But My Back Hurts Only When I m Standing!

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1 But My Back Hurts Only When I m Standing! Axial Loading for Spinal Canal Stenosis Matthew Cham, MD; Akio Hiwatashi, MD; Per-Lennart Westesson, MD, PhD, DDS Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University of Rochester Medical Center, Rochester, NY Presentation material is for education purposes only. All rights reserved URMC Radiology Page 1 of 29

2 Spinal Canal Stenosis! Progressive narrowing of the central canal, lateral recesses, and neural foramina most commonly due to degenerative disease! In the United States, majority of individuals over 60 years old are affected Presentation material is for education purposes only. All rights reserved URMC Radiology Page 2 of 29

3 Symptoms of Lumbar Stenosis! Most commonly presents as midline back pain aggravated by standing or walking! Improved by leaning forward Presentation material is for education purposes only. All rights reserved URMC Radiology Page 3 of 29

4 Purpose! To review the role of axial-loading in MRI for the diagnosis of spinal canal stenosis! To learn how axial-loading in MRI can be performed during conventional supine MRI Presentation material is for education purposes only. All rights reserved URMC Radiology Page 4 of 29

5 Effect of Positioning! Myelography may demonstrate worsening of spinal stenosis during extension Presentation material is for education purposes only. All rights reserved URMC Radiology Page 5 of 29

6 Axial Loading Axial Load! Some individuals are symptomatic only in the upright position! May be secondary to axial load exerted by bodyweight on the spine, making spinal stenosis worse in the standing position Presentation material is for education purposes only. All rights reserved URMC Radiology Page 6 of 29

7 Effects of Axial Loading! MRI is typically performed in the supine position with no axial load! Surgically treatable spinal stenosis may become hidden during supine MRI Presentation material is for education purposes only. All rights reserved URMC Radiology Page 7 of 29

8 Axial Loading Device! Device used to generate axial loading! Simulates the upright standing position during conventional supine MRI! Consists of a harness and a platform Presentation material is for education purposes only. All rights reserved URMC Radiology Page 8 of 29

9 Harness! Harness comes in several sizes to fit various body types! Two nylon straps fasten the harness to the foot platform Presentation material is for education purposes only. All rights reserved URMC Radiology Page 9 of 29

10 Foot Platform! Foot platform applies an adjustable tension to the harness Presentation material is for education purposes only. All rights reserved URMC Radiology Page 10 of 29

11 Patient Interview! Identify patients who might benefit from axial-loading during MRI Presentation material is for education purposes only. All rights reserved URMC Radiology Page 11 of 29

12 Evaluation of Symptoms! Patient may complain of pain that occurs only when standing My back hurts only when I m standing!! Pain may be relieved by lying down Presentation material is for education purposes only. All rights reserved URMC Radiology Page 12 of 29

13 Evaluation of Prior MRI! Prior MRI might show no significant spinal stenosis due to lack of axial load My back doesn t hurt lying down. I have no pain at all!! Patient may have been asymptomatic during prior MRI due to supine positioning Presentation material is for education purposes only. All rights reserved URMC Radiology Page 13 of 29

14 Using the Axial Loading Device! Harness is worn like a vest! Vest is buckled in place Presentation material is for education purposes only. All rights reserved URMC Radiology Page 14 of 29

15 Using the Axial Loading Device! The foot platform is placed at patient s feet! One size fits all Presentation material is for education purposes only. All rights reserved URMC Radiology Page 15 of 29

16 Using the Axial Loading Device! Harness is fastened to the foot platform with two nylon straps Presentation material is for education purposes only. All rights reserved URMC Radiology Page 16 of 29

17 Using the Axial Loading Device! Tension is applied to the harness by adjusting two large blue knobs! As the two knobs are turned, the axial load increases Presentation material is for education purposes only. All rights reserved URMC Radiology Page 17 of 29

18 Using the Axial Loading Device! Axial load (in pounds) is indicated by two display gauges.! Recommended total axial load is 50% of patient s bodyweight Presentation material is for education purposes only. All rights reserved URMC Radiology Page 18 of 29

19 MRI with Axial Loading! Patients usually become symptomatic due to the axial load My back hurts! It feels as if I am standing!! Patient should be given reassurance Presentation material is for education purposes only. All rights reserved URMC Radiology Page 19 of 29

20 MRI with Axial Loading No Pain! Ouch! No Axial Load With Axial Load Presentation material is for education purposes only. All rights reserved URMC Radiology Page 20 of 29

21 Female 41y! Neurogenic claudication at L4-L5 No Axial Load! Increasing central stenosis with axial load Axial Load Presentation material is for education purposes only. All rights reserved URMC Radiology Page 21 of 29

22 Male 63y! Neurogenic claudication at L4-L5 No Axial Load! Increasing disc herniation and central stenosis with axial load Axial Load Presentation material is for education purposes only. All rights reserved URMC Radiology Page 22 of 29

23 Female 58y! Neurogenic Claudication at L4-L5 No Axial Load! Increasing synovial cyst bulge with axial load Axial Load Presentation material is for education purposes only. All rights reserved URMC Radiology Page 23 of 29

24 Female 52y! Neurogenic Claudication at L4-L5 No Axial Load! Increasing central stenosis with axial load Axial Load Presentation material is for education purposes only. All rights reserved URMC Radiology Page 24 of 29

25 Will it affect Management?! The incremental increase in diagnosis of operative spinal canal stenosis with the use of an axial-loading device is currently under investigation.! There is some evidence that management could change for some patients. (Hiwatashi, et al. AJNR 2004; 25: ) Presentation material is for education purposes only. All rights reserved URMC Radiology Page 25 of 29

26 Is it safe?! FDA-approved for both CT and MRI! If patient cannot tolerate their back pain, hip or knee flexion instantly relieves the axial load! Large display gauge allows MRI technologist to see absence of axial load in those situations Axial load is relieved by knee flexion Presentation material is for education purposes only. All rights reserved URMC Radiology Page 26 of 29

27 What are other options?! Axial Loading Device! Upright MRI Presentation material is for education purposes only. All rights reserved URMC Radiology Page 27 of 29

28 Conclusion! Axial-loading during MRI can unmask operative cases of spinal canal stenosis that may otherwise appear inconsequential! Axial-loading can be performed during conventional supine MRI! The incremental diagnostic yield of axial loading for spinal canal stenosis is currently under investigation Presentation material is for education purposes only. All rights reserved URMC Radiology Page 28 of 29

29 References! Danielson BI, Willen J, Gaulitz A, et al. Axial loading of the spine during CT and MR in patients with suspected lumbar spinal stenosis. Acta Radiol. 1998; 39(6): ! Hiwatashi A, Danielson B, Moritani T. Axial loading during MRI imaging can influence treatment decision for symptomatic spinal stenosis. AJNR 2004; 25: ! Jinkins JR, Dworkin J. Upright, weight-bearing, dynamic-kinetic MRI of the spine. Acta Clin Croat 2002; 41(Suppl):31-35.! Kimura S, Steinbach GC, Watenpaugh DE. Lumbar spine disc height and curvature responses to an axial load. Spine 2001; 26: ! Willen J, Danielson B. The diagnostic effect from axial loading of the lumbar spine during computed tomography and magnetic resonance imaging in patients with degenerative disorders. Spine 2001; 26(23): Presentation material is for education purposes only. All rights reserved URMC Radiology Page 29 of 29

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