Imaging Degeneration of the Lumbar Spine: What It All Means.

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Alfred Norton
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1 Imaging Degeneration of the Lumbar Spine: What It All Means

2 Spine Nomenclature and Evidence for Imaging

3 p,

4 Talk Objectives Background Nomenclature for disc findings Who should be imagedevidence basis?

5 The Rape of the Spine Surg Neurol, 1993; 39:5-12

7 The Rape of the Spine Radiologists: Innocent By-Standers? Are we helpful or harmful? What s the evidence that imaging helps patients? Are we diagnosing the causes of back pain?

8 Frequency of Back Pain Types 2% visceral 1% tumor, infection, inflammatory arthritis 97% mechanical

9 Mechanical Causes of Low Back Pain (Jarvik and Deyo, Annals Int Med 2002) Lumbar strain, sprain (70%) Degen (disc and facets) (10%) Herniated disc (4%) Spinal stenosis (3%) Osteoporotic comp fracture (4%)

10 What Causes Back Pain?

11 Alf Nachemson, MD PhD Editor of: Founding Editor Emeritus, Cochrane Back Review Group

12 Alf Nachemson, MD PhD What s the cause of back pain? In most cases I don t know!

13 The Least We Can Do: Speak the Same Language Nomenclature for disc findings

14 Consensus Nomenclature Pierre C. Milette Reporting Lumbar Disk Abnormalities: At Last, Consensus! AJNR Am J Neuroradiol : American Academy of Orthopaedic Surgeons (AAOS) American Academy of Physical Medicine and Rehabilitation (AAPM&R) American College of Radiology (ACR) American Society of Neuroradiology (ASNR) American Society of Spine Radiology (ASSR) Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons (AANS) Congress of Neurological Surgeons (CNS) European Society of Neuroradiology (ESNR) North American Spine Society (NASS) Physiatric Association of Spine, Sports and Occupational Rehabilitation (PASSOR)

15 Question??? What is the ASNR/NASS nomenclature for describing lumbar discs?

16 Consensus Nomenclature normal degeneration anular tears herniation

17 Consensus Nomenclature normal well hydrated disc central dark band= central fibrosus age-related changes=not normal

18 Intranuclear Cleft

19 Normal

20 Consensus Nomenclature normal degeneration desiccation narrowing bulging endplate changes osteophytes

21 Disc Degeneration Desiccation Narrowing

22 Disc Degeneration: Findings? Narrowing Osteophytosis Vacuum Disc Endplate sclerosis

23 Bulging

24 Consensus Nomenclature normal degeneration anular tear=anular fissure (high intensity zones=hiz) herniation

25 Degeneration and Tears

26 Degeneration and Tears

27 Degeneration and Tears

28 Consensus Nomenclature Herniation localized displacement of disc >50% (180 o ) = bulge <50% = herniation

29 Consensus Nomenclature normal degeneration anular tears herniation protrusion extrusion

30 Disc Bony Endplate Normal Canal Bulge Protrusion Extrusion

31 Protrusion

32 Protrusion

33 Extrusion

34 Extrusion

35 Extrusion

36 Extrusion

37 Reliability of Pro/Ex Classification Intrareader kappa= Interreader kappa= Kappa value Degree of agreement 0-.2 Poor.2-.4 Fair.4-.6 Moderate.6-.8 Substantial Near Perfect

38 Classification of Nerve Roots (Pfirrmann et al, Radiology 2004) Normal Contacted Displaced Compressed

39 Normal Nerve Roots (Pfirrmann et al, Radiology 2004)

40 Contacted Nerve Root (Pfirrmann et al, Radiology 2004)

41 Contacted Nerve Root

42 Displaced Nerve Root (Pfirrmann et al, Radiology 2004)

43 Compressed Nerve Root (Pfirrmann et al, Radiology 2004)

44 Displaced and Compressed Nerve Root

45 Displaced and Compressed Nerve Root

46 Reliability of Pfirrmann Nerve Root Grade Intrareader κ Interreader κ Kappa value Degree of agreement 0-.2 Poor.2-.4 Fair.4-.6 Moderate.6-.8 Substantial Near Perfect

47 Talk Objectives Background Nomenclature for disc findings Who should be imagedevidence basis?

48 Fundamental Problem Many findings Poor association with pain

49 Herniations in Normals Modality Author/Yr Finding Prev Myelo CT MR MR MR MR Hitselberger/ 1968 Wiesel/ 1983 Boden/ 1990 Jensen/ 1994 Stadnik/ 1998 Jarvik/ 2001 Any 24% HNP 20-27% HNP 22-36% Protrusion 20-60% Extrusion 1% Protrusion 26-80% Extrusion 0% Protrusion 32% Extrusion 6%

50 Prevalence of Disc Findings in Subjects without LBP 100% 80% 60% 64% 40% 32% 20% 6% 0% bulge protrusion extrusion Bulge Protrusion Extrusion

51 Disc Degeneration Signal loss on T2-weighted images Height loss

52 Disc Degeneration

53 Disc Degeneration

54 Prevalence of Disc Degeneration in Normals Modality Author/ MR MR MR MR Year Boden/ 1990 Stadnik/ 1998 Weishaupt/ 1998 Jarvik/ 2001 Age Prev Range % 93% % % % %

55 Anular Tear

56 Anular Tears s LBP - Modality Author/ MR MR MR MR MR Year Jensen/ 1994 Stadnik/ 1998 Weishaupt/ 1998 Carragee/ 2000 Jarvik/ 2001 Age Prev Range % % 100% % % %

57 Take Home Points Regarding Prevalence many imaging findings are common in asx s certain findings are related to prior low back pain and more likely to be clinically important extrusions, root comp, stenosis

58 Rationale for Imaging r/o low prob red flag condition rule-in treatable conditions stenosis herniated disc spondyloarthropathy instability?

59 Early Imaging Red Flags? Fx h/o major trauma minor trauma in older or osteoporotic pt

60 Red Flags age>50 or <20 h/o malignancy constitutional sx infection risk (IVDA, HIV, etc)

61 Red Flags possible cauda equina syndrome saddle anesthesia urinary retention severe/progressive neurologic deficit in lower extremity

62 Recommended Reports Disc degeneration: Approximately 80%-100% of people without back pain have this, so finding may not be related to patient s pain.

63 What Is Evidence Based Medicine? Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values - Sackett, et al 2001

64 Strength of Evidence A. Metaanalysis or sytematic review of 2 or more good quality studies B. 1 or more RCTs or good observational studies C. No or poor RCTs or observational studies D. No acceptable scientific support

65 Post-Test Normal Bulge Protrusion Extrusion

66 Post-Test Normal Bulge Protrusion Extrusion

67 Post Test Nerve Root is Normal Contacted Displaced Compressed

68 Take Home Points Use standard nomenclature to increase interpretation reliability Discs Bulge, Protrusion, Extrusion Nerve Root Contacted, Displaced, Compressed

69 Take Home Points By reporting epidemiologic information, we can educate clinicians and patients reduce harm from inappropriate interpretation of reports

70 Take Home Points Who is responsible for how our reports are used?

Degenerative Disc Disease. Nafi Aygun, MD. Associate Professor of Radiology

Degenerative Disc Disease. Nafi Aygun, MD. Associate Professor of Radiology Degenerative Disc Disease Nafi Aygun, MD. Associate Professor of Radiology Big Problem Great majority of adults suffer from at least one episode of acute low back pain during life time Disc degeneration