Imaging of Low Back Pain Dinesh Rao MD Assistant Professor Department of Radiology Neuroradiology and Musculoskeletal Radiology University of Florida College of Medicine - Jacksonville

Disclosures I have no disclosures

Overview Types of Low Back Pain (LBP) Modalities of Imaging Risks of Inappropriate Imaging Review MRI/CT findings in patients with LBP with neurological symptoms

Low Back pain – 3 Types Uncomplicated low back pain Low back pain associated with neurological symptoms Low back pain with “red flags” Trauma, infection, tumor, acute neurological symptoms

Modalities of Imaging Plain Film: "…the value of a lumbar spine radiograph is to establish the presence of a spine.” – Michael Modic MD

Modalities of Imaging CT Workhorse for trauma CT myelogram Problem solving (tumor, etc.) Surgical planning

Modalities of Imaging MRI – for neurological symptoms Myelopathy – spinal cord disease Neurogenic claudication – canal stenosis below conus Radiculopathy – after failed conservative treatment if patient is considering surgery or pain intervention

Uncomplicated Low Back Pain Poorly understood, multifactorial In young adults, likely related to weak core muscles, weight, bad posture, muscle strain 1 Usually self limiting with conservative treatment 1 Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363–370

MRI for LBP is Inappropriate Fewer than 1% of patients in primary care setting have “red flags” 1 Up to 38% of lumbar MRI not indicated 2 Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363–370 Swedlow A, Johnson G, Smithline N, Milstein A. Increased costs and rates of use in the California workers’ compensation system as a result of self-referral by physicians. N Engl J Med. 1992;327:1502–6.

Risks of Inappropriate Imaging Costs Much higher costs with early imaging Direct costs of scan Up to 10x as much cost compared to conservative management and testing. 3 No difference in outcome between early MRI and usual care 4 3. Joines JD, McNutt RA, Carey TS, et al. Finding cancer in primary care outpatients with low back pain: a comparison of diagnostic strategies. J Gen Intern Med 2001; 16:14–23 4. Deyo RA, Mirza SK, Turner JA, et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22:62–68

Risks of Inappropriate Imaging Increased rate of surgery Lumbar MRI leads to more surgery without better outcome 2 times more likely to have surgery with plain film 5 8 times more likely to have surgery with MRI 6 5. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289;2810-2818. 6. Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52:900-907.

Risks of Inappropriate Imaging False positives – 57% of patients without back pain have a herniated disk 7 “Many imaging based degenerative features are likely part of normal aging and unassociated with pain.” 8 Degenerative changes correlate poorly with pain and disability 1 7. Modic, M. T., Obuchowski, N. A., Ross, J. S., Brant-Zawadzki, M. N., Grooff, P. N., Mazanec, D. J., & Benzel, E. C. (2005). Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology, 237(2), 597-604. 8. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR. 2015 Apr;26(4):811-6. 1. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363–370

Risks of Inappropriate Imaging Patient Labelling – patients become less happy with their life 9 Longer work disability and higher treatment costs Increased fear and avoidance of activities 10 9. Sloan TJ, Walsh DA. Explanatory and diagnostic labels and perceived prognosis in chronic low back pain. Spine 2010;35:E1120–5. 10. Webster, BS, Bauer AZ, Choi YS. Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain. SPINE 2013 Volume 38, (22) 1939-1946

LBP with Neurological Symptoms Radiculopathy Usually recover within a few weeks Imaging useful for surgical or pain intervention in cases refractory to conservative treatment. Neurogenic Claudication – chronic spinal stenosis Cauda Equina – acute injury/stenosis Myelopathy

Radiculopathy

1 month post op

1 year post op

Neurogenic Claudication

Myelopathy

Low Back Pain with Red Flags Trauma Infection Immunosuppresion Suspicion/history of malignancy Anticoagulation

Type 1 DJD Radiologykey.com

Discitis/Osteomyelitis (bacterial)

Discitis/Osteomyelitis (atypical)

Hemorrhage

Trauma

Tumor

Summary Plain film not useful CT for trauma or specialized issue MRI “red flags” Neurological symptoms possibly requiring surgery