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Lumbar PainChrista Marx, APRN, CNP
Center for Diagnostic Imaging
Sartell, MN320-229-4634 office
612-723-4110 cell
Disclosures
• None
Objectives:
1. Participants will be able to
identify lumbar anatomy.
2. Participants will be able to
identify 2 etiologies of lumbar pain.
3. Participants will be able to
identify several lumbar treatment
options.
Lumbar Pain
• Low back pain is a leading cause of why people seek medical care.
• 500,000 operations/year
• The American Academy of
Pain Medicine estimates 100
million adults suffer from
chronic pain.
• Annual direct and indirect cost of up to $635 billion.
• A 2015 National Institutes of
Health analysis found 25.3
million people with chronic pain suffered daily for at least
three months, and 40 million
described their pain as
severe.
• Why do some seek out
healthcare but most do not?
History• Location
• Onset
• Severity
• Frequency
• Duration
• Quality
• Rating
• Associated Factors
• Alleviating Factors
• Aggravating Factors
Medical & Surgical History• Contributing history: diabetes, lumbar surgeries, osteoporosis, cardiac, respiratory, sleep
apnea, abuse etc
• Hx chemical dependency
• Alcohol intake, drug use
Family History• Chemical dependency, alcohol use, drug use
• Chronic pain issues & how did they managed pain
Medications & Allergies• Current
• Tried
• Thoughts on Medications
Social Hx• Current
• Past
ROS• General
• Loss of bladder or bowel function
Treatments for Pain• Current
• Past
• Expectations
• Start setting the stage for long term and short term expectations and goals
Goals• Short term and Long term
Examination • General examination
• Attention to neurological exam
• Reflex
• Sensation
• Strength
• Drop foot
• Changes from previous exams
• Perceived vs apparent leg weakness
• Distracted exam
• Waddell testing
• Lumbar exam leading to etiology
• Facet loading
• Straight leg raise
• Muscle related
• ROM
Imaging• Past
• Current
• Thorough review with patient
Approach to Imaging
• Advanced imaging of the spine can be overwhelming
• Choose wisely
• ABIM (American Board of Internal Medicine) initiative to reduce
waste/unnecessary medical tests
• Do not do imaging for low back pain in the first six weeks unless
RED FLAGS are present:
• Severe/progressive neurological defects
• Fever (discitis/osteomyelitis)
• Sudden back pain with spinal tenderness
• Serious underlying medical condition (malignancy)
• Trauma
• Cauda equina syndrome (bowel/bladder issues and saddle region
paresthias/numbness)
• Gadolinium based contrast agent
• Excellent for further pathology in cord, marrow, discs, and endplates
• Often used if one year post surgery
Imaging OptionsXray: limited to bone structure, limited information
MRI: Primary modality to detect abnormalities of the spinal cord,
bulging discs, herniated discs, and nerve compression. Also acuity of
compression fractures
• Most used compared to CTs
CT: Secondary modality to detect more calcified tissues such as
bone-osteoarthritis. Shows bones well, soft tissue better than plain film
but not as well as MRI
• Often used more in ED for acute trauma
• If patients can not have an MRI, ex: due to an older pacemaker
•PET-CT, Bone Scan: Very limited role in imaging LBP. Primarily used in
oncology imaging.
Imaging for Low Back Pain
Most patients with radicular symptoms improve without
intervention
Most disc herniations will regress/reabsorb in eight weeks
MRI of the Lumbar Spine
Sagittal T2
Sagittal T1
Sagittal STIR
MRI of the Lumbar Spine
Axial T2
Axial T1
Optional pre and post-contrast T1 (sagittal and axial)
Diagnostic Category & Subcategory
Normal- Normal disc morphology.
Congenital/developmental variation- congenitally abnormal or have undergone changes related to congenital abnormality (scoliosis/spondylolisthesis)
The Spine Journal 14 (2014)
2525–2545
Diagnostic Category & Subcategory
Degenerative- subclassifiedinto annular fissure, degeneration, and herniation
Annular fissure- separation between the annular fibers and/or the annular fibers’ attachment to the bone
The Spine Journal 14 (2014)
2525–2545
Degenerative
Concentric fissure-separation/delamination of fibers parallel to disc margin
Radial fissure- vertically, horizontally, or obliquely oriented separation/rent of fibers from nucleus pulposisinto the annulus
The Spine Journal 14 (2014)
2525–2545
Degenerative
Transverse fissure-horizontally oriented radial fissure, sometimes refers to horizontal separation of the fibers within the annulus from apophyseal bone
Degeneration- includes dessication, fibrosis, disc space narrowing, diffuse bulging of disc beyond annulus, intradiscal gas (T1), osteophytes, defects, inflammatory changes, mucinous degeneration of the annulus, and sclerosis of the endplates
The Spine Journal 14 (2014)
2525–2545
Degenerative
Herniation- localized or focal (<25% or 90°) displacement of disc material beyond the disc margin, subcategorized into protrusion and extrusion
Bulging- NOT considered herniation, disc extending beyond ring apophyses and >25%
The Spine Journal 14 (2014)
2525–2545
Degenerative
Protrusion- greatest distance between the edges of disc material and disc margin is less than the width of the base at the disc margin
Extrusion- greatest distance
between edges of disc
material and disc space is
greater than the width of
the base at the disc margin
The Spine Journal 14 (2014)
2525–2545
Degenerative
Schmorl’s node- herniated disc into adjacent endplate
Contained- herniation in which disc material is covered by annulus fibers of posterior longitudinal ligament
The Spine Journal 14 (2014)
2525–2545
Degenerative/Trauma
Uncontained- disc herniation without overlying annulus
Trauma- disruption of disc with physical/imaging evidence of violent fracture and/or dislocation
Inflammation/InfectionInflammation/infection-infection, infection-like inflammatory discitis, inflammatory response to spondyloarthropathy, inflammatory changes of the subchondral endplate (Modic type 1)
Modic changes- subchondralendplate degenerative changes, Type 1 are edematous, Type 2 are fatty, and Type 3 are sclerotic
The Spine Journal 14 (2014)
2525–2545
Lumbar Spinal Stenosis
Normal- no compromise Mild- compromise <1/3
The Spine Journal 14 (2014)
2525–2545
Lumbar Spinal Stenosis
Moderate- compromise
between 1/3-2/3
Severe- compromise >
1/3
Lumbar Foraminal Stenosis
Normal- circumferential fat surrounding ganglion
Mild- 1/3 compromise, typically disc protrusion/bulge, endplate osteophyte, or degenerative facet arthropathy
Lumbar Foraminal Stenosis
Moderate- 1/3-2/3 compromise, abutment/mild impingement of ganglion, disc herniation/bulge, endplate osteophytes, and/or degenerative facet arthropathy
Severe- >2/3 compromise,
impingement of ganglion, disc
herniation/bulge, endplate
osteophytes, and/or
degenerative facet arthropathy
Inflammatory Facet Disease•STIR images best- facet joint effusion progressing to perifacet edema and eventually bony edema, cervical and lumbar spine, also demonstrates enhancement
•Correlate for point tenderness
•Amenable to steroid/anesthetic injection
Sacroiliitis
STIR- edema involving the subchondral regions of the SI joints
Post-contrast T1 fat sat- patchy enhancement along joint margins
Pars Interarticularis Defects
(Spondylolysis)CT is best for identifying, however STIR can show edema in adjacent pedicle and facets
Spondylolisthesis widens the spinal canal and narrows the foramina
Synovial Cyst
• Cyst connected to a degenerated facet joint
• Lined by epithelium
• Sometimes can be aspirated
• When intraspinal, can cause nerve root compression
• Treatment
• Either facet is injected with steroid/anesthetic mixture until cyst ruptures, or a second needle may be passed through the cyst
Myofascial Lumbar pain
• Often a
secondary
response
• Contributing
factor with most
lumbar pain
issues
• Protective
response
• Often radiates to
Thoracic or
Cervical area
Treatments:• The body will often heal on its own
• Onset of pain less than 6 weeks
• Ice first, then heat
• Light stretching
• Keep moving/active
• NSAIDS
• Tylenol
• Medrol dose pak
• Muscle relaxers- Tizanidine, cyclobenzaprine (addictive properties), baclofen
(caution abrupt discontinuation)
• Physical therapy or chiropractic care
• Imaging if Red Flags are present or if lumbar radiculopathy symptoms
• Other non-opioid medications
• Gabapentin, lyrica, cymbalta
• Limit opioids
• Have an exit plan and use it
• Think of patient perception when opioids are used as “first line” treatments
• Set expectations and timeline
• Give warnings and talk about complicating health issues
• Monitor exactly like long term opioid plan
Treatments:• Pain greater than 6 weeks
• Consider and proceed with imaging if other conservative therapies have
not decreased pain or symptoms
• Continue with conservative treatments• Physical therapy
• Chiropractic care
• Non-opioid medications
• Anti-inflammatory diet
• Sleep hygiene
• Stress management
• Consider pain specialist referral
• Think of as any other specialist referral• Quicker the treatments, the better the outcomes
• Chronic pain program
• Consider psychology
• Depression and anxiety management• CBT-Cognitive Behavioral Therapy
• Interventional therapy options
• Spinal Cord Stimulator
Interventional Therapy:• Some practices do IV sedation on every patient which is not always necessary
• Pros to sedation
• Cons to sedation
• Cost
• Always use image guidance plus experience to provide safety and assurance of
location of intervention
• Equipment
• C-arm fluoroscopy is an x-ray tube/data connected to a real-time video
system
• Ultrasound is used mainly for tendons and superficial structures for injections,
including trigger point muscle injections, sometimes for SI joints• CT scan-SI joints
• Educate patient
• Outline expectations
• Pre-injection instructions
• Post-injection instructions
• Hold anti-coagulants
C-Arm Fluoroscopy
CT Scanner and Ultrasound
Injection Mechanisms
Diagnostic Injections with Anesthetic:
• Pain blockage to confirm/exclude pain
source
Diagnostic & Therapeutic Injections Anesthetic
& Steriod:
• Decrease nerve root inflammation and
swelling at the nerve-disc interface
• Steriod and anesthetic injection may break
the pain cycle and allow the patient to
begin to recover from the initial insult
Interventional Therapy Risks
Potential Risks:
• Hemorrhage
• Infection
• Vessel or nerve root injury
• Arachnoidits- inflammation of membrane
surrounding nerves and spinal cord
• Spinal Headache
• Contrast reaction
• For these reasons:
• Only experienced and trained providers should
do interventional therapy options
• Imaging guidance should be required to
confirm and document needle placement
Lumbar Interventional Options
• Interlaminar epidural steroid injection
• Transforaminal epidural steroid injection
• Caudal epidural steroid injection
• Nerve blocks
• Facet injections
• Facet steroid joint injections
• Medial branch blocks
• Rhizotomy
• SI Joint Injection
• Discography
• Vertebroplasty/Kypoplasty
• Trigger Point Injections
Lumbar Interlaminar ESI
Renfrew DL, Moore TE, Kathol MH, El-Khoury GY, Lemke JH, Walker CWCorrect placement of epidural steroid
injections: fluoroscopic guidance and contrast administration. Am J Neurorad 1991;12:1003-1007
• Low back and leg pain
• Clinically proven diffuse or non-
focal injection for disc, facet,
nerve root irritation
• Low morbidity when properly
performed
• Steroid in the body up to 14
days
• Varied results, no relief to years
relief
• Limit number per year
depending on age & medical
hx
• Epidural space-between the
dura mater and vertebral wall
Link SC, El-Khoury GY, Guilford WB. Percutaneous epidural and nerve root block and percutaneous lumbar
sympatholysis. Rad Clin North Am 1998;36:509-521.
Lumbar Transforaminal ESI
• Predominant leg pain
• Variation of a nerve block
with greater injection volumes
• Greater efficacy in single level disease
• Increased specificity in
diagnoses and treatment
• Steriod in the body up to 14
days
• Varied results, no relief to
years relief
Lumbar Nerve Root Block
Caudal Epidural Injection
• Injection through the sacral hiatus
• Very safe approach
• Dependent on the ability to reflux
medication over the length of the
sacrum
• Best for diffuse sacral disease, lower
fusions, or L5-S1 pain
• Same steroid duration and results as ESI
and transforaminal ESI
Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. Clinical features of patients with pain stemming from the
lumbar zygapohyseal joints: is the lumbar facet syndrome a clinical entity? Spine 1994;19:1132-1137.
Lumbar Facet Injection
• Axial lumbar pain,
occasionally referred to
buttocks, hips, or thighs
• Intra-articular injection
sometimes difficult
• Occasional long-term pain
relief
• Diagnstic- Medial branch
blocks
• Therapeutic-Steriod joint
injections
van Kleef M, Barendse GAM, IKessels A, Voets HM, Wever WEJ, de Lange S. Randomized trial of radiofrequency lumbar
facet denervation for chronic low back pain. Spine 1999 24:1937-1942.
Lumbar Facet Block & Rhizotomy/RFA
• Axial/central low back
pain due to facet arthritis
or inflammation
• Responds to steroid
facet injections but
without long term relief
• Long term improvement
in appropriate chosen
patients
• Low chance of nerve
regrowth after 9-12
months
Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995;20:31-37
Sacroiliac Joint Injection
• Low back pain, hip
or groin (referred)
pain
• CT or ultrasound
guided
• Often unsuspected
source of back, hip,
and groin pain
Lumbar Discography
• Performed as pre-surgical
workup
• Disc is pressurized
• “Pressure” is a normal sensation
• Patient rates level of pain and
describes location of the pain
and familiarity of the location
• Assists surgeons to determine
surgery options
Vertebroplasty
• Vertebral body compression fractures-only
acute or subacute
• Frequently very painful until they heal
• Determine exact level of pain, specific
examination to confirm fracture is the
cause of the pain
• Injection of the bone cement can help
stabilize the fracture, lessening the pain
• Majority of the time, gives immediate relief
T12 Compression fracture on plain film and MRI
Procedure Facts
• Injections with steroids can be repeated 14-
21 days after initial injection, sometimes
insurance based timeline
• Determine effectiveness to lead to a
repeat injection vs other options
• Minimize injections for maximum benefit,
cost savings and safety
• Limit number of steroid injections per year
depending on patient age
REGENERATIVE MEDICINE• PRP (Platelet Rich Plasma)
• Venous blood taken from arm, placed in centrifuge
• PRP layer (60 mg of blood=6 ml of PRP) is injected into area of
interest under US/Fluroscopy guidance.
• Takes about 60 minutes from start to finish.
• No NSAIDS for 2 weeks prior, 3 months post procedure
• No oral or injected steroids for 8 weeks prior and 3 months post-injection
• No strenuous activity for 2 weeks
• Should perform physical therapy
• May take 8 weeks for start of improvement
• Results and outcomes in evolution
• Currently cash pay
Regenerative Medicine
•Bone Marrow Cellular
•Harvest bone marrow from ilium
•It is preferred in areas of decreased vascularity- joints,
discs, bursa
•Autologous cells. From patient into same patient.
•Rebuilding tendon and cartilage
•Disc matrix regeneration when used with PRP
•Sedation, local anesthetic, etc can be 1-2 hours from
start to finish
•Results and outcomes in evolution
•Currently cash pay
Surgery Consultation??
New or worsening symptoms
• Drop foot- exam confirmed
• Extremity weakness-exam confirmed
• Sensory deficits-exam confirmed
• Loss of bladder or bowel control
• Trauma
• Conservative treatment options have been exhausted
• Lumbar imaging (MRI or CT) showed specific change at
a level that warrants surgical attention
• Patients sometime just need to hear options from a
surgeon
Questions?