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Appropriateness Criteria in the evaluation of back pain Edgar Colón Negrón, MD Angel Gómez Cintrón, MD, MPH Diagnostic Radiology UPR-RCM

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  • 1. Appropriateness Criteria in the evaluation ofback pain
    Edgar Coln Negrn, MD
    Angel GmezCintrn, MD, MPH
    Diagnostic Radiology
    UPR-RCM

2. www.acr.org
3. 4. 5. UNIVERSITY OF PUERTO RICO SCHOOL OF MEDICINE DIAGNOSTIC RADIOLOGY
6. 7. 8. 9. 10. 11. Introduction
Acute low back pain is the leading cause of disability for persons younger than 45 in the US
High prevalence and high cost in dealing with this problem
After multiple studies it is clear that uncomplicated LBP is a benign self-limited condition that does not warrant any imaging studies
Vast majority of patients are back to their usual activities in 30 days
The challenge for the clinician is to distinguish who should be evaluated to exclude a more serious problem
12. Indicationsforradiographicevaluationofthespine
Red Flags:
Significant trauma, ormilderifage >50
Unexplainedweightloss
Unexplainedfever
Immunosuppression
HistoryofCancer
IV Drug use
Osteoporosis, prolonged use ofsteroids
Age > 70
Focal neurologicdeficitordisablingsymptoms
Durationlongerthan 6 weeks
13. Imaging Modalities
Plain films
Bone scintigraphy
CT
MRI
Myelography
14. Plain films
Inexpensive
Available
Screening ( trauma )
Assessment of subluxation and alignment
15. Normal AP, Lat, Obl and Swimmers view of cervical spine
Look for alignment, vertebral body shape, posterior elements and prever
tebral soft tissues. Examination must include C7.Oblique views for
evaluation of uncovertebral joints, neural foramina stenosis and facet
alignment
16. Legend:
1, v. body
2, transverse process
3, posterior arch atlas
4, 5 facet joints
6, lamina
7, spinous process
8, uncinate process
10, disc space
11, articular facet joint
12, left neural foramina
14, pars interarticularis
15, pedicle
17. 18. Indicationsforradiographicevaluationofthespine
Red Flags:
Significant trauma, ormilderifage >50
Unexplainedweightloss
Unexplainedfever
Immunosuppression
HistoryofCancer
IV Drug use
Osteoporosis, prolonged use ofsteroids
Age > 70
Focal neurologicdeficitordisablingsymptoms
Durationlongerthan 6 weeks
19. 20. IsotopeBone Scan
Moderatelysensitiveforthepresenceoftumors, infectionoroccult fractures; notspecific
Bonescintigraphywith SPECT followedwith CT is more sensitive in the diagnosis ofspondylolysisthan MR
SPECT may localizethesourceofpain in patientswith articular facet OA
21. 22. CT of the spine
Superior bone detail, not as useful as MR in depicting disc protrusions
CT is useful in depicting spondylolysis
Poor visualization of the cord, intrathecal contrast needed.
Great technique for the assessment of pseudoarthosis, scoliosis, post surgical evaluation of bone graft integrity, surgical fusion and instrumentation
23. 24. 25. 26. 27. 28. 29. 30. 31. MRI
Examination of choice in complicated LBP
Multidisciplinary agreement on terminology facilitates reporting of MR findings
No radiation
Excellent contrast resolution
Multiplanarcapabilities
Great visualization of the spinal cord
Higher soft tissue contrast than CT
32. MR in low back pain
Acute back painwith radiculopathy suggeststhepresenceofdemonstrablenerverootcompressionon MR
MR findingsofModicendplatechanges, anterolisthesis or disk extrusion are more stronglyassociatedwithlow back painthan disk changeswithoutendplatechanges
Particularlyefficacious in thedetectionof red flags diagnosis
Post operativepatientsenhanced MR allowsdistinctionbetweendiscandscartissue
33. T1 (left) and T2 (right) weighted
images of a normal dorsal spine
34. T2 weighted images of
the lumbar spine.
Extreme parasagital
views demonstrating
root foraminas
dorsal root ganglion
35. T2
T1
Normal Lumbar
Spine
36. CT vs MRI
37. Imaging in the diagnosis of spinal diseases
38. Degenerative diseases and back pain; epidemiologic facts
Affects 5% of the adult population per year with a lifetime incidence of 70%-80%
90% of patients recover within 3 months
286,000 surgeries per year
The estimated cost of this entity to the society is between 16 60B, with 10B in direct medical care alone
2B in MRI alone
Modic MT, MRI Clinics of North Amer, Aug 1999
39. Spinal Degeneration
Normal consequence of the aging process, that can be predisposed or accelerated by developmental and acquired factors
Two major degenerations;
Osteochondral which affects the intervertebral disc ( synchondral articulation)
Osteoarthritic affecting the synovial joints (uncovertebral joints in the cervical spine and the facet joints)
40. Sagital fluid sensitive
Pulse sequences
Multisegmental degenerative
osteochondral changes
Normal sagital fluid sensitive
Pulse sequence
41. 42. T2
T1
annular fissure
43. Spinal canal stenosis
44. 45. Degenerative osteoarthritic changes to the right uncovertebral
joint of the cervical spine with nerve root foramina
narrowing
46. Annular displacement
47. Displacement of the nucleus pulposus (disc herniations)
Due to degeneration of the annular fibers
Displacement can be superior, inferior or most commonly posterior
Definition
Protrusion: within the annulus, annular fissure
Extrusion: beyond the annulus but contained by the PLL
Sequestrum = free fragment
48. A-C normal variants, D protruded , E extruded, F and G free fragments
49. Degenerative osteochondral
changes in the with resultant
end plate herniations
(Schmorls nodes)
50. Protruded disc
51. T1
T2
small annular fissures
52. Central extruded disc limited by the posterior
Longitudinal ligament
53. Free fragment
54. Correlation of symptoms
The three most important for localization and causal differential are:
Pain
Sensory changes
Weakness
55. Patients more likely to have a favorable outcome
from surgery should have;
- A clear history of sciatica
- Straight leg raising of less than 30
- Objective neurologic signs
- Imaging evidence of a disc herniation
that corresponds with the anatomical
area of concern
56. Poor surgical outcome is likely when treating for;

  • Disc disruption syndrome

57. Degenerative segmental instability 58. Bulging discs 59. Pain alone