Morning presentation - SpinePlus GP Education Day

1. “Doc, my back is killing me!”
Practical guidelines for the management of
back pain and sciatica
Brisbane
4 March 2017

2. Dave is a 38 yo factory worker on a production line. He comes to see you
as a new patient, complaining of back pain that goes down his left leg. He
tells you he has a long history of intermittent back pain which he reports
first starting in his teens and worsened mid-twenties after starting work
as a labourer. Previous episodes have usually settled with a few days of
rest. These episodes have become frequent and severe over the years.
The most recent episode started 4 weeks ago and is getting worse. Dave
does not recall a particular injury or incident but remembers doing some
heavy lifting at about the time the pain started. Dave reports that the
current pain is not settling and he has missed time from work using his
sick leave. He is unable to return to work now. He needs advice about
what is wrong, what painkillers to take and putting a WorkCover claim in.

3. Your first step is to assess him clinically. Dr Adrian Nowitzke is now
going to run through a concise history and examination for back
pain.
Dave describes constant pain in the midline of the low back that is
worse with movement and shoots down his left leg. It goes as far as
the mid calf. His whole leg goes numb if he sits for too long. He
doesn’t feel his foot is weak. The examination reveals midline low
back pain, worse on flexion with some catching on extension. He is
tentative with all movement and shows some signs of abnormal
illness behaviour. He has no signs of neurological deficit but has
reproduction of leg pain on straight leg raise at 60 degrees.

4. Dave has not had any previous imaging of his back. He advises he
would like a scan to see “what damage work has done”. Dr David
Lisle will now discuss the best imaging to order and how to
interpret and explain the findings to Dave.
Because of the inability to work and the likelihood of a claim, you
decide to an MRI. The CT scan shows chronic pars defects and a
Grade I isthmic spondylolisthesis and some degeneration, and the
MRI confirms the slip and shows multilevel disc degeneration with a
small disc bulge on the right at L4-5.

5. Imaging talk

6. T1 T2 STIR

8. Appropriate imaging for back pain
• Imaging modalities
• Guidelines

9. Appropriate imaging for back pain
• Imaging modalities
–Radiographs (X-rays)
–Scintigraphy (bone scan)
–CT
–MRI
• Guidelines

10. Radiographs
What you see
• Bony anatomy and
alignment
• Disc height

11. Bone scan
What you see
• Bone pathology
– Osteoblastic activity

12. CT
What you see
• Bony anatomy and
alignment
• Cross sectional view
of spinal canal and
foramina
• Disc, thecal sac,
nerve roots

13. MRI
What you see
• Bony anatomy and
alignment
• Bone pathology
• Multiplanar view of
spinal canal and
foramina
• Disc: hydration and
structure
• Neural structures:
cord, nerve roots

14. CT radiation dose
• Background average 2–3 mSv/year
– Natural background 85%
– Medical 14%
– CT 40-67% of medical
• CT use increased by 600-820% over 14-18
years

15. Radiation doses
Imaging test Effective
dose (mSv)
CXRs Background
exposure
Flying hours
CXR 0.02 1 3 days 4
Lumbar X-ray 1.5 75 6/12 300
Lumbar CT 2-10 100-500 8/12 - 3 years 400 - 1800
Bone scan 6 300 2 years 1200

16. CT risk controversies
• Validity of linear, no threshold model
• Variable literature
– Increased cancer risk in some
– Beneficial effect of low level radiation in others
• Children more radiosensitive and at greater risk
for decades
• Triple risk secondary tumours
– Leukaemia 50mGy
– Brain tumour 60mGy
• Lancet 2012;380:499-505

17. Degenerative changes on imaging
• Ubiquitous and nonspecific
– Brinjikji AJNR 2015;36:811 Systematic literature review of imaging features of spinal
degeneration in asymptomatic populations
Imaging Finding
Age (yr)
20 30 40 50 60 70 80
Disk degeneration 37% 52% 68% 80% 88% 93% 96%
Disk signal loss 17% 33% 54% 73% 86% 94% 97%
Disk height loss 24% 34% 45% 56% 67% 76% 84%
Disk bulge 30% 40% 50% 60% 69% 77% 84%
Disk protrusion 29% 31% 33% 36% 38% 40% 43%
Annular fissure 19% 20% 22% 23% 25% 27% 29%
Facet
degeneration
4% 9% 18% 32% 50% 69% 83%
Spondylolisthesis 3% 5% 8% 14% 23% 35% 50%

18. Appropriate imaging for back pain
• Clinical presentations: classification into 3
broad categories
1. Nonspecific low back pain
2. Back pain associated with radiculopathy
3. Back pain associated with a specific
cause requiring prompt evaluation

19. Back pain categories
3. Back pain associated with a specific
cause requiring prompt evaluation
− Cauda equina syndrome
− Cancer
− Vertebral infection
− Vertebral compression fracture
− Ankylosing spondylitis

20. LOW BACK PAIN GUIDELINES
Diagnostic triage
1.Non-specific LBP
2.Radiculopathy
3.Specific LBP
• ‘Red flags’
‘Red Flags’
• Cauda equina syndrome
• Known 10 tumour
• Weight loss
• Severe symptoms, not
settling
• Fever
• Recent infection or Sx
• Osteoporosis
• Steroid use
• Non-mechanical pain
• Child*

21. LOW BACK PAIN GUIDELINES
• American College of Physicians & American
Pain Society Recommendations
– Ann Intern Med 2007;147:478-491
• Choosing Wisely Australia
– www.choosingwisely.org.au
• National Institute for Clinical Excellence (NICE)
UK
• ACR Appropriateness Criteria

22. LOW BACK PAIN GUIDELINES
1.Focused Hx and examination to place patients
into 1 of 3 categories
2.No imaging for nonspecific LBP
3.Imaging for LBP + severe or progressive
neurological deficits OR risk factors for specific
cause
4.Imaging for LBP and radiculopathy if candidates
for surgery or epidural injection

23. Dave has taken only over the counter medication for his previous
episodes of back pain. However, his wife had Endone in the
cupboard which she was prescribed after some recent surgery.
Dave has taken that for the last few days but advises that it is not
helping and he needs something stronger. Dr Brendan Moore will
now discuss Dave’s medication plan.
You complete the medication scripts for Dave and ask if there is
anything else you can help with.

24. Dave tells you that he wants to open a WorkCover claim and would
like a certificate backdated to last week. He tells you that he now
thinks that work caused the problem in the first place. Dr Angus
Forbes will discuss the implications of WorkCover in the process.
Dave is referred to SpinePlus. An epidural steroid injection is
arranged as well as a referral to a coordinated rehabilitation team
(physiotherapist, exercise physiologist and psychologist). The plan
for Dave is graduated return to activity, including work.

26. Peter is a 32 year old accountant. He has a 5 week history of severe
right sciatica. Peter recalls no accident or injury; he just woke up with
the pain. He has managed to continue working through the busy tax
time but now needs to sort out the problem. He has tried various
therapies including chiropracty twice a week and two sessions of
physiotherapy using TENS and neural glides which seemed to make
things worse. He is taking Nurofen, occasional Panadeine Forte and
has recently commenced Lyrica.

27. You clinically assess Peter. Dr Adrian Nowitzke is now going to
run through the history and examination.
Peter describes lower limb pain which starts in the buttock and
radiates to his posterior thigh and calf. He has numbness in his
right foot. On examination he has a significantly reduced range
of lumbar flexion because of leg pain. He cannot single heel
raise on the right. He has an absent right ankle reflex. The
lateral aspect of his foot is numb. His SLR is 20o with a crossed
SLR of 45o

28. You proceed to MRI scan. Dr David Lisle will clarify disc
herniations and other causes of sciatica.
His MRI shows a large right-sided disc herniation at L5-S1
causing compression of right S1 nerve root.

29. Imaging talk

32. NOMENCLATURE
• 2 morphological characteristics:
– Nature of disc pathology
– Location

33. Annular tear/ fissure
• Annular high intensity zone (HIZ)
– Not synonymous with ‘fissure’
– Does not imply trauma
– Does not imply pain generator

34. Disc bulge
• Extension of disc tissue beyond intervertebral
disc space = displacement of annulus
• >25% circumference (>900)
• Relatively short distance, <3mm
• Normal at L5/S1

36. Herniated disc
• ‘Localised’ = <25% circumference (<900)
• ‘Herniation’ or ‘protrusion’

37. Protrusion vs extrusion
• Based on appearance
• Extrusion = greatest distance in any
plane between edges > base
OR
• Protrusion: contained
• Extrusion: uncontained = ruptured PLL
• Presence or absence of containment
more clinically relevant:
– Surgical approach
– Prediction of resorption

38. Sequestered disc
• Extruded disc material that has no continuity
with the disc of origin
• = free fragment
• Migrated disc:
– Disc material displaced away from site of
extrusion

39. T2 T2
T1

40. Location of herniation
• Anatomic system that correlates with surgery
• Landmarks, transverse plane:
– Sagittal and coronal planes at centre of disc
– Medial edge of articular facet
– Medial, lateral borders of pedicles

41. Location of herniation
• Locations, transverse plane:
– ‘Central’ = midline

42. Location of herniation
• Locations, transverse plane:
– ‘Central’ = midline
– ‘Right central’ & ‘left central’ =
paracentral/ posterolateral

43. Location of herniation
• Locations, transverse plane:
– ‘Central’ = midline
– ‘Right central’ & ‘left central’ =
paracentral/ posterolateral
– ‘Subarticular’ = lateral recess

44. Location of herniation
• Locations, transverse plane:
– ‘Central’ = midline
– ‘Right central’ & ‘left central’ =
paracentral/ posterolateral
– ‘Subarticular’ = lateral recess
– ‘Foraminal’

45. Location of herniation
• Locations, transverse plane:
– ‘Central’ = midline
– ‘Right central’ & ‘left central’ =
paracentral/ posterolateral
– ‘Subarticular’ = lateral recess
– ‘Foraminal’
– ‘Extraforaminal’ = far lateral

46. Volume: degree of canal
compromise
• X-sectional area at site of maximal narrowing
• ‘Mild’: <1/3
• ‘Moderate’: 1/3 – 2/3
• ‘Severe’: > 2/3
• Correlation with fluid around cauda and
‘crowding’ of neural structures
• Other descriptors such as compression of
specific neural structures

47. Mild Moderate Severe

49. Modic 2
• Proliferation of fatty tissue
• Most common form T2 T1

50. Modic 3
• Sclerotic bone
• Long standing
degenerative change
T2 T1

51. Modic 1
• Vascularised bone marrow
• Oedema
• Overlap with inflammatory
changes
T2 T1

52. You refer Peter to see a spine surgeon. Dr Paul Licina
recommends surgery.
He undergoes a right L5-S1 microdiscectomy as a day patient.
He is working from home two days after surgery, having
stopped his analgesia. He is driving to work a week after the
operation. At the three week clinic review, he has minimal back
discomfort, no leg symptoms and no residual weakness.