OA imaging of spine.docx

RED FLAG FEATURES TO LOOK OUT FOR ON HISTORY Pain at rest or at night Trauma History of malignancy Constitutional symptoms (fever, chills, night sweats, weight loss) Incontinence Saddle anesthesia Substance abuse Systemic steroids/ immunosuppressed First episode of severe pain age > 50 Physical E...

RED FLAG FEATURES TO LOOK OUT FOR ON HISTORY Pain at rest or at night Trauma History of malignancy Constitutional symptoms (fever, chills, night sweats, weight loss) Incontinence Saddle anesthesia Substance abuse Systemic steroids/ immunosuppressed First episode of severe pain age > 50 Physical Examination Decreased ROM (passive) Midline tenderness New or progressive neurologic deficit UMN findings (spasticity) Loss of balance/abnormal gait CAUDA EQUINA SYNDROME Symptoms Back Pain (Acute or chronic) Saddle Anesthesia (S3-S5 dermatomes) Bladder and bowel dysfunction (S2-S3) Lower leg weakness Lower leg sensory changes Diagnose by CT or MRI Need to be admitted to hospital because cauda equina syndrome is a medical emergency MECHANICAL BACK PAIN DDX Ligament sprains and muscle strains Discogenic Pain Degenerative Disc Disease (DDD) Disc protrusion or herniation Facet Arthropathy Spondylolithesis Spinal Stenosis Lateral canal/neural foraminal stenosis Sacroiliac (SI) ligament sprain Congenital disease (severe scoliosis, kyphosis) DISCOGENIC BACK PAIN (i.e. DDD) Can be related to degenerative disc disease (DDD) or disc herniation In general, degenerative changes such as DDD or disc herniation may be an asymptomatic part of aging Not all patients will have symptoms, so do NOT treat imaging findings DDD – microfracture of collagen and loss of proteoglycans and fluid leading to a dry, desiccated disc On x-ray see disc space narrowing DISCOGENIC BACK PAIN (i.e. DDD) DDD is often more insidious onset of chronic pain Pain from disc herniation/protrusion often occurs acutely related to lifting or a specific injury DISCOGENIC BACK PAIN DDD can be seen on a plain Xray (we usually order AP, lateral and oblique views and DDD is best seen on AP and lateral views. We may elect in some cases to go on to a CT scan or MRI scan. DISCOGENIC BACK PAIN Disc protrusion/ herniation/ prolapse is best seen on CT or MRI scan and is not seen on plain X-ray. May cause a “pinched or compressed nerve” May cause neurologic findings such as weakness of muscle, sensory dermatomic pain and reflex loss Example: Sciatica (explain) Disc protrusion/hernia/prolapse can lateralize to one side or it may be centrally located Often symptoms occurs acutely with precipitating traumatic event FACET ARTHROPATHY Facet joints are also called the zygaphyseal joints or z joints These are synovial joints with hyaline cartilage cartilage surface and prone to OA FACET ARTHROPATHY Most common etiology is aging Often patients have unilateral neck or low back pain in non-dermatomic pattern. Pain is worse with leaning back or lumbar extension or lateral flexion to the affected side Imaging Can be seen on oblique view x-rays CT or MRI more useful Bone Scan can demonstrate increased uptake suggesting active bone turnover and pain SPONDYLOLITHESIS Occurs when one vertebra is sitting forward on the vertebra below it. (seen on lateral X-ray views) Sometimes due to non union or lysis or “fracture” Often due to developmental variation of the neural arches called spondylolysis = Spondylolytic spondylolisthesis This is a VERY common (up to 6% of population) Can be graded based on severity Often have worse back pain with forward flexion (imagine that the forward slip moves more forward with bending forward) SPINAL STENOSIS Narrowing of the spinal canal Can be due to many processes: Congenitally narrowed canal Degenerative disease with ligamentum flavum hypertrophy or osteophytes from facet hypertrophy Central disc herniation that compresses the spinal cord Mass effect from an abscess or tumor that compresses the spinal cord SPINAL STENOSIS History of spinal or neurogenic claudication with walking (pain in legs worse with walking) Imaging: CT or MRI MRI can assess for spinal cord signal. If abnormal cord signal detected, then patient often needs surgery SPINAL STENOSIS Spinal Claudication Comes on with walking, better when sitting Walking with shopping cart easier (bending forward) Walking uphill easier, walking downhill spine is often hyperextended Vascular claudication Comes on with walking, better with stop and stand Risk factors for peripheral vascular disease or known atherosclerosis Abnormal ABI (anklebrachial index) Weak pedal pulses NEURAL FORAMINAL STENOSIS Sometimes facet joints can narrow and develop osteophytes that can protrude into the neural foramina Can lead to lateral canal stenosis or neural foraminal stenosis, where nerve roots come out Leaning to the affected side may hurt or reproduce symptoms with nerve root pain at the affected level SI LIGAMENT SPRAIN Common cause of back pain Often leads to buttock pain and difficulty sitting or standing in one spot for long Can be due to acute injury, overuse, musculature weakness and imbalance SCOLIOSIS Sideways curvature of the spine Mild scoliosis often does not cause any symptoms, but severe cases can cause significant pain and even respiratory issues May be progressive over time Most common etiology is genetic and develops in Childhood MECHANICAL BACK PAIN When to investigate No set rule, but if symptoms are not settling within 3-6 months or continue significantly impact functioning with rehabilitation and core strengthening, consider imaging We have options to help settle symptoms such as radiology guided injections that can help many patients KEY POINTS ARE UNDER HERE! History is a key component in back pain. Do not forget the RED FLAGS Worse with lumbar flexion: Discogenic back pain, Spondylolisthesis Worse with lumbar extension: Spinal claudication, Facet arthropathy