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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

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Correlating Clinical and MRI Scan Findings in Low Back Pain

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  1. Correlating Clinical and MRI Scan Findings in Low Back Pain Jim Messerly D.O.

  2. 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

  3. Mechanical low back pain-differential 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

  4. Neurogenic low back/lower extremity pain • 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

  5. Lumbar Disc Anatomy

  6. Lumbar nerve root anatomy

  7. Nerve root pain patterns/dermatomes

  8. Lower extremity deep tendon reflexes • Patella-L4 • Achilles-S1

  9. Lower extremity muscle strength testing -Hip Flexor L3 -Quadriceps, Anterior Tibialis L4 -Extensor Hallucis Longus L5 -Flexor Hallucis Longus S1

  10. 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

  11. Disc protrusion patterns • Central disc protrusion • Lateral disc protrusion • Far lateral/Foraminal disc protrusion

  12. Central Disc Protrusion

  13. 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

  14. 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

  15. MRI scan slide #1

  16. MRI scan slide #2

  17. MRI scan slide #3

  18. MRI scan slide #4

  19. Lateral disc protrusion

  20. 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

  21. 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

  22. MRI scan slide #5

  23. MRI scan slide #6

  24. Far lateral/foraminal disk protrusion

  25. 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

  26. 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

  27. MRI scan slide #7

  28. MRI scan slide #8

  29. MRI scan slide #9

  30. MRI scan slide #10

  31. MRI scan slide #11

  32. Facet joint pain

  33. 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

  34. 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

  35. MRI scan slide # 12

  36. Spinal stenosis

  37. 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

  38. MRI scan slide #13

  39. 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?

  40. MRI scan slide #14

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