Lying down or standing up - what are the possibilities with upright MRI? Alan Breen DC, PhD, MIPEM, FRCC Clinical Director for Special Imaging, AECC

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1 Lying down or standing up - what are the possibilities with upright MRI? Alan Breen DC, PhD, MIPEM, FRCC Clinical Director for Special Imaging, AECC

2 Contents of this talk Indications for referral Issues to consider when referring Case summaries Our research so far Professional responsibilities

3 Main indications for referral Non-resolving MSK problems to investigate the possibility of Serious pathology Neural encroachment Functional soft tissue derangements only symptomatic during loading Certain sports injuries Patients who need a scan but Cannot lie in a scanner (e.g. diaphragmatic paralysis) Claustrophobia MEET MR SAFETY CRITERIA - e.g. no pacemaker, implanted programmable device, ferrous metal in body (e.g. eyes)

4 Patient information Clinical details Investigations requested Safety information Referring clinician details Authorisations (office use)

5 Female, age 68 Lower limb hyperreflexia and weakness plus lower limb stenotic symptoms Marked claustrophobia, breathing difficulties.? Canal stenosis? Patient scanned sitting

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10 Paramed MrJ T

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12 Esaote S-Scan open coil horizontal solid magnet 0.25T 400,000 Wt 6.7 Tons

13 Fonar open coil upright solid magnet 0.6T 1,000,000 Wt Tons

14 Upright or lying?

15 No abnormality in any position Lying Standing Sitting

16 The erect sitting and standing imaging does not significantly alter the pattern of alignment. Equally, no new neural compromise is seen in the latter positions. Standing Sitting

17 EXAMPLE OF FINDINGS MORE PROMINENT IN THE SUPINE POSITION SUPINE UPRIGHT

18 Example of patient movement whilst standing compared with sitting and supine. Supine Sitting Stand ing

19 Large right posterolateral disc extrusion compressing the traversing right S1 nerve root at L5/S1. Lying Sitting

20 Alignment L4-5 Lying Flexion Extension

21 Patient 3 Male, Age 53 Clinical history: Pain right buttock, paraesthesiae both feet. Symptoms worse when upright. Some neuro changes worse on right. Previous MR 2012 and 2014 show facet hoint arthritis. Examination: MRI Lumbar spine, Supine, Sitting flexion/extension

22 Patient 3 Flexion Extension

23 Patient 3 Sitting

24 Patient 3 Facet joint degenerative change, more marked at L4-5 and L5-S1. At L4-5 this is causing some narrowing of the lateral recesses on both sides, but on the left there is also a prominent 18mm complex synovial cyst further narrowing the lateral recess and intervertebral foramen. This is also compressing the theca and restricting the space around the cauda equine roots. This is more marked in extension.

25 Male, age 49 Chronic, persistent back pain increases with being upright Lying

26 Sitting

27 Lying

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29 Findings In Back Pain Patients Referred For Upright MRI Melanie Jones BSc (Hons) BA, MSc, Andy Morris MB, ChB, DMRD, FRCR, Andy Pope BSc, MBBS, MRCP (UK), FRCR, Ravi Ayer BSc (Hons) BM, MRCS, FRCR, Alan Breen DC PhD 45 patients referred to Bournemouth Open Upright MRI for upright scans between November 1 st 2014 and June 30 th 2015.

30 Number of patients Reason for referral (not exclusive) 30 leg pain, (6 of which was bilateral) 15 suspicion of a stenotic lesion 1 possible malignancy 4 effects of degenerative change 2 spondylolisthesis 1 fracture 3 previous surgery 1 trauma 1 sacroiliitis 3 instability

31 Results 9% No changes seen Changes seen in Upright Changes seen in Supine 31% 60%

32 FINDINGS Changes prominent in Upright 31% Of those with changes Positional alignment No change 60% Changes prominent in Supine 9% 23% 27% Neural or root canal disruption 50% both neural or root canal disruption and positional alignment

33 Summary Most upright MRI requests have been for patients with leg pain. 60% of the time there was no difference in findings upright and lying When findings were in evidence, they were three times more prevalent upright than lying. The most common findings were neural disruption. Full clinical details are needed from the referrer for best results.

34 So Upright or lying?

35 Both! In order to....find out if suspected structural abnormalities correspond with clinical findings provoked by loading or loading position. and inform a patient management rationale based on structure and loading.

36 And finally

37 Female age 27 student. Persistent non-radiating central neck pain 6 months after mild trauma (tripped), unchanging course. Constant, not aggravated by movement or position. Orthopaedic and neurological (including cranial nerve) testing normal except for some tingling in feet.

38 Findings.. Cervical cord from C1-C6 largely obliterated by tumour mass (possibly meningioma).

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40 What you are required to do when you refer a patient for imaging record the rationale for, and outcomes of, all investigations use the results of your clinical assessment of the patient to arrive at a working diagnosis or rationale document the results of the examination in the patient s records and fully explain these to the patient.