Transcript Correlating clinical and MRI scan findings in low back pain

Correlating Clinical and MRI
Scan Findings in Low Back Pain
Jim Messerly D.O.
Classification of low back pain
• Mechanical/Axial-majority of pain is
localized to the lumbosacral spine
• Neurogenic/Radicular-majority of the pain
is in the lower extremity usually following a
specific nerve root/dermatomal pattern
Mechanical low back paindifferential diagnosis
– Central disc protrusion/posterior annulus tear
– Facet mediated pain
– Sacroiliac joint pain
– Spinal stenosis
– Pars interarticularis stress fracture
– Spondylolisthesis
– Lumbar strain/sprain
– Compression fracture
– Inflammatory/infectious/tumor
Neurogenic low back/lower
extremity pain
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Lateral disc protrusion
Far lateral disk protrusion
Neuroforaminal stenosis-Spondylolisthesis
Spinal stenosis with neurogenic
component
• Others-Piriformis Syndrome, Lateral
Femoral Cutaneous Nerve Entrapment,
Tumors, Lyme disease
Lumbar Disc Anatomy
Lumbar nerve root anatomy
Nerve root pain
patterns/dermatomes
Lower extremity deep tendon
reflexes
• Patella-L4
• Achilles-S1
Lower extremity muscle strength
testing
-Hip Flexor L3
-Quadriceps, Anterior Tibialis L4
-Extensor Hallucis Longus L5
-Flexor Hallucis Longus S1
Indications for MRI lumbar spine
• Progressive neurological deficit- weakness
most important
• Cauda equina syndrome- bowel/bladder
retention/incontinence, saddle anesthesia
• No significant improvement with 4-8 weeks
of conservative therapy/PT
• Severe, intractable pain
• Red flags- fever, weight loss, previous
cancer, IV drug use
Disc protrusion patterns
• Central disc protrusion
• Lateral disc protrusion
• Far lateral/Foraminal disc protrusion
Central Disc Protrusion
Central Disc Protrusion General
Characteristics
• Frequent cause of recurrent mechanical/axial
low back pain in the <50 year-old
• Frequently injured/aggravated by flexion
• Pain is frequently worse with coughing,
sneezing, laughing or valsalva
• Pain is frequently worse with prolonged
sitting/long car ride
• Pain is frequently worse with both standing
flexion and extension
• Pain is frequently worse with bilateral sitting
straight leg raises
Central disc protrusion continued
• Low back pain is frequently worse with bilateral
supine straight leg raising
• Normal lower extremity neuro exam
• Posterior annulus tear frequently associated with
central disc protrusion as seen on MRI scan
• Try to treat in extension advising the patient to
maintain his lordosis with bending
• Oral steroids/caudal or transforaminal epidural
injections can be helpful
• Avoid diskectomy alone
MRI scan slide #1
MRI scan slide #2
MRI scan slide #3
MRI scan slide #4
Lateral disc protrusion
Lateral disc protrusion general
characteristics
• Lower extremity radicular pain worse than low
back pain
• Lower extremity pain follows radicular and
dermatomal pattern
• Pain is generally worse with coughing and
sneezing, valsalva maneuvers
• Pain is generally worse with flexion and sitting
• L3-4 disc-L4 radicular pain, L4-5 disc- L5
radicular pain, L5-S1 disc- S1 radicular pain
Lateral disc protrusion continued
• Careful lower extremity neuro exam may be able
to identify specific nerve root lesion
• Straight leg raising usually reproduces radicular
pain
• Try to treat with extension to centralize pain
• May respond to oral steroids or transforaminal
epidural steroid injections
• Persisting pain may need discectomy to relieve
lower extremity pain
MRI scan slide #5
MRI scan slide #6
Far lateral/foraminal disk protrusion
Far lateral/foraminal disk protrusion
general characteristics
• Lower extremity radicular pain much worse with
standing and walking, usually improved with
sitting
• Lower extremity pain follows radicular and
dermatomal pattern
• Usually not worsened by coughing or sneezing
• Careful lower extremity neuro exam may be able
to identify specific nerve root involvement
• Increased radicular pain with lumbar Spurling’s
testing
Far lateral/foraminal disc protrusion
continued
• L3-4 foraminal disc protrusion-L3 radicular pain,
L4-5 foraminal disk protrusion-L4 radicular pain,
L5-S1 foraminal disk protrusion-L5 radicular pain
• Treat with lumbar stabilization exercises since
extension usually aggravates radicular pain,
consider pelvic traction
• Trial of oral steroid medications
• Frequently respond to transforaminal epidural
steroid injections (selective nerve root blocks)
• Diskectomy can be difficult because of facet joint
blocking exposure
MRI scan slide #7
MRI scan slide #8
MRI scan slide #9
MRI scan slide #10
MRI scan slide #11
Facet joint pain
Facet mediated pain general
characteristics
• Mainly mechanical/axial low back pain with
occasional buttock pain
• Generally worse with standing and walking and
improves with sitting
• No increased pain with coughing or sneezing
• Lower extremity neuro exam is usually normal
• X-rays and MRI show facet arthritis without focal
disc protrusion
Facet mediated pain continued
• PT is frequently helpful for lumbar
stabilization, ?pelvic traction
• Oral versus topical NSAIDs
• Medial branch block injection therapy to
confirm facet mediated pain followed by
radiofrequency ablation
• Consider fusion for instability/resistant
pain
MRI scan slide # 12
Spinal stenosis
Spinal stenosis
• Low back pain with radiation to bilateral buttocks
and lower extremities which is worse with
prolonged standing and walking
• Neurogenic claudication may need to rule out
vascular claudication first
• PT for stabilization and flexibility
• Caudal epidural steroid injections
• Surgical decompression for resistant cases
MRI scan slide #13
Pars interarticularis stress fracture
• Very common cause of low back pain in young athlete
less than 25 years old
• Worse with extension, stork test
• Normal lower extremity neuro exam
• MRI probably best test versus SPECT bone scan,
consider CT scan to look for spondylolysis
• Removal from offending activity until symptoms improve
• PT for hamstring flexibility and abdominal strengthening
• Bracing?
• Bone stimulator?
MRI scan slide #14