strategies for identifying source of lbp

Strategies for Identifying Source of LBPClinical & Imaging Predictor Variables

Douglas Beall, MD

Confidential and proprietary. For internal VIVEX use only. May not be used, copied, or distributed without consent.

Predictor Variables:

A. 1 or 2 Levels That are Likely to be Symptomatic

B. Pfirrmann Grade DDD of 3-6

C. Modic Changes of Grade II or Less

D. Normal Disc or Contained Disc Protrusion at Index Level

Discogenic Low Back Pain

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1 or 2 Levels of Degenerative Disc Disease15

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DDD More Likely to be Painful –Greater Amount of Disc Degeneration

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DDD Characteristics More Likely to be Painful –Modic Changes

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Pfirrmann Grade DDD of 3-6

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Modic Changes of Grade II or Less

Modic Changes:

• Follows a Progressive Course

– Type 1 – Fluid (↓T1/↑T2 Signal)

– Type 2 – Fat (↑T1 & ↓T2 Signal

[With Fat Sat])

– Type 3 – Sclerosis (↓T1 & T2 Signal)

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Modic Type 1 End-Plate Changes

Sag T1 Sag T2 Sag STIR

Sagittal Post-Contrast T1

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Modic Type 2 End-Plate Changes

Sag T1 Sag T2

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Modic Type 3 End-Plate Changes - Not OK for Inclusion

Sag T1 Sag T2

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Herniation – is a general term &

the process may be further characterized as

protrusions or extrusions based on the shape of

the displaced disc material

Protrusion Extrusion

Herniation

Disc Herniations – Morphology

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Protrusion Extrusion27


Protrusion – If greatest distance of the edges of the protruded material is ≤ theedges of the normal disc in the same plane (best determined in sag plane)

Extrusion – If the distance the disc is

displaced (at least in one plane) is > the

distance between the edges of the base of the

herniation As measured in the same plane


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Case 2

Performed MBB’s at L3-4 and L4-5 w/ < 50% relief of LBP

Discogram concordant at L4-5 & pain decreased from 6/10 to 0/10 after anesthetic injection at L4-L5

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Normal Protrusion Extrusion30


Discogenic LBP Patients – Case 1

2 Level DDD w/ Pfirrmann grade 6 disc at L4-5

Looks ~ same height as L5-S1 disc but 5-1 disc most often shorter even when normal

OK even w/ higher grade disc degeneration @ L4-5 (<Pfirrmann Gr 7)

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Discogenic LBP Patients – Case 1

Discogram concordant at L4-5 & L5-S1 & pain decreased from 6/10 to 0/10 after anesthetic injection at L4-5 and L5-S1

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Predictor Variables – Rule Out


A. 3 or More Levels of DDD Likely to be Symptomatic

B. Pfirrmann Grade DDD of 1-2 or 7-8C. Modic Grade III Changes D. Disc Extrusions or SequestrationE. Neural Compression due to Spinal StenosisF. Spondylolisthesis of Grade 2 or HigherG. Lumbar SpondylitisH. Spinal Deformity with Cobb Angle Greater

than 15 DegreesI. Any Fracture at Incident Level

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Pfirrmann Grade Disc Degeneration of 3-6

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Extrusion – may be further classified

into migrated discs or sequestrations.

SequestrationMigrated disc

Extrusion


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Protrusion Extrusion & Inferior Migration

Extrusion & Sequestered Disk

Fragment

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Grades of Spondylolisthesis – Grade II or Higher Rule Out

Grade 125% of vertebral body has slipped forward

Grade 2 50%

Grade 3 75%

Grade 4 100%

Grade 5Vertebral body completely fallen off (i.e. spondyloptosis)

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Inflammation/Infection - Spondylodiscitis

Spondylitis – Infection of the spine

Discitis – Infection of the intervertebral disc

Spondylodiscitis – Both osseous structures &

intervertebral discs are affected

Lumbar Spondylitis

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Cobb Angles >15° are excluded

Spinal Deformity with Cobb Angle Greater than 15 Degrees Rule Out

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Discogenic Low Back PainImaging & Clinical Criteria

Douglas P. Beall, M.D.

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Pfirrmann Grade DDD of 3-6

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Modified Pfirrmann Scores1

GradeSignal from Nucleus and Inner Fibers

and Annulus

Distinction Between Inner and Outer Fibers of Annulus at Posterior Aspect of Disc

Height of Disc

IUniformly hyperintense,

equal to CSF Distinct Normal

IIHyperintense

(>presacral fat and <CSF) ± hypointense intranuclear cleft

Distinct Normal

IIIHyperintense

though < presacral fatDistinct Normal

IVMildly hyperintense

(slightly > outer fibers of annulus)Indistinct Normal

VHypointense

(= outer fibers of annulus)Indistinct Normal

VI Hypointense Indistinct < 30% reduction

VII Hypointense Indistinct 30 - 60% reduction

VIII Hypointense Indistinct > 60% reduction

1. 1. Score determined based upon highest score of the three categories evaluated

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Modified Pfirrmann Grading Adaptation

Modified Pfirrmann scoring based upon worst grade for 3 categories evaluated• Signal from Nucleus & Inner Fibers & Annulus• Distinction Between Inner & Outer Fibers of Annulus at Posterior Aspect of Disc• Height of Disc

An exception to the rule above for the L5-S1 level only• L5-S1 level can be naturally narrower than other lumbar levels• Use of worst score of the 3 categories at a naturally narrower L5-S1 level could

skew scoring to Pfirrmann Scores 7 & 8 because of the disc height• At the L5-S1 level only, height is only considered for categorization if the nucleus

is hypointense and there is no distinction between inner and outer fibers of the annulus at the posterior aspect of the disc

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Case Studies:Pain Generating Discs

Douglas P. Beall, MD

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Sagittal STIR Sequence

Case 1

2 Level DDD but L5-S1 is more severe in this caseModic 1 or 2 changes more likely to be assoc w/ LBPSTIR Sequence more sensitive to fluid differences w/in discsAt L5-S1 look for abnormal signal within nucleus pulposus first then judge disc height (disc normally shorter at L5-S1)

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Case 1

If in doubt, inject anesthetic & record provocative response AND the anesthetic response (how much pain goes away)

If the pain is concordant w/ injection or is gone or nearly gone later after injection of 1-2cc of anesthetic this indicates a pain generating disc

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Case 2

2 Level DDD w/ borderline Pfirrmann grade 6 disc at L4-5Looks ~ same height as L5-S1 disc but 5-1 disc most often shorter even when normalAxial LBP usually either facet or disc related

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strategies for identifying source of lbp

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