Part 2: Pick up at Back Pain

- trauma

- improper alignment/mechanisms causing injury

- malignancy

Most common etiologies of back pain...

Herniated discs

less than 2% of back pain cases. Diagnosed by MRI. Causes back pain and sciatica (radicular pain, paresthesia) as sx's. Positive SLR test

L4-L5

most common disc herniation

Posterolateral

____ herniation of a disc is the most common

MRI

CT is less sensitive. It is okay to do screening with X-rays especially in outpatient settings.

Imaging used for diagnosis of herniated disc

Degenerative disc disease (DDD)

dehydration of the nucleus pulposus causing compression of the disc space. End plates become sclerotic with osteophyte production at endplates.

X-rays

initial study for DDD

MRI

study of choice for DDD

Degenerative disc disease (DDD)

Osteoarthritis of facet joints

cause of back pain that involves osteophyte formation at the neural foramina. Causes radicular pain due to nerve root compression. High association with later stage DDD.

CT scan

the best imaging for the visualization of facet joints.

MRI

imaging that is best to visualize nerve roots and discs

Diffuse idiopathic skeletal hyperostosis (DISH)

thick, bridging calcifications between 4 consecutive VBs. Usually lower thoracic or cervical spine. Usually anterior, occasionally posterior. Disc spaces/spaces joints PRESERVED. Back stiffness, but usually NO pain.

SI joints are not affected by DISH

How do you differentiate DISH from Ankylosing Spondylitis?

X-rays

appropriate fist diagnostic study for DISH

DISH

DISH

Vertebral body compression fracture

cause of back pain more common in females, usually secondary to osteoporotic lesions. Anterior and superior VB more common location. Wedge shaped deformity. Radiologically note a 20% compression vs VB increase or decrease the compressed VB. Greater than or equal to 3 mm different between anterior vs posterior VB height.

NO

Are there typically neuro deficits with vertebral body compression fracture?

X-ray

initial screening for vertebral body compression fracture

CT (trauma related)

MRI (malignancy vs. osteo)

Bone scan (age of fracture)

imaging that may be used after X-ray in vertebral body compression fracture

VB compression fracture

VB body fracture (MRI)

VB compression fracture (CT scan)

Spondylolisthesis

slippage of 1 vertebral body, upon another. Caused by degenerative changes, trauma, malignancy, congenital anormalies.

Anterolisthesis and Retrolisthesis

two directions of spondylolisthesis

L4-L5

most common location of spondylolisthesis

spondylolysis

bilateral pars interarticularis fractures

X-rays

primary imaging for spondylolisthesis

slippage of vertebral bodies

What would be seen on lateral view of spondylolisthesis

Scottie dog collar

Oblique view X-ray or CT for spondylolysis would display __________ disruption in the case of a pars fracture.

CT scan

if spondylolisthesis is seen on X-ray, ____ is performed to identify spondylolysis which is often difficult to see on X-ray

Spondylolysis

scotty dog collar

Spondylolisthesis

Spinal stenosis

canal or foraminal narrowing. May be related to soft tissue pathologies (hypertrophy of ligamentum flavum, building discs, ossification of the posterior longitudinal ligament), bony pathologies (osteophytes, facet osteoarthritis, spondylolisthesis), acquired. Cuases radiculopathy and neurogenic claudication.

Cervical and lumbar

spinal stenosis most commonly occurs at which reginos?

X-ray

screening study for spinal stenosis

MRI

study of choice for spinal stenosis

spinal stenosis

spinal stenosis

Ankylosing Spondylitis

condition that involves inflammation, calcification, ossification around entheses (insertion sites of tendons, ligaments, joint capsule). Chronic, progressive arthritic condition associated with HLA-B27 antigen, commonly seen in young males. Involves inflammation/fusion of the SI joints and spinal facet joints.

Sacroiliitis

hallmark sign of Ankylosing spondylitis

Bamboo spine

In Ankylosing Spondylitis, ossification of outer fibers of annulus fibrosis leads to bony bridges between VBs called syndesmophytes which leads to ___________

X-ray

screening study for Ankylosing Spondylitis

Syndesmophytes

bamboo spine appearance in Ankylosing Spondylitis

Bamboo spine indicated of Ankylosing Spondylitis

Bamboo spine indicative of AS