Transcript Oh my aching back

Oh my aching back
Application of diagnostic imaging
studies to Physical Therapy in the
acute care setting
By: Nicole M. Boyko, MSPT
Objectives

To use a case study format to:
– Identify what imaging studies may be
useful in the work-up of intractable back
pain in the acute care setting
– Relate the results of imaging studies to the
formulation of a PT diagnosis and plan of
care
Overview: Mr. F’s aching back
History and Physical Examination
 PT/OT Examination
 Results of Imaging Studies
 Rationale for Use of Imaging Studies
 Implications to PT plan of care
 Patient Outcomes

History and Physical Examination

60 y/o African-American male presents to
Hospital X on 1/24/05 with c/o intractable
back pain and is admitted to med/surg floor
 PMH: none
 PSH: s/p hernia repair

No bowel or bladder complaints
History & Physical Exam Cont’

History of Present Illness:
– 1/19: presented to Hospital Y with same
complaints; received injection in ER and was
D/C’d home with appt for ortho follow-up
– 1/21:Had ortho consult and was scheduled for
MRI as outpatient
– 1/22: to ER at Hospital Y where he received L-S
X-Ray and was D/C’d home on Skelaxin and
Percocet with min relief.
– 1/24: MRI as outpatient at Hospital Y. Results
unavailable but pt reports “two herniated disks.”
History & Physical Exam Cont’

Admitting MD’s plan of care:
– Pharmaceuticals for relief of pain/inflammation
• Dilaudid 42-4 mg IV q 6hr
• Toradol 3 mg IV q 8 hr prn
• Prednisone 40 mg po x 1
• Flexeril 10 mg po tid
– PT/OT consults ordered
– Ortho consult ordered
– X-Ray and MRI reports requested from Hospital Y
PT/OT Initial Examination 1/25
* X-Ray & MRI results not yet available at time of initial exam *
 Subjective: “I can’t move.

My son has to lift
me.”
Prior level of function: Lives with wife, son
and mother in 1 level home. (I) with ADLS
and amb, no A.D. up until 1 wk ago. Was
given standard walker at hospital Y but states
he is unable to use it. Relies on his son to
help him mobilize.
PT/OT Initial Exam Cont’

Pain: 10+/10 (L) low back/buttock
– Exacerbated by: supsit txfrs, sitting with wt
bearing on (L) pelvis, standing with wt bearing on
(L) pelvis
– Relieved by: min relief with sidelying on (L) side in
semi-fetal position, min relief from pain meds

Palpation/observation: tenderness and
“puffiness” (L) low back/pelvis
 Sensation:  lt touch (L) L2
PT/OT Initial Exam Cont’

ROM: grossly WFLs but painful to LEs
 Strength: limited by pain with resistance
– L4, L5, S1: 5/5 (B)
– L1-2, L3: grossly 3+/5

Special Tests: SLR (-) (R), (+) 40º (L)
 ADLs:
– UE ADLs: mod (I)
– LE ADLs: max (A) due to pain
– Toileting/bathing: max (A) due to pain
PT/OT Initial Exam Cont’

Functional Mobility:
– Rolling: mod (I) with rails to (L); unable to roll to
(R) due to pain
– Scooting: mod (I)
– Sup  Sit: mod (I) with rails. Min verbal cues for
logrolling technique.
– Sit  Stand/Gait: Pt unable to achieve due to
severe (L) LBP with attempt despite max (A)
provided by PT/OT
PT/OT Initial Intervention

Patient instructed in positioning for comfort:
sidelying with pillow between knees or supine
with pillow under knees
 Patient instructed in proper log rolling
technique
 Patient instructed in the following therapeutic
exercises: single knee to chest (L), piriformis
stretch (L), gentle abdominal setting
Initial Assessment by Therapy

Pt is a 60 y/o male with 1 wk history of intractable
back pain causing him to be unable to sit up or walk
without significant assistance from his son. Pt did well
today with logrolling to sit but was unable to stand or
walk due to significant pain. Suspicious for HNP,
perhaps L2 or L3, but MRI results are unavailable at
this time. Recommend PT and OT to follow to
maximize mobility/ADLs for safe D/C to home where
pt will be further worked up by neurosurgeon.
Initial Therapy Goals

PT Goals x 3-4
days:
– (I) HEP
– (I) sup sit via
logrolling
– (I) sit stand
– (I) amb > 50 ft with
least restrictive
assistive device

OT Goals x 3-4
days:
– Pt will be mod (I) for
all ADLs with
appropriate adaptive
equipment
– Equipment needs: 3
in 1 commode,
reacher, sock aide
Radiology Results

X-Rays: AP and lat
views of the L-spine
demonstrate mild
osteophyte production
at several levels with
mild narrowing of the
L5-S1 disc space. No
acute fx/dislocation is
seen.
Example of claw osteophyte
(white arrows)
Example of traction osteophyte
(white arrow)
Radiology Results Cont’
Lateral View: Normal
Radiology Results Cont’
AP View: Normal
Radiology Results Cont’
Degenerative changes to the lumbar spine (lateral view)
Radiology Results

MRI Results
– Technique: sagittal and axial T1- and T2 weighted
images and sagittal STIR images
– Findings: DDD L3-4, L4-5, L5-S1
• Diffuse disc bulge L3-4 moderately narrowing the central
spinal canal and resulting in (B) neural foramina
narrowing with (L) L3 nerve root impingement
• Disc bulge L4-5 which mildly narrows the central canal
and results in (B) neural foramina narrowing without
nerve root impingement
• Diffuse disc bulge L5-S1 with (B) neural foramina
narrowing and possible (L) sided nerve root impingement
Radiology Results Cont’
Normal
HNP L5-S1
Radiology Results Cont’
Axial View of a normal L4 disc
Axial view of a 4mm L5 HNP
To Image or Not To Image?

Lifetime prevalence of LBP = 80%
– Often relieved by analgesics and activity modification with no
further workup needed

In 80% of cases of LBP, imaging does NOT affect the
treatment
– Can lead to unnecessary additional testing due to the
discovery of incidental benign lesions or degenerative
processes
• Ex: In one study, MRI scans revealed herniated discs in
approximately 25 percent of asymptomatic persons less than
50 years of age and in 33 percent of those more than 50 years
of age.
American College of Radiology’s
Criteria to Justify Further Evaluation with
Imaging for Low Back Pain
Recently
significant trauma
Unexplained weight loss
Unexplained fever
Immunosuppression
History of cancer
IV drug use
Prolonged use of corticosteroids
Age >70
Duration > 3 months
Additional Clinical Indications for Advanced
Imaging in LBP
Radiating
pain
Symptoms of nerve root compression/cauda
equina syndrome
(B) LE weakness
Urinary retention
Saddle anesthesia
Rationale For Use of Imaging
Studies for Mr. F

Incapacitating LBP > 1wk
 Unrelieved by analgesics/activity modification
 (+) SLR indicating space occupying lesion
 Signs of possible nerve root compression
– Motor weakness
– Sensory changes
Choice of Imaging Modality

X-Rays: Screening tool to detect abnormalities of
bone
– i.e: abnormalities of the spine, fx/dislocation, ankylosing
spondylitis, RA, OA, tumors, osteoporosis, Paget’s disease
– Discs not visualized on X-Ray but DDD is suspected
whenever there is IV disc space narrowing
– Most cost effect modality for spinal imaging

MRI: used to delineate abnormalities
– Superior visualization of soft tissue and bone marrow
– Sagittal view best to delineate herniation of nucleus
pulposus through annulus fibrosis
– Transverse images best to define compression of thecal sac
and nerve root
– Costs approximately 2x as much as CT imaging
Choice of Imaging Modality

Myelography: requires injection of radio-opaque dye
in subarachnoid space via lumbar puncture
– Offers good visualization of nerve roots
– Excellent for diagnosing diseases of spinal cord and canal
• HNP seen as a defect in the normal filling of the dye
– Formerly gold standard for spinal cord radiography
• Falling out of favor as it is more invasive and less accurate than
MRI or CT

CT Scan: best modality for looking at bone
– Delineates anatomy and pathology better than myelography
– Used to diagnose occult spinal fx, determine the extent of fx
and localize vertebral fx fragments, especially those
displaced into spinal canal
– Can determine presence of intervertebral disc disease
Narrowing in on Mr. F




Signs and symptoms pointing to suspected nerve
root compression
Standard AP and lat radiographs inexpensive
screening tool to rule out tumor/fx fragment as
sources of compression
X-Rays also revealed presence of osteophytes and
disc space narrowing
MRI best option for visualizing soft tissue (nerve
roots, IV discs) leading to our ultimate dx of multiple
level HNP and nerve root impingement
Implications to PT Plan of Care



MRI results coupled with neurosurgery consult
identified patient as potential surgical candidate
Discussion with pt and surgeon revealed willingness
to explore conservative PT while surgical work-up in
progress
PT focus on:
– Restoring functional mobility
– Relief of nerve root compression through stretching,
positional distraction and manual techniques
– Instruction in self-management of pain and HEP
Patient Outcomes

Patient D/C’d from Hospital X on 1/27 with:
– Neurosurgery follow-up appt
– Recommendation for outpatient PT pending outcome of
neurosurgery appt

Patient lost to follow-up as he normally receives care
at Hospital Y, which is closer to his home
– Patient’s neurosurgeon operates out of both Hospital X and
Hospital Y.
– Pt has not yet appeared on OR list for Hospital X to date.
Questions?
References
(for facts and figures)
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Erkonen WE, Smith WL, eds. Radiology 101: The Basics and Fundamentals of Imaging.
Philadelphia, PA: Lippincott-Raven, 1998.
Gillard DM. How To Read Your MRI or CT. 2002. http: www.chirogeek.com/003_CTAxial_Tutorial.htm. 5 April 2005.
Jensen MC, Brant-Zawadski MN, Obuchowski N, Modic MT, Malkasian D, Ross JS.
Magnetic resonance imaging of the lumbar spine in people without back pain. New England
Journal of Medicine, 1994, 331:69-73.
Kraus G. Radiology of low back pain. 2005. http://www.lowbackpain.com/radiology.htm. 5
April 2005.
Miller JC. When is Imaging Helpful for Patients with Back Pain? MGH Radiology Rounds
[serial online] January 2004; Volume 2, Issue 1.
Palmer, W. Spine Imaging: Modality Approach Spectrum of Cases. MGH Dept of Radiology.
[Prepared as PowerPoint presentation for this course)
Pfirrmann, CW, Resnick, D. Schmorl Nodes of the Thoracic and Lumbar Spine:
Radiographic- Pathologic Study of Prevalence, Characterization and Correlation with
Degenerative changes of 1,650 Spinal Levels in 100 Cadavers. Radiology. 2001, 219: 368374.
Richardson, ML. Radiographic Anatomy of the Skeleton- Lumbar Spine. 1997.
http://www.rad.washington.edu/RadAnat/Lspine.html. 5 April 2005.