IMAGING EVALUATION FOR LOW BACK PAIN. Christine Athwal, M.D. Faculty Advisor: Timothy Cobb, M.D.

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1 IMAGING EVALUATION FOR LOW BACK PAIN Christine Athwal, M.D. Faculty Advisor: Timothy Cobb, M.D.

2 TABLE OF CONTENTS Introduction Case presentation Differential diagnoses of low back pain Evaluation of low back pain Discussion and conclusion

3 INTRODUCTION Acute low back pain is the 5 th most common reason for all physician visits. Greater than 85% of these patients have nonspecific back pain Less than 1% will have serious systemic etiologies such as cauda equina syndrome, metastatic cancer and spinal infection. Less than 10% will have less serious conditions such as vertebral compression fracture radiculopathy and spinal stenosis.

4 CASE PRESENTATION 49 y/o F presents with low back pain that started approximately 2 months ago. Pain is rated 10/10 and described as aching and shooting pain. Pain located in the lumbar and sacro-iliac region and radiates to right thigh and right knee. Pain aggravated by twisting, lying down and bending at the hip. Associated symptoms include chronic night sweats, leg pain and weakness. Pertinent negatives include no abdominal pain, bladder incontinence, bowel incontinence, dysuria, fever, numbness/tingling, pelvic pain, perianal numbness and/or weight loss. Pt has tried heat, analgesics, bed rest, muscle relaxants, ice, walking and NSAIDs, all of which provided mild relief.

5 PAST MEDICAL HISTORY Past medical history: Diabetes Mellitis type 2 Hypertension ESRD on dialysis Bipolar disorder Past Surgical History: Includes tubal ligation, Ankle surgery and AV fistula placement Medications include Amlodipine, Aspirin, Carvedilol, Clonidine, Docusate, Furosemide, Insulin, Lamotrigine, Oxycodone, Pregabalin and Prochlorperazine

6 PHYSICAL EXAM Heart rate and blood pressure is within normal limits, no fever present. Musculoskeletal exam of the back: tenderness over lower thoracic and lumbar vertebrae as well as paraspinal tenderness over lumbar and thoracic area. Pain with flexion, extension and rotation. No edema and/or deformity present. Neurological exam: normal reflexes and normal muscle tone. Sensation was intact. Straight leg test positive of right lower extremity. Rectal exam showed normal rectal tone.

7 What are some differential diagnoses? What is the next step in management?

8 DIFFERENTIAL DIAGNOSES OF LOW BACK PAIN Etiologies of low back pain can be classified into 4 categories: Nonspecific back pain Serious Systemic etiologies Less serious, specific etiologies Other

9 NONSPECIFIC BACK PAIN Back pain in the absence of a specific underlying condition. Most patients with nonspecific back pain improve within a few weeks.

10 SERIOUS SYSTEMIC ETIOLOGIES Spinal cord or cauda equina compression Metastatic Cancer Spinal epidural abscess Vertebral osteomyelitis

11 LESS SERIOUS, SPECIFIC ETIOLOGIES Vertebral compression fracture Radiculopathy Spinal stenosis

12 OTHER ETIOLOGIES Ankylosing spondylitis Osteoarthritis Scoliosis and hyperkyphosis Etiologies outside the spine (pancreatitis, pyelonephritis, abdominal aortic aneurysm, herpes zoster..)

13 EVALUATION OF LOW BACK PAIN History and physical to evaluate for signs and symptoms that indicate need for immediate imaging and further evaluation. For most patients with acute low back pain, lab tests and imaging are not necessary.

14 EVALUATION OF LOW BACK PAIN Some guidelines suggest red flag signs and symptoms may identify patients at risk for more dangerous causes of back pain and therefore indicate further imaging. Studies show that some red flags are better than others and that overall red flags are poor at ruling in a more serious cause of lower back pain.

15 EVALUATION OF LOW BACK PAIN A Cochrane review by Williams et al. show that the best red flags for diagnosis of acute vertebral compression fracture include use of chronic steroids, age above 74, and recent trauma. A systemic review by Henshke et al. show that a previous history of cancer to be most informative red flag for malignancy; whereas age greater than 50 and no prior history of back pain and/or failure to improve after one month were less useful.

16 EVALUATION OF LOW BACK PAIN: RED FLAGS Possible Etiology Weak red flags Strong red flags Cancer Vertebral tenderness Limited spine range of motion Unexplained weight loss Cancer metastasis to bone Current or recent history of cancer* Cauda equina syndrome Limited spine range of motion Bladder or bowel incontinence Urinary retention Progressive motor or sensory loss/deficit Loss of anal sphincter tone Saddle anesthesia

17 EVALUATION OF LOW BACK PAIN: RED FLAGS Possible etiology Weak red flags Strong red flags Fracture Hx of osteoporosis Vertebral tenderness Limited spine range of motion Age greater than 74 Significant trauma* Prolonged use of steroids Infection Pain increased or unrelieved by rest Vertebral tenderness Limited spine range of motion IVDA Immunosuppression Chronic hemodialysis Severe pain with distant lumbar spine surgery

18 EVALUATION OF LOW BACK PAIN: LABORATORY STUDIES CBC with differential ESR CRP Order if infection or cancer is suspected

19 EVALUATION OF LOW BACK PAIN: IMAGING Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain. A 2009 systemic review and meta-analysis of 6 trials that compared immediate imaging with usual care for patients with acute and subacute low back pain without signs and symptoms of infection or malignancy found no significant differences in short or long term outcomes of patient pain and/or function.

20 EVALUATION OF LOW BACK PAIN: IMAGING CONT. MRI is preferred over CT because of less radiation and better soft-tissue visualization. When there are only weak risk factors for cancer or infection present, with no neurological signs, initial imaging with lumbar radiography and ESR is a reasonable approach. When you suspect a vertebral compression fracture or ankylosing spondylitis, plain radiography is recommended. Myelograph is used in patients who cannot have MRI or CT.

21

22 BACK TO CASE 49 y/o F with PMHx of ESRD on dialysis presents with low back pain for 2 months. Red flags: 1. Chronic hemodialysis 2. Vertebral tenderness

23 IMAGING RESULTS MRI showed diskitis osteomyelitis at L3-L4 with an associated right psoas abscess

24

25

26 DISCUSSION Plain Radiography plus ESR should be ordered immediately on patients with: Major risk factors for cancer (multiple risk factors and/or symptoms, Hx of Cancer) Signs, symptoms, risk factors for spinal infection but level of suspicion is LOW.

27 DISCUSSION MRI should be ordered immediately on patients with Signs or symptoms of cauda equina syndrome (new urinary retention, fecal or urinary incontinence, or saddle anesthesia) Signs, symptoms, or risk factors for spinal infection with HIGH level of suspicion* Significant neurologic deficits (progressive motor weakness or motor deficits at multiple neurologic levels)

28 DISCUSSION Imaging after a trial of therapy should be considered in patients with Weaker risk factors for cancer (unexplained weight loss, age greater than 50, no improvement of pain after 1 month, no relief of pain with bed rest) Risk factors for vertebral fracture (age >70, Hx of prolonged systemic glucocorticoid use, significant trauma, mild trauma with hx or risk factors of osteoporosis) Signs, symptoms of radiculopathy (back pain radiating to legs, positive straight leg raise or crossed straight leg raise test) in patients who are candidates for surgery or epidural steroid injection Signs, symptoms or risk factors or spinal stenosis (radiating leg pain, pseudoclaudication) who are candidates for surgery.

29 DISCUSSION Repeat imaging should only be done if new symptoms have developed or clinical features have changed for example progressive neurologic symptoms or new recent trauma.

30 CONCLUSION Clinicians should not routinely obtain imaging in patients with nonspecific low back pain Diagnostic Imaging studies should be performed only in selected, higher-risk patients who have severe or progressive neurologic deficits or are suspected of having a serious underlying condition. Back pain in dialysis patients should not be overlooked as spinal osteomyelitis is a recognized complication amongst this population

31 REFERENCES 1. Bratton, Robert L., Assessment and Management of Acute Low Back Pain, Am Fam Physician Nov 15;60(8): Jarvik JG, Deyo RA. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging, Ann Intern Med 2002; 137: Chou, Roger et. al, Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care from the Anterior College of Physicians, Ann Intern Med 2001; 154(3): Casazza, Brian, Diagnosis and Treatment of Acute Low Back Pain, Am Fam Physicain Feb 15;85(4): Wheeler et. al, Evaluation of low back pain in adults, UpToDate

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