Degenerative Lumbar Spine Disease

Beth Israel Deaconess
Medical Center
A Member of Caregroup
Harvard
Medical
School
Degenerative Lumbar Spine
Disease
Michael Barnett, HMS III
Core Radiology Clerkship
BIDMC PCE
Overview
„
„
„
„
„
„
Patient Presentation: Ms. S
Clinical Work-up of Low Back Pain
Menu of Radiological Tests
Lumbar Spine Anatomy
Patient Imaging: Ms. S
Discussion of Degenerative Spine Disease
2
Our Patient, Ms. S
„
„
88 year old woman with chronic low back
pain
4 year history of back pain
„
„
„
The pain is inconstant
„
„
Relief with sitting
Ms. S is normally an active woman
„
„
Radiation: left hip, thigh, calf, ankle
L5 dermatome distribution
Controls pain with Celebrex and epidural steroid
injections
Presents to the pain clinic after 3 epidural
steroid injections failed to provide relief
3
Clinical DDx Low Back Pain
Musculoskeletal
„ Bone
„
„
„
„
„
„
Ligament hypertrophy or
ossification
Primary tumors, metasstatic cancecr,
lymphoma, multiple myeloma
Visceral Condition
„
Muscles
„
Strain
„
„
RA, AS, Psoriasis
Neoplastic
„
„
Osteomyelitis, spondylodiscitis, epidural
abscess
Inflammatory Arthritis
„
Herniation, annular tears
Ligaments
„
„
Facet joint degeneration
Disks
„
„
Fracture, spondylosis,
spondylolisthesis
Joints
„
Systemic Disease
„ Infection
„
CV: Aortic aneurysm
GU: stones, infection
GI: pancreatitis, ulcers
Gyn: Endometriosis, PID
Adapted from Stern, SD, Cifu AS and Altkorn D, From Symptom to Diagnosis, McGraw-Hill: NY, 2006.
4
Low Back Pain
„
„
„
„
„
A challenging issue in outpatient
medicine
Point prevalence as high as 33%
Lifetime prevalence as high as 80%
Fifth most common reason for physician
visits in US
1 in 5 patients report substantial
limitations in activity due to LBP
Wilson JF, In The Clinic: Low Back Pain. Ann Internal Medicine 2008: 148(9):ITC5-1-ITC5-16
5
Low Back Pain Work-Up
„
„
Imaging can create more questions than
answers
Especially in the elderly, degenerative spinal
is incredibly common in asymptomatic
subjects
„
„
„
„
Disk herniation: 25-50%
Disk degeneration: 25-70%
Annular tears: 14-33%
Most LBP resolves spontaneously, as do
many radiographic findings
Carragee, EJ Persistent Low Back Pain, NEJM 2005 352:18, 1891-8.
6
However, it is important to be
aware of red flags which
necessitate imaging …
7
Red Flags with LBP
Fracture
„
„
„
„
Age >70
History of
osteoporosis
Trauma
Corticosteroid
use
Tumor
ƒ Age >50
ƒ History of
previous cancer
ƒ Unexplained
weight loss
Infection
ƒ Fever, chills
ƒ Recent skin or urinary
infection
ƒ Immunosuppresion
ƒ IVDU
ƒ Recent spine surgery
Neurologic
ƒ Sciatica
ƒ New onset urinary/fecal
incontinence
ƒ Abnormal neurologic
exam: motor, sensory,
reflexes
Adapted from Stern, SD, Cifu AS and Altkorn D, From Symptom to Diagnosis, McGraw-Hill: NY, 2006 and Lieberman, G Primary Care
Radiology:Radiologic assessment of low back pain, http://eradiology.bidmc.harvard.edu/primarycare/index.html Accessed 10/17/2008
8
Menu of Tests for Low Back Pain
Assessment
„
More Commonly Used:
„
„
„
„
„
Plain Films
CT and CT Myelography
MRI
Bone Scintigraphy - assessing for metastatic cancer
Less Commonly Used:
„
„
„
Plain Myelography - supplanted by CT myelography
Discography - contrast injection into disk to assess for disk source of pain
Spinal Angiogram - assess vasculature of spine
9
L-Spine Plain Films
„
„
Pros:
„ Fast, no contraindications
„ Good for evaluating bony
structures
„ Trauma
„ Bony degeneration
„ Spine alignment
Cons:
„ Poor soft tissue discrimination
„ Frequently will need CT/MRI
anyway
„ Radiation exposure
Lumbar spine plain X-ray film
Image courtesy Dr. Kleefield, BIDMC
10
CT and CT Myelography
„
Pros:
„ Excellent resolution of bony
anatomy
„
„
„
„
„
Trauma eval
Degenerative bony changes
Good for visualizing calcifications
and gas
Myelography: useful for LBP eval
when MRI is contraindicated
Cons:
„
„
„
Poor differentiation of soft tissues
within the spine
Radiation exposure
Myelography: invasive procedure
Lumbar Spine CT
Image courtesy Dr. Kleefield, BIDMC
11
Magnetic Resonance Imaging (MRI)
„
„
Pros:
„ Excellent soft tissue discrimination
„ No radiation exposure
„ Most sensitive modality for evaluating
the spine
Cons:
„ Less sensitive for evaluating bony
anatomy and calcifications
„ Contraindicated for patients with
metal devices, etc.
„ Expensive
Lumbar Spine MRI T2
Image from PACS, BIDMC
12
Simplified LBP Diagnostic Algorithim
Red Flags?
YES
NO
Conservative
management, reevaluate in 4 weeks
Subacute
neurologic
symptoms?
(i.e sciatica)
NO
Concerned about
tumor, infection, or
acute neurologic
deficits?
OR
CT and/or
Plain Films
Trauma
YES
MRI
No further evaluation
YES
NO
Re-eval in 4-6 weeks
MRI
Improvement?
Adapted from Stern, SD, Cifu AS and Altkorn D, From Symptom to Diagnosis, McGraw-Hill: NY, 2006 and Lieberman, G Primary
Care Radiology:Radiologic assessment of low back pain, http://eradiology.bidmc.harvard.edu/primarycare/index.html Accessed
10/17/2008
MRI
13
Lumbar Spine: Sagittal Anatomy
T12
L1
Ligamentum flavum
Note thickness
L2
L3
Vertebral disk
Note central high T2
signal (NP) and low
peripheral signal (AF)
L4
L5
Spinal canal
Note the width and
amount of CSF
Normal Lumbar Spine MRI Sagittal T2
MRI Image from PACS, BIDMC
Schematic images from Drake, Vogl and Mitchell, Gray’s Anatomy for Students, New York: Elsevier, 2005.
14
Lumbar Spine: Bone and Joint Anatomy
aka facet joint
Images from Drake, Vogl and Mitchell, Gray’s Anatomy for Students, New York: Elsevier, 2005.
15
Lumbar Spine: Axial Anatomy
Psoas
NP
AF
Paraspinal
Image courtesy of Dr. Kleefield
Lumbar Spine MRI Axial T2
Image from PACS, BIDMC
Ligamentum flavum - Note the thickness here
Facet joint - Note how the joint surfaces align and the thin layer of high signal fluid
between layers of low signal cartilage
Vertebral disk - Note the clean, concave margin of the annulus fibrosus (AF) next to
the dura of the spinal canal. Nucleus pulposus = NP.
Neural foramina - This is an important area because the nerve roots exit here; note
16
the space between the vertebral body (VB) and the facet joints here
Due to her neurologic
symptoms and lack of
response to pain control Ms. S
had an MRI of her lumbar
spine …
Ms. S: Extradural Masses and Spinal Stenosis on MRI
Findings
Spinal canal stenosis
from L2-L5 due to
extradural masses
T12
L1
Protruding low signal
masses in posterior
spinal canal L2-L5
L2
L3
*
L4
*
L5
Normal
MRI Sagittal T2
Images from PACS, BIDMC
Ms. S
Lumbar Spine MRI Sagittal T2
Disks - Low signal
intensity from L2-L5 in
addition to extension of
disk into the spinal canal
Vertebrae - Posterior
displacement of the L4
vertebrae
18
Differential Diagnosis: Extradural Mass
„
„
„
Degenerative
„ Disk herniation
„ Spinal stenosis
„ Ligament ossification
„ Synovial cyst
Neoplastic
„ Primary vertebral
tumor
„ Others: meningioma,
neurogenic tumor
„ Lymphoma
„ Metastasis
Infection
„ Osteomyelitis
„ Epidural abscess
„
„
Trauma
„ Epidural scar
„ Iatrogenic
„ Hematoma
„ Fracture fragment
Others
„ Lipomatosis
„ Paget’s disease
„ Extramedullary
hematopoesis
„ Amyloidosis
„ Granulomatous
diseases
Image from PACS, BIDMC
Adapted from: Reeder, M. Gamuts in Radiology: Fourth Edition. Springer 2003.
19
Ms. S: Facet Arthropathy on MRI
Ms. S
Normal
L4 vertebral body
Psoas
NP
AF
*
Paraspinal
PACS, BIDMC
MRI Axial T2
MRI Axial T2
PACS, BIDMC
PACS, BIDMC
Low signal mass in posterior spinal column
Spinal canal - marked reduction of CSF signal and compression of canal
Facet joint arthropathy - osteophyte formation and distortion of joint alignment
20
Ms. S: Disk Bulge on MRI
Ms. S
Normal
L3-L4 disk
Psoas
NP
Psoas
AF
Paraspinal
muscles
Paraspinal
MRI Axial T2
MRI Axial T2
PACS, BIDMC
PACS, BIDMC
Disk - Bulging of disk beyond margin of L4 vertebrae
Facet joint arthropathy - osteophyte formation and distortion of
joint alignment
Ms. S’s Diagnosis: Degenerative Spinal Stenosis
„
Most likely: degenerative spinal stenosis
„
Broad radiological differential
„
However, characteristic set of findings present
„
„
„
„
„
Narrowed by history
„
„
„
„
„
Osteophytes + misalignment: facet joint arthropathy
Low signal posterior masses: ligamentum flavum hypertrophy
Disc extension into canal: disc bulge
Posterior vertebrae displacement: spondylolisthesis
Chronic nature of pain
Relief with sitting (neurogenic claudication)
Advanced age
No other red flags: no evidence of infection, tumor, trauma
Neurological signs possibly consistent with stenosis
present at L4-L5, but most severe stenosis is L3-L4
22
Let’s discuss in more detail
the degenerative spine
disease found in Ms. S’s
imaging
Facet joint arthropathy and ligamentum
flavum hypertrophy
„
Degenerative change
in facet joints can be
due to:
„
„
„
Ligamentum flavum
hypertrophy
„
„
Osteoarthritis
Disk degeneration
Due to vertebral
instability
Joint changes only
present in a few
percent of
asymptomatic patients
Image from Katz and Harris NEJM 2008
Katz JN and Harris, MB. Lumbar Spinal Stenosis, NEJM 2008 358:818-25
24
Companion Patient #1: Facet joint arthropathy
Companion Patient #1
Ms. S
*
*
Axial T2 MRI
Image courtesy Dr. Kleefield, BIDMC
Axial T2 MRI
PACS, BIDMC
Hypertrophic bone formation (CT>MRI)
Joint space narrowing
Associated: ligamentum flavum hypertrophy
Not seen here: subchondral sclerosis (CT>MRI)
25
Disk Herniation
„
„
„
Many asymptomatic individuals have evidence
of disk herniation
Often spontaneously regresses
If herniation is symptomatic, results in symptoms
in nerve root inferior to level of herniation
„
„
i.e L3-L4 herniation --> L4 radiculopathy
Different types of herniation
„
Disk Bulge (technically not herniation), Protrusion and
Extrusion
26
Ms. S: Disk Bulge
Ms. S
Circumferential
increase in
diameter without
annulus rupture
(not a true
herniation)
Axial T2 MRI
PACS, BIDMC
27
Companion Patient #2: Disk Protrusion
Companion Patient #2
Focal bulge
without complete
annulus rupture
Axial T2 MRI
Image courtesy Dr. Kleefield, BIDMC
28
Companion Patient #3: Disk Extrusion
Companion Patient #3
Nucleus pulposus
ruptures through
annulus fibrosus
and extends into
epidural space
Sagittal T2 MRI
Image courtesy Dr. Kleefield, BIDMC
29
Spondylolisthesis
„
Spondylolisthesis = slippage of vertebrae
anteriorly or posteriorly
„
„
„
Can be caused by congenital factors,
degenerative disease, trauma, or systemic
disease
Severe displacement result in radiculopathy
by compression or stretch
Also contributes to spinal canal stenosis
30
Companion Patient #4: Spondylolisthesis
Ms. S
Companion Patient #4
T12
L1
L2
L3
L4
L5
Sagittal T2 MRI
Sagittal CT Lumbar Spine
Two examples of posterior spondylolisthesis
Images courtesy Dr. Kleefield, BIDMC and PACS, BIDMC
31
Conclusions
„
„
Ms. S’s continued symptoms are consistent with
an L5 radiculopathy
However, her imaging is not consistent with this
„
„
What can be done?
„
„
„
„
She has more severe degeneration elsewhere
Surgery can be considered
Continued pain management
Alternative therapies: acupuncture, exercise
Sometimes imaging can confuse the clinical
picture, especially with low back pain
32
Acknowledgements
„
„
„
„
„
Dr. Gillian Lieberman - for her help,
encouragement and this opportunity
Dr. Alice Fisher - for guidance
Dr. Jonathan Kleefield - for many images and
encouragement
Maria Levantakis - making everything happen
Larry Barbaras - webmaster
33
References
„
„
„
„
„
„
„
„
„
(1) Carragee, EJ Persistent Low Back Pain, NEJM 2005 352:18, 1891-8.
(2) Katz JN and Harris, MB. Lumbar Spinal Stenosis, NEJM 2008 358:818-25.
(3) Modic MT and Ross JS, Lumbar Degenerative Disk Disease, Radiology 2007 245:
43-61.
(4) Wilson JF, In The Clinic: Low Back Pain. Ann Internal Medicine 2008:
148(9):ITC5-1-ITC5-16.
(5) Rumboldt Z, Degenerative Disorders of the Spine, Semin Roentgenology 2006
327-361.
(6) Reeder, M. Gamuts in Radiology: Fourth Edition. Springer 2003.
(7) Weissleder, R et al Primer of Diagnostic Imaging: Third Edition Philadelphia:
Mosby, 2003.
(8) Stern, SD, Cifu AS and Altkorn D, From Symptom to Diagnosis, McGraw-Hill: NY,
2006.
(9) Lieberman, G Primary Care Radiology:Radiologic assessment of low back pain,
http://eradiology.bidmc.harvard.edu/primarycare/index.html Accessed 10/17/2008
34