.

15 Cervical Laminoplasty Clinical Presentation Evaluation Less common, most occur below T8, (lack of ribs support) Risk factors: genetic, nicotine use, exposure to high-frequency vibration, and heavy lifting, associated with Scheuermann kyphosis Mostly asymptomatic, most resolving over time Thoracic pain wraps around the chest or abdomen in a dermatomal distribution, Signs of myelopathy, including clumsiness of gait and frequent falling, * Decreased or absent lower extremity reflexes think lumbar root or cauda compression than a thoracic disk herniation. * Hoffman sign or upper extremity hyperreflexia suggests a cervical lesion MRI-modality of choice CT thoracic in suspected calcified disc (dural usually adherent in these cases) Electromyography can confirm nerve root involvement, and somatosensory and motor-evoked potentials can exclude a spinal cord lesion. Injections at the level of the suspected nerve root can be both diagnostic and therapeutic. Imaging Management Brief period of relative rest (~24 to max 48 hrs) Quit smoking Activity modification (avoid pain provoking activity) Limited course of medications-nsaids etc. Physical therapy Heat, ice, massage, ultrasonography, and transcutaneous electrical nerve stimulation Thoracic epidural injections Failed non surgical treatment: Surgical intervention 15

Surgical Options Surgical Treatment MIS technique Indicated if the patient has more than 6 to 8 weeks of

extremity weakness) Failed non surgical treatment Axial low back pain Extremely common source of disability

Fifth most common cause of hospitalization Third most common reason for surgical procedures in the United

treatment Etiology Etiology Idiopathic or Nonspecific Up to 85% Degenerative disk disease discogenic pain,

Congenital scoliosis secondary to failures of formation and segmentation Traumatic Infectious osteomyelitis and

16 Surgical Options Surgical Treatment MIS technique Indicated if the patient has more than 6 to 8 weeks of severe, recalcitrant radiculopathy or neurologic compromise (signs and symptoms of myelopathy and lower extremity weakness) Failed non surgical treatment Axial low back pain Extremely common source of disability Lifetime incidence in the general population nearly 70%. Fifth most common cause of hospitalization Third most common reason for surgical procedures in the United States Natural history of low back pain is generally favorable, surgery is seldom offered as an initial treatment Etiology Etiology Idiopathic or Nonspecific Up to 85% Degenerative disk disease discogenic pain, herniation, and degenerative scoliosis Developmental isthmic spondylolisthesis and idiopathic scoliosis Congenital scoliosis secondary to failures of formation and segmentation Traumatic Infectious osteomyelitis and discitis Inflammatory ankylosing spondylitis and other spondyloarthropathies Neoplastic Benign, primary malignant, and metastatic Metabolic Osteoporosis Referred pancreatitis, duodenal ulcer, dissection 16

Risk factors Discogenic pain Increasing age; Heavy physical work; Long periods of static posture, Work or activities that involve lifting, or twisting; Obesity; smoking;

Leg-length inequality, poor posture, and scoliosis probably have only a limited effect Typically reports pain that worsens with sitting and often increases with forward flexion

The pain usually is dull in nature and can be decreased by shifting to a different position.

Patients may report morning stiffness that initially improves but later worsens during the course of the day, particularly with walking.

17 Risk factors Discogenic pain Increasing age; Heavy physical work; Long periods of static posture, Work or activities that involve lifting, or twisting; Obesity; smoking; depression; and work dissatisfaction. Leg-length inequality, poor posture, and scoliosis probably have only a limited effect Typically reports pain that worsens with sitting and often increases with forward flexion or a prolonged axial loading The pain may be poorly localized to the low back area, often in a band-like distribution. The pain usually is dull in nature and can be decreased by shifting to a different position. Facet pain Often is better localized, Activity related, More severe when the back is extended. Patients may report morning stiffness that initially improves but later worsens during the course of the day, particularly with walking. The quality of pain may be described as sharp Courtesy: SI Bone website Evaluation Typical pain in SI reproduced 3/5 tests positive Laslett study: 3/5 has 91%-sensitivity 78%-specificity Courtesy: SI Bone website History: explore pain, r/o red flags Physical-comprehensive spine exam, root tension signs, check hip joints & SI joints, vascular exam Xrays-Standing AP & lateral if no red flags and no releif in 4-6 weeks Lat, Flex-ex lumbar xrays for instability (if listhesis/slip seen) Add oblique xrays to check for pars defect MRI-plain (add contrast if previous surgery) CT-for bone detail 17

between MRI findings and clinical picture

(~24 to max 48 hrs) Quit smoking Activity

18 Xray evaluation X-ray Examples Check alignment (sag/cor) Looks for all pedicles (winking owl sign!) Vertebral lesion/destruction Loss of disc height Disc destruction? Slip? Disc hydration, bulge Stenosis-central, lateral recess and foraminal Neural elements Facet quality No correlation between MRI findings and clinical picture Management Brief period of relative rest (~24 to max 48 hrs) Quit smoking Activity modification (avoid pain provoking activity) Limited course of medications-nsaids etc. Physical therapy Diet, exercise, weight loss Heat, ice, massage, ultrasonography, and transcutaneous electrical nerve stimulation Injections: epidural/facet/medial branch block RF ablation Last resort: Surgical intervention Patient selection key! 1. Highly motivated individual 2. No depression 3. Eager to return to work 4. Non smoker 5. Isolated/limited spinal involvement 18

Lumbar radiculopathy Presentations Pain that radiates into the leg (usually past the knee) Risk factors: Smoking, Obesity, Distress, Work requiring heavy manual labor, Sagittal malalignment, genetic

followed by an acute onset of gluteal and leg pain with some resolution of the back pain.

outcome MRI may be useful to confirm as well as to rule out serious causes No good correlation of disc herniation seen on MRI and symptoms Emergent Situations: foot drop, new bowel and bladder issues

19 Lumbar radiculopathy Presentations Pain that radiates into the leg (usually past the knee) Risk factors: Smoking, Obesity, Distress, Work requiring heavy manual labor, Sagittal malalignment, genetic factors Mainly due to disk herniation, rarely due to infections, tumors or injuries (explore for red flag symptoms) May be superimposed on spinal stenosis, spondylo-listhesis, DDD Classic: back pain followed by an acute onset of gluteal and leg pain with some resolution of the back pain. Activities that increase the disk pressure such as coughing, sneezing will worsen pain Diagnosis can usually be made with a good history as well as a detailed clinical examination Overall favorable outcome MRI may be useful to confirm as well as to rule out serious causes No good correlation of disc herniation seen on MRI and symptoms Emergent Situations: foot drop, new bowel and bladder issues needs emergently evaluation and surgery Evaluation History, explore red flags r/o hip, vascular pathology Spine exam with root tension signs (SLR/Femoral stretch) In the absence of red flags, reasonable to treat non surgically for about 6 weeks before imaging is obtained MRI-confirmatory Non surgical Management Surgical treatmentdiscectomy Brief period of relative rest Quit smoking Activity modification (avoid pain provoking activity) Limited course of medications-nsaids, muscle relaxants Physical therapy, Diet, exercise, weight loss Injections: LESI has Fair evidence for moderate, short-term effectiveness for pain relief in radiculopathy from HNP LESI has Poor evidence and functional improvement in chronic pain, back pain (not leg pain) 4 yr f/u:. SPORT trial combined as-treated analysis of the randomized and observational groups surgically treated patients had a superior result on all primary outcome measures Older, better educated, and those that reported milder symptoms did not choose surgical treatment Smoking, Workers compensation claim, psychological distress, poor prognosis with surgery 19

Spinal stenosis Presentation Lumbar spinal stenosis is defined as narrowing of the spinal canal with compression of the nerve root or cauda equina Typically have pain,

translation of one vertebral body onto the subjacent vertebral body Often use a shopping cart that allows one to lean and relieve leg heaviness shopping cart sign R/O hip OA,

In general, a mid-sagittal diameter of less than 13 mm at the disk level is considered relatively stenotic, and a diameter of less than 10 mm constitutes absolute stenosis

20 Spinal stenosis Presentation Lumbar spinal stenosis is defined as narrowing of the spinal canal with compression of the nerve root or cauda equina Typically have pain, weakness, pins and needles, weakness, heaviness in their buttocks and legs when they walk Risk factors: >50 yrs age, women, They usually rest for several minutes, lean forward and carry on again. Usually degenerative, congenital less common Pathophysiology: Disc degeneration, osteoarthritis of facet joints, hypertrophy of facets and ligamentum flavum, may lead to translation of one vertebral body onto the subjacent vertebral body Often use a shopping cart that allows one to lean and relieve leg heaviness shopping cart sign R/O hip OA, vascular causes and peripheral neuropathy Exam is usually normal, evaluate for cervical spinal stenosis (tandem stenosis) Lumbar Xrays to look for slip and MRI gold standard. In general, a mid-sagittal diameter of less than 13 mm at the disk level is considered relatively stenotic, and a diameter of less than 10 mm constitutes absolute stenosis Imaging Non op management Pain management, LESI injections (indicated only for short-term use and primarily for leg pain) Physical therapy- flexion-based lumbar spine strengthening and range-ofmotion exercises. Surgery an option if failed non op treatment-3 months at least Mainly to relive radiculopathy and to improve walking distance 20

21 Surgical Treatment Options 1. Decompression 2. Decompression and fusion MIS approach: Lateral approach Is a clinical diagnosis with acute radiculopathy, weakness, urinary retention (first), over flow incontinence, may have bowel incontinence MRI confirmation Abnormal rectal exam (anal wink, perianal sharp and dull differentiation and rectal tone) Abnormal post void residual (>200 cc) Emergent decompression (>48 hrs-recovery of bladder function is <40%) 21

22 Reasons for elective referral Reasons for urgent referral Neck pain with radiating arm pain (cervical radiculopathy) Cervical Myelopathy with hand clumsiness, unsteadiness Back pain with pain running down the leg (lumbar radiculopathy) Spinal stenosis with buttock pain, leg pain, leg heaviness, weakness Degenerative scoliosis with fatigue, pain and inability to cope with or without leg symptoms Back pain with red flags (suspected tumor, metastatic disease, infection) Cervical myelopathy with hand clumsiness, gait abnormality, progressive weakness, saddle anesthesia Cervical/Thoracic kyphosis with acute neurological symptoms Thoracic disc with neurological deterioration Lumbar radiculopathy with recent foot drop Thoraco lumbar Kyphosis with pain and functional disability Acute urinary retention/incontinence or bowel incontinence (ER transfer, workup) Back /Neck pain approach Take home points Red flags 4-6 week trial of non surgical treatment of back pain Yes No Recognition of red flags in acute back pain X-rays, MRI (with contrast if tumor/infection) 4-6 week trial non surgical Rx Chronic back pain is difficult to manage Team approach Life style modification (smoking etc.) very important Improved F/U Not improved Xrays, MRI (plain) Identifying pain generator is key to management (difficult!) Surgery may improve quality of life in patients who failed non surgical treatment Thank you "good surgeons know how to operate, better ones when to operate, and the best when not to operate -unknown" Office: 1010, East Third Street, Chattanooga, TN Cell Phone: Office: Medical Assistant: Stephanie Smith 22

23 BIO Director, Orthopedic spine surgery at UT-COM American & Canadian board certified Orthopedic surgeon Canadian board certified in Family Medicine Orthopedic surgery residency, Dalhouise University, in Halifax, Nova Scotia, Canada Two fellowships in complex spine (University of Toronto & University of Western Ontario, Canada) Treat all conditions from cervical spine to sacrum (scoliosis, kyphosis, disc herniation, degenerative conditions, myelopathy, tumours, fractures, infection) Subspecialty interest in adult spinal deformity (scoliosis, kyphosis, minimally invasive, complex spine & failed back surgery) 4 years work experience in primary care in rural Canada 3 years academic spine practice at the Southern Illinois University School of Medicine, Springfield, IL 23

Objectives. Comprehension of the common spine disorder

Objectives. Comprehension of the common spine disorder Objectives Comprehension of the common spine disorder Disc degeneration/hernia Spinal stenosis Common spinal deformity (Spondylolisthesis, Scoliosis) Osteoporotic fracture Destructive spinal lesions Anatomy