Archive for ‘Spine’

May 23, 2014

Case of Note: Herniated Disc

herniated lumbarAs we worked through spinal conditions and imaging this week, we found a useful and not entirely uncommon case study: A patient with low back pain.

 

This patient presented with severe lower back pain and pain extending into both lower legs.

 

This imaging was done using MRI technology. He was prescribed the procedure due to the severity of pain in his lower legs, a symptom called radiculopathy, which is a shooting pain distributed through the nerves in the legs. You can see a disc has protruded from the normal position between the lumbar vertebrae and presses on the spinal canal (between numbers 3 and 4 the black gap between vertebrae seems to “spill” out in the back). This MRI exam was extremely useful in identifying the level of patients abnormality and and the extent of abnormality.

 

Initially, the patient elected a conservative route for treatment and had an epidural pain injection. Pain medicine is injected to the area around the herniated disc for relief of pain. This procedure resulted in temporary partial pain relief. After that treatment and a course of physical therapy he was referred for a surgical consultation as his pain continued. A microdiscectomy gave relief and has allowed him to return to normal activity.

Diagnostic Imaging Centers blogs on regularly about women’s health atwww.mammographykc.com and general radiology atwww.diagnosticimagingcenterskc.com. Visit our sites for more helpful information!

May 21, 2014

MRI Case Study: “Thoracic Cord Syrinx” or “Some new vocab words for today”

SAG t2 8Here is an example of an MRI of the thoracic spine. The image on the left is taken as if the body were being sliced from head to toe (sagittal image) and the image below is as if the body were being sliced across the middle like a loaf of bread (axial image).

 

The image to the left shows the vertebral bodies as blocks and the spinous processes back behind the spinal canal as obliquely oriented blades. The spinal canal on both contains the spinal cord which is mostly black surrounded by the normal cerebrospinal fluid which is white. The thoracic cord normally has a little bit of a bulge as it ends in the upper lumbar spine, seen on the sagittal image towards the bottom.

 

This patient presented for evaluation of mid-back pain. On the left side sagittal image, the cord has an area of white running through it centrally from top to bottom. This is seen as the central spot of white within the normally dark cord on the axial image. The signal of this area matches the signal of the cerebrospinal fluid surrounding the cord.

 

This area of white is one example of cord pathology that might be picked up on an MRI. This is known as a syrinx (or syringohydromyelia – how’s that for a long name!) and is an abnormal buildup of fluid in the central canal of the cord. Over time, this fluid buildup can enlarge and start to affect the nerves running through the cord, sometimes resulting in symptoms like muscle weakness.

 

Remember, most patients with back pain will find their symptoms resolve within 4 weeks. If symptoms do not improve or are accompanied by other changes like muscle weakness, evaluation by your doctor is warranted.

 

 

Diagnostic Imaging Centers blogs on regularly about women’s health atwww.mammographykc.com and general radiology atwww.diagnosticimagingcenterskc.com. Visit our sites for more helpful information!AX t2

May 8, 2014

Imaging of the Lumbar Spine

Lumbar vertebrae anterior by Anatomography via Wikimedia Commons Copyright Creative Commons  Creative Commons Attribution-Share Alike 2.1 JapanTo continue our conversation about back pain, today we’re going to focus on the different imaging tests that may be requested to evaluate someone with back pain, specifically lower back pain. Imaging for lower back pain will likely focus on the lumbar spine. It’s the lower back region, usually the lower 5 vertebral levels – the series of vertebrae highlighted in the picture here.

 

There are several modalities we use to examine the lumbar spine, including (but not limited to) x-ray, MRI  and CT.

 

Conventional films or X-rays are often the starting point when evaluating someone with back pain. This allows an overall assessment of alignment and can look for signs of a more serious issue requiring additional imaging, like a fracture or an area of abnormal appearing bone. If the back pain follows recent trauma, is seen in someone with known osteoporosis or is in someone over the age of 70, conventional films may be the imaging study of choice and may be the only imaging needed.

 

MRI (magnetic resonance imaging) of the lumbar spine is the most common imaging test for back pain because of its ability to see details of the soft tissues, including the nerves as well as the bones.  As an added benefit, no radiation is involved. Remember with MRI the images are made with a large magnet and radiofrequency pulses (those are the loud sounds you hear). With MRI we can examine all of the following:  the structure of the discs (the cartilage cushions between the vertebrae) and look for how the disc relates to adjacent nerve roots; the bones that make up the spine including the vertebral bodies;  the conus (the lower end of the spinal cord); and the soft tissues surrounding the area. Imaging takes about 30 minutes, and remember – you can’t have an MRI if you have a pacemaker (most types anyway!) or some implanted devices like stimulators. Lastly for the safety of all you cannot bring metal of any kind into the room!

 

CT (computed tomography) is an additional means of looking at the spine. Images with CT are made with x-rays that are created in a ring around the body allowing the body to be imaged in thin slices. CT allows an excellent look at the bones making up the spine. It may be the study of choice for evaluation of acute trauma or fracture. Changes in the discs can be seen, but the nerve roots are not visualized in a routine CT. There are times when a CT of the spine is performed after a myelogram – this is a procedure where contrast material is put in the fluid- containing space surrounding the spinal cord and nerve roots. This then allows CT to better evaluate the nerve roots and soft tissues of the spinal canal. A CT scan may be used to help with planning before back surgery. A CT lumbar spine takes around 10 minutes. It should not be used in those who are pregnant unless it is an emergency (as with severe trauma).

 

All of these are straightforward procedures that can give an excellent anatomic evaluation. Remember imaging of the spine will often reveal age-related changes in the discs and bones, not all of which will be associated with symptoms. Imaging is not always needed for back pain – see your doctor to determine if imaging can help get you on the path to your best possible health!

(Image credit: Lumbar vertebrae anterior by Anatomography via Wikimedia Commons Copyright Creative CommonsAttribution-Share Alike 2.1 Japan)

Diagnostic Imaging Centers blogs on regularly about women’s health atwww.mammographykc.com and general radiology atwww.diagnosticimagingcenterskc.com. Visit our sites for more helpful information!

 

May 6, 2014

Oh! The Pain in my Back!

Low back pain by Harrygouvas via Wikimedia Commons Copyright Creative Commons Attribution-ShareAlike 3.0 Unported (CC BY-SA 3.0)Lower back pain is common. In fact, in the US it is a leading reason for a trip to see the doctor. There are many causes for back pain – some of them related to the spine and its components and others related to adjacent structures. Things like kidney stones and diverticulitis can present with back pain. There are also times when the source of back pain is never fully found.

 

When should you see your doctor and when is imaging for back pain appropriate?

 

The good thing about back pain is that the natural course for most is improvement of symptoms by around 4 weeks – whether you have specific treatment or not. If you have severe back pain, if it is associated with other symptoms like pain or nerve changes in one of your legs (numbness, burning sensation or tingling) or if symptoms are not improving, a visit to the doctor is in order.

 

There are published guidelines helping your healthcare provider decide if you will benefit from imaging of the spine. A careful history and physical are key.

 

Why not image everyone with back pain? Imaging the spine in the majority of us will show abnormalities – our discs (those cartilage cushions between the vertebral bodies) will begin to show changes as we get older. This is a natural age-related process related to being upright – the discs are only good for so many miles! The problem with imaging for back pain is we will often see abnormalities of the discs – some can even be large and impressive – but they do not always correlate with your symptoms. Imaging can lead to confusion and over-treatment, and for uncomplicated back pain will likely not affect how your back pain is managed.

 

When will imaging for back pain help most? Imaging is recommended for immediate evaluation of some patients with back pain with history or signs that might indicate a serious problem requiring immediate intervention. These include patients with history or signs that might make cancer (a RARE cause of back pain) more likely – things like a known cancer elsewhere in the body or significant weight loss. Signs that there might be an infection are important. Any symptoms that suggest there might be involvement of the nerves to the lower body may also warrant immediate imaging.

 

Imaging after a trial of physical therapy (usually after a 6 week period) may be indicated in patients who fail to show improvement or have worsening of symptoms. Imaging may also be performed if symptoms persist in patients with history of osteoporosis and concern for new fractures.

 

How do we image and which test do we pick? Those will be explored in our next post on back pain!

 

So, if you have low back pain remember that in the vast majority of patients, symptoms will get better – although it may take a few weeks. A visit to your doctor will help determine if imaging is needed and will help in the management of your pain.

Image Credit: Low back pain by Harrygouvas via Wikimedia Commons Copyright Creative CommonsAttribution-ShareAlike 3.0 Unported (CC BY-SA 3.0).

Diagnostic Imaging Centers blogs on regularly about women’s health atwww.mammographykc.com and general radiology atwww.diagnosticimagingcenterskc.com. Visit our sites for more helpful information!