Degenerative Lumbar Spine Disease
Michael Barnett, HMS IIICore Radiology Clerkship
BIDMC PCE
Beth Israel DeaconessBeth Israel Deaconess HarvardHarvardMedical CenterMedical Center MedicalMedicalA Member of A Member of CaregroupCaregroup SchoolSchool
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OverviewOverview
Patient Presentation: Ms. SClinical Work-up of Low Back PainMenu of Radiological TestsLumbar Spine AnatomyPatient Imaging: Ms. SDiscussion of Degenerative Spine Disease
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Our Patient, Ms. S
88 year old woman with chronic low back pain4 year history of back pain
Radiation: left hip, thigh, calf, ankle L5 dermatome distribution
The pain is inconstantRelief with sitting
Ms. S is normally an active womanControls pain with Celebrex and epidural steroid injections
Presents to the pain clinic after 3 epidural steroid injections failed to provide relief
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Clinical DDx Low Back PainMusculoskeletal
BoneFracture, spondylosis, spondylolisthesis
JointsFacet joint degeneration
DisksHerniation, annular tears
LigamentsLigament hypertrophy or ossification
MusclesStrain
Adapted from Stern, SD, Cifu AS and Altkorn D, From Symptom to Diagnosis, McGraw-Hill: NY, 2006.
Systemic DiseaseInfection
Osteomyelitis, spondylodiscitis, epidural abscess
Inflammatory ArthritisRA, AS, Psoriasis
NeoplasticPrimary tumors, metasstatic cancecr, lymphoma, multiple myeloma
Visceral ConditionCV: Aortic aneurysmGU: stones, infectionGI: pancreatitis, ulcersGyn: Endometriosis, PID
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Low Back PainA challenging issue in outpatient medicinePoint prevalence as high as 33%Lifetime prevalence as high as 80%Fifth most common reason for physician visits in US1 in 5 patients report substantial limitations in activity due to LBP
Wilson JF, In The Clinic: Low Back Pain. Ann Internal Medicine 2008: 148(9):ITC5-1-ITC5-16
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Low Back Pain Work-UpImaging can create more questions than answersEspecially in the elderly, degenerative spinal is incredibly common in asymptomatic subjects
Disk herniation: 25-50%Disk degeneration: 25-70%Annular tears: 14-33%
Most LBP resolves spontaneously, as do many radiographic findings
Carragee, EJ Persistent Low Back Pain, NEJM 2005 352:18, 1891-8.
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However, it is important to be aware of red flags which necessitate imaging …
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Red Flags with LBPFracture
Age >70History of osteoporosisTraumaCorticosteroid use
Adapted from Stern, SD, Cifu AS and Altkorn D, From Symptom to Diagnosis, McGraw-Hill: NY, 2006 and Lieberman, G Primary Care Radiology:Radiologic assessment of low back pain, http://eradiology.bidmc.harvard.edu/primarycare/index.html Accessed 10/17/2008
InfectionFever, chillsRecent skin or urinary infectionImmunosuppresionIVDU Recent spine surgery
NeurologicSciaticaNew onset urinary/fecal incontinenceAbnormal neurologic exam: motor, sensory, reflexes
TumorAge >50History of previous cancerUnexplained weight loss
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Menu of Tests for Low Back Pain Assessment
More Commonly Used:Plain FilmsCT and CT MyelographyMRIBone Scintigraphy - assessing for metastatic cancer
Less Commonly Used:Plain Myelography - supplanted by CT myelography
Discography - contrast injection into disk to assess for disk source of pain
Spinal Angiogram - assess vasculature of spine
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L-Spine Plain Films
Pros:Fast, no contraindicationsGood for evaluating bony structures
TraumaBony degenerationSpine alignment
Cons:Poor soft tissue discriminationFrequently will need CT/MRI anywayRadiation exposure
Image courtesy Dr. Kleefield, BIDMC
Lumbar spine plain X-ray film
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CT and CT MyelographyPros:
Excellent resolution of bony anatomy
Trauma evalDegenerative bony changesGood for visualizing calcifications and gas
Myelography: useful for LBP evalwhen MRI is contraindicated
Cons:Poor differentiation of soft tissues within the spineRadiation exposureMyelography: invasive procedure
Image courtesy Dr. Kleefield, BIDMC
Lumbar Spine CT
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Magnetic Resonance Imaging (MRI)
Pros:Excellent soft tissue discriminationNo radiation exposureMost sensitive modality for evaluating the spine
Cons:Less sensitive for evaluating bony anatomy and calcificationsContraindicated for patients with metal devices, etc.Expensive
Image from PACS, BIDMC
Lumbar Spine MRI T2
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Simplified LBP Diagnostic Algorithim
Red Flags?
Conservative management, re-
evaluate in 4 weeks
Concerned about tumor, infection, or acute neurologic
deficits?
YES
MRI
TraumaCT and/or Plain Films
Subacute neurologic symptoms?(i.e sciatica)
YESMRI
NO
Re-eval in 4-6 weeks Improvement? MRI
YES
No further evaluation
NO
OR
NO
Adapted from Stern, SD, Cifu AS and Altkorn D, From Symptom to Diagnosis, McGraw-Hill: NY, 2006 and Lieberman, G Primary Care Radiology:Radiologic assessment of low back pain, http://eradiology.bidmc.harvard.edu/primarycare/index.html Accessed 10/17/2008
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Lumbar Spine: Sagittal Anatomy
L5
L4
L3
L2
L1
T12
Ligamentum flavumNote thickness
Spinal canalNote the width andamount of CSF
Vertebral diskNote central high T2 signal (NP) and low peripheral signal (AF)
Normal Lumbar Spine MRI Sagittal T2
Schematic images from Drake, Vogl and Mitchell, Gray’s Anatomy for Students, New York: Elsevier, 2005. MRI Image from PACS, BIDMC
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Lumbar Spine: Bone and Joint Anatomy
Images from Drake, Vogl and Mitchell, Gray’s Anatomy for Students, New York: Elsevier, 2005.
aka facet joint
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Lumbar Spine: Axial Anatomy
Ligamentum flavum - Note the thickness hereFacet joint - Note how the joint surfaces align and the thin layer of high signal fluid between layers of low signal cartilageVertebral disk - Note the clean, concave margin of the annulus fibrosus (AF) next to the dura of the spinal canal. Nucleus pulposus = NP. Neural foramina - This is an important area because the nerve roots exit here; note the space between the vertebral body (VB) and the facet joints here
Psoas
Paraspinal
NP
AF
Image from PACS, BIDMCImage courtesy of Dr. Kleefield Lumbar Spine MRI Axial T2
Due to her neurologic symptoms and lack of
response to pain control Ms. S had an MRI of her lumbar
spine …
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Ms. S: Extradural Masses and Spinal Stenosis on MRI
L5
L4
L3
L2
L1
T12
Normal
FindingsSpinal canal stenosis from L2-L5 due to extradural masses
Protruding low signal masses in posterior spinal canal L2-L5
Disks - Low signal intensity from L2-L5 in addition to extension of disk into the spinal canal
Vertebrae - Posterior displacement of the L4 vertebraeMs. S
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Images from PACS, BIDMC
Lumbar Spine MRI Sagittal T2MRI Sagittal T2
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Differential Diagnosis: Extradural Mass
DegenerativeDisk herniationSpinal stenosisLigament ossificationSynovial cyst
NeoplasticPrimary vertebral tumorOthers: meningioma, neurogenic tumorLymphomaMetastasis
InfectionOsteomyelitisEpidural abscess
TraumaEpidural scarIatrogenicHematomaFracture fragment
OthersLipomatosisPaget’s diseaseExtramedullaryhematopoesisAmyloidosisGranulomatousdiseases
Adapted from: Reeder, M. Gamuts in Radiology: Fourth Edition. Springer 2003.
Image from PACS, BIDMC
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Ms. S: Facet Arthropathy on MRI
Low signal mass in posterior spinal columnSpinal canal - marked reduction of CSF signal and compression of canal
Facet joint arthropathy - osteophyte formation and distortion of joint alignment
MRI Axial T2
L4 vertebral body
*
PACS, BIDMC
PACS, BIDMC
Psoas
Paraspinal
NP
AF
MRI Axial T2
Normal Ms. S
PACS, BIDMC
Ms. S: Disk Bulge on MRI
Disk - Bulging of disk beyond margin of L4 vertebraeFacet joint arthropathy - osteophyte formation and distortion of
joint alignment
MRI Axial T2
L3-L4 disk
Psoas
Paraspinalmuscles
Psoas
Paraspinal
NP
AF
MRI Axial T2
PACS, BIDMC
Normal Ms. S
PACS, BIDMC
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Ms. S’s Diagnosis: Degenerative Spinal Stenosis
Most likely: degenerative spinal stenosisBroad radiological differential
However, characteristic set of findings presentOsteophytes + misalignment: facet joint arthropathyLow signal posterior masses: ligamentum flavum hypertrophyDisc extension into canal: disc bulgePosterior vertebrae displacement: spondylolisthesis
Narrowed by history Chronic nature of pain Relief with sitting (neurogenic claudication) Advanced ageNo other red flags: no evidence of infection, tumor, trauma
Neurological signs possibly consistent with stenosispresent at L4-L5, but most severe stenosis is L3-L4
Let’s discuss in more detail the degenerative spine
disease found in Ms. S’s imaging
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Facet joint arthropathy and ligamentum flavum hypertrophy
Degenerative change in facet joints can be due to:
OsteoarthritisDisk degeneration
Ligamentum flavumhypertrophy
Due to vertebral instability
Joint changes only present in a few percent of asymptomatic patients
Image from Katz and Harris NEJM 2008
Katz JN and Harris, MB. Lumbar Spinal Stenosis, NEJM 2008 358:818-25
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Companion Patient #1: Facet joint arthropathy
PACS, BIDMC
Hypertrophic bone formation (CT>MRI)Joint space narrowing
Associated: ligamentum flavum hypertrophyNot seen here: subchondral sclerosis (CT>MRI)
Image courtesy Dr. Kleefield, BIDMC
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Axial T2 MRIAxial T2 MRI
Companion Patient #1 Ms. S
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Disk Herniation
Many asymptomatic individuals have evidence of disk herniationOften spontaneously regressesIf herniation is symptomatic, results in symptoms in nerve root inferior to level of herniation
i.e L3-L4 herniation --> L4 radiculopathyDifferent types of herniation
Disk Bulge (technically not herniation), Protrusion and Extrusion
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Ms. S: Disk Bulge
Circumferential increase in
diameter without annulus rupture
(not a true herniation)
PACS, BIDMC
Ms. S
Axial T2 MRI
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Companion Patient #2: Disk Protrusion
Focal bulge without complete annulus rupture
Image courtesy Dr. Kleefield, BIDMC
Companion Patient #2
Axial T2 MRI
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Companion Patient #3: Disk Extrusion
Nucleus pulposus ruptures through annulus fibrosus and extends into epidural space
Image courtesy Dr. Kleefield, BIDMC
Companion Patient #3
Sagittal T2 MRI
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Spondylolisthesis
Spondylolisthesis = slippage of vertebrae anteriorly or posteriorly
Can be caused by congenital factors, degenerative disease, trauma, or systemic diseaseSevere displacement result in radiculopathyby compression or stretchAlso contributes to spinal canal stenosis
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Companion Patient #4: Spondylolisthesis
L5
L4
L3
L2
L1
T12
Two examples of posterior spondylolisthesisImages courtesy Dr. Kleefield, BIDMC and PACS, BIDMC
Ms. S Companion Patient #4
Sagittal T2 MRI Sagittal CT Lumbar Spine
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ConclusionsMs. S’s continued symptoms are consistent with an L5 radiculopathyHowever, her imaging is not consistent with this
She has more severe degeneration elsewhereWhat can be done?
Surgery can be consideredContinued pain managementAlternative therapies: acupuncture, exercise
Sometimes imaging can confuse the clinical picture, especially with low back pain
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AcknowledgementsAcknowledgements
Dr. Gillian Lieberman - for her help, encouragement and this opportunity Dr. Alice Fisher - for guidanceDr. Jonathan Kleefield - for many images and encouragementMaria Levantakis - making everything happenLarry Barbaras - webmaster
Dr. Gillian Lieberman - for her help, encouragement and this opportunity Dr. Alice Fisher - for guidanceDr. Jonathan Kleefield - for many images and encouragementMaria Levantakis - making everything happenLarry Barbaras - webmaster
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References
(1) Carragee, EJ Persistent Low Back Pain, NEJM 2005 352:18, 1891-8.(2) Katz JN and Harris, MB. Lumbar Spinal Stenosis, NEJM 2008 358:818-25.(3) Modic MT and Ross JS, Lumbar Degenerative Disk Disease, Radiology 2007 245: 43-61.(4) Wilson JF, In The Clinic: Low Back Pain. Ann Internal Medicine 2008: 148(9):ITC5-1-ITC5-16.(5) Rumboldt Z, Degenerative Disorders of the Spine, Semin Roentgenology 2006 327-361.(6) Reeder, M. Gamuts in Radiology: Fourth Edition. Springer 2003. (7) Weissleder, R et al Primer of Diagnostic Imaging: Third Edition Philadelphia: Mosby, 2003. (8) Stern, SD, Cifu AS and Altkorn D, From Symptom to Diagnosis, McGraw-Hill: NY, 2006. (9) Lieberman, G Primary Care Radiology:Radiologic assessment of low back pain, http://eradiology.bidmc.harvard.edu/primarycare/index.html Accessed 10/17/2008