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?