Imaging work-up of lower back pain
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1 Imaging wrk-up f lwer back pain David Ornan, MD Assistant Prfessr, Neurradilgy September 11, 2015 Outline Tls Utility f imaging Chsing mdality ACR apprpriateness criteria Take hme pints and cnclusin 1
2 Tls Radigraphy Fractures Degenerative changes Lytic r sclertic bne lesins Hardware Dynamic instability Sclisis Crss-sectinal CT/CT myelgram High spatial reslutin fr assessment f bne Multiplanar capabilities MRI High cntrast reslutin fr assessment f sft tissues, including discs and ligaments Radigraphy Tls 2
3 Tls CT Tls CT 3
4 Tls MRI T2 STIR T1 pre T1 pst Cntrast Tls Indicatins Infectin, inflammatin, malignancy Pst-perative spine Cntraindicatins Severe allergy Facial edema with dyspnea, laryngeal edema with stridr, brnchspasm with hypxia, anaphylaxis Renal insufficiency CT: GFR < 45 MRI: GFR < 30 Pregnancy (MRI) Breast feeding can cntinue after gadlinium 4
5 Tls Cntrast Pre-medicatin fr minr and mderate reactins Prednisne 50 mg, 13, 7, 1 hr Benadryl 50 mg, 1 hr Utility f imaging Limited in the setting f acute back pain <1% f patients will have serius systemic etilgies Mst will imprve with cnservative management Chu et al, Lancet 2009, meta-analysis N significant difference in shrt and lng-term utcmes cmparing immediate imaging t cnservative management Difficult t crrelate symptms t imaging findings Disc herniatins seen in 22-67% f asymptmatic adults Findings ften d nt crrelate with severity f symptms High likelihd f finding extraspinal incidentals that require further cstly wrkup 5
6 Chsing mdality Risk assessment Thrugh histry and physical exam Assume exclude ther etilgies utside the spine Hw cncerned am I? Red flags Risk assessment Red flags Cnstitutinal symptms Histry f malignancy Neurlgic deficits Weakness Numbness, including saddle Bwel/bladder symptms Recent bacterial infectin IV drug use Sterids/immuncmprmised Recent spine prcedures 6
7 ACR apprpriateness criteria 6 clinical scenaris 1: Uncmplicated acute lw back pain r radiculpathy 2: Minr trauma, steprsis, fcal deficit, prlnged duratin, age >70 3: Suspicin f cancer, infectin, r immunsuppressin 4: Lw back pain r radiculpathy, interventin candidate 5: Prir surgery 6: Cauda equina, multifcal deficits Scring system 1-3: Usually nt apprpriate 4-6: May be apprpriate 7-9: Usually apprpriate ACR apprpriateness criteria N imaging 6 clinical scenaris 1: Uncmplicated acute lw back pain r radiculpathy 2: Minr trauma, steprsis, fcal r prgressive deficit, prlnged duratin, age >70 3: Suspicin f cancer, infectin, r immunsuppressin 4: Lw back pain r radiculpathy, interventin candidate 5: Prir surgery 6: Cauda equina, multifcal deficits 7
8 ACR apprpriateness criteria MRI 6 clinical scenaris 1: Uncmplicated acute lw back pain r radiculpathy 2: Minr trauma, steprsis, fcal r prgressive deficit, prlnged duratin, age >70 3: Suspicin f cancer, infectin, r immunsuppressin 4: Lw back pain r radiculpathy, interventin candidate 5: Prir surgery 6: Cauda equina, multifcal deficits ACR apprpriateness criteria MRI 6 clinical scenaris 1: Uncmplicated acute lw back pain r radiculpathy 2: Minr trauma, steprsis, fcal r prgressive deficit, prlnged duratin, age >70 3: Suspicin f cancer, infectin, r immunsuppressin 4: Lw back pain r radiculpathy, interventin candidate 5: Prir surgery 6: Cauda equina, multifcal deficits 8
9 Scenari 1: Uncmplicated acute lw back pain r radiculpathy Herniated disc Scenari 1: Annular fissure/herniated disc 9
10 Scenari 1: Annular fissure/herniated disc Scenari 1: Annular fissure 10
11 Scenari 1: Disc prtrusin Scenari 1: Disc extrusin 11
12 Scenari 1: Sequestered disc Scenari 2: Minr trauma, steprsis, fcal r prgressive deficit, prlnged duratin, age > 70 Osteprtic fracture Spndylwhinthewhat? Spndylsis: Degenerative changes Spndyllisthesis: Slip Spndyllysis: Fracture 12
13 Scenari 2: Spndylsis Scenari 2: Spndylsis 13
14 Scenari 2: Spndylsis Scenari 2: Spndylsis 14
15 Scenari 2: Spndylsis Mdic type 1 Mdic type 2 Mdic type 3 Zhang et al., Int J Bil Sci 2009; 5(7): Scenari 2: Spndylsis 15
16 Scenari 2: Spndylsis Scenari 2: Osteprtic fracture 16
17 Scenari 2: Osteprtic fracture Scenari 2: Osteprtic fracture, burst type 17
18 Scenari 3: Suspicin f cancer, infectin, r immunsuppressin Scenari 3: Suspicin f cancer, infectin, r immunsuppressin Prstate mets RCC mets 18
19 Scenari 3: Suspicin f cancer, infectin, r immunsuppressin Multiple myelma Scenari 3: Suspicin f cancer, infectin, r immunsuppressin 19
20 Scenari 3: Suspicin f cancer, infectin, r immunsuppressin Scenari 3: Suspicin f cancer, infectin, r immunsuppressin 20
21 Scenari 4: Lw back pain r radiculpathy, interventin candidate Scenari 4: Lw back pain r radiculpathy, interventin candidate 21
22 Scenari 4: Lw back pain r radiculpathy, interventin candidate Scenari 4: Lw back pain r radiculpathy, interventin candidate 22
23 Scenari 4: Lw back pain r radiculpathy, interventin candidate Scenari 4: Lw back pain r radiculpathy, interventin candidate scttlaneycansell.wrdpress.cm 23
24 Scenari 5: Prir surgery Hardware Adjacent level disease Recurrent disc versus pstperative scar Scenari 5: Prir surgery Hardware 24
25 Scenari 5: Prir surgery Adjacent level disease Scenari 5: Prir surgery Recurrent disc versus pstperative scar Sept
26 Scenari 5: Prir surgery Recurrent disc versus pstperative scar Scenari 6: Cauda equina, multifcal deficits 26
27 Scenari 6: Cauda equina, multifcal deficits Epidural lipmatsis Scenari 6: Cauda equina, multifcal deficits 27
28 Scenari 6: Cauda equina, multifcal deficits Scenari 6: Cauda equina, multifcal deficits Sarcidsis 28
29 Take hme pints Thank yu! 29
Key Primary CPT Codes: Refer to pages: 5-6 Last Review Date: May 28, 2015 Medical Coverage Guideline Number:
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