Oh my aching back

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Oh my aching back

• Application of diagnostic imaging studies to
  Physical Therapy in the acute care setting

By Nicole M. Boyko, MSPT
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Objectives

• To use a case study format to
• Identify what imaging studies may be useful in
  the work-up of intractable back pain in the acute
  care setting
• Relate the results of imaging studies to the
  formulation of a PT diagnosis and plan of care

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Overview Mr. Fs aching back

• History and Physical Examination
• PT/OT Examination
• Results of Imaging Studies
• Rationale for Use of Imaging Studies
• Implications to PT plan of care
• Patient Outcomes

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History and Physical Examination

• 60 y/o African-American male presents to Hospital
  X on 1/24/05 with c/o intractable back pain and
  is admitted to med/surg floor
• PMH none
• PSH s/p hernia repair
• No bowel or bladder complaints

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History Physical Exam Cont

• History of Present Illness
• 1/19 presented to Hospital Y with same
  complaints received injection in ER and was
  D/Cd home with appt for ortho follow-up
• 1/21Had ortho consult and was scheduled for MRI
  as outpatient
• 1/22 to ER at Hospital Y where he received L-S
  X-Ray and was D/Cd home on Skelaxin and Percocet
  with min relief.
• 1/24 MRI as outpatient at Hospital Y. Results
  unavailable but pt reports two herniated disks.

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History Physical Exam Cont

• Admitting MDs plan of care
• Pharmaceuticals for relief of pain/inflammation
• Dilaudid 42-4 mg IV q 6hr
• Toradol 3 mg IV q 8 hr prn
• Prednisone 40 mg po x 1
• Flexeril 10 mg po tid
• PT/OT consults ordered
• Ortho consult ordered
• X-Ray and MRI reports requested from Hospital Y

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PT/OT Initial Examination 1/25

• X-Ray MRI results not yet available at time
  of initial exam
• Subjective I cant move. My son has to lift
  me.
• Prior level of function Lives with wife, son and
  mother in 1 level home. (I) with ADLS and amb, no
  A.D. up until 1 wk ago. Was given standard
  walker at hospital Y but states he is unable to
  use it. Relies on his son to help him mobilize.

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PT/OT Initial Exam Cont

• Pain 10/10 (L) low back/buttock
• Exacerbated by sup?sit txfrs, sitting with wt
  bearing on (L) pelvis, standing with wt bearing
  on (L) pelvis
• Relieved by min relief with sidelying on (L)
  side in semi-fetal position, min relief from pain
  meds
• Palpation/observation tenderness and puffiness
  (L) low back/pelvis
• Sensation ? lt touch (L) L2

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PT/OT Initial Exam Cont

• ROM grossly WFLs but painful to LEs
• Strength limited by pain with resistance
• L4, L5, S1 5/5 (B)
• L1-2, L3 grossly 3/5
• Special Tests SLR (-) (R), () 40º (L)
• ADLs
• UE ADLs mod (I)
• LE ADLs max (A) due to pain
• Toileting/bathing max (A) due to pain

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PT/OT Initial Exam Cont

• Functional Mobility
• Rolling mod (I) with rails to (L) unable to
  roll to (R) due to pain
• Scooting mod (I)
• Sup ? Sit mod (I) with rails. Min verbal cues
  for logrolling technique.
• Sit ? Stand/Gait Pt unable to achieve due to
  severe (L) LBP with attempt despite max (A)
  provided by PT/OT

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PT/OT Initial Intervention

• Patient instructed in positioning for comfort
  sidelying with pillow between knees or supine
  with pillow under knees
• Patient instructed in proper log rolling
  technique
• Patient instructed in the following therapeutic
  exercises single knee to chest (L), piriformis
  stretch (L), gentle abdominal setting

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Initial Assessment by Therapy

• Pt is a 60 y/o male with 1 wk history of
  intractable back pain causing him to be unable to
  sit up or walk without significant assistance
  from his son. Pt did well today with logrolling
  to sit but was unable to stand or walk due to
  significant pain. Suspicious for HNP, perhaps L2
  or L3, but MRI results are unavailable at this
  time. Recommend PT and OT to follow to maximize
  mobility/ADLs for safe D/C to home where pt will
  be further worked up by neurosurgeon.

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Initial Therapy Goals

• PT Goals x 3-4 days
• (I) HEP
• (I) sup ?sit via logrolling
• (I) sit ?stand
• (I) amb gt 50 ft with least restrictive assistive
  device

• OT Goals x 3-4 days
• Pt will be mod (I) for all ADLs with appropriate
  adaptive equipment
• Equipment needs 3 in 1 commode, reacher, sock
  aide

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Radiology Results

• X-Rays AP and lat views of the L-spine
  demonstrate mild osteophyte production at several
  levels with mild narrowing of the L5-S1 disc
  space. No acute fx/dislocation is seen.

Example of claw osteophyte (white arrows)
Example of traction osteophyte (white arrow)
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Radiology Results Cont
Lateral View Normal
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Radiology Results Cont
AP View Normal
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Radiology Results Cont
Degenerative changes to the lumbar spine (lateral
view)
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Radiology Results

• MRI Results
• Technique sagittal and axial T1- and T2 weighted
  images and sagittal STIR images
• Findings DDD L3-4, L4-5, L5-S1
• Diffuse disc bulge L3-4 moderately narrowing the
  central spinal canal and resulting in (B) neural
  foramina narrowing with (L) L3 nerve root
  impingement
• Disc bulge L4-5 which mildly narrows the central
  canal and results in (B) neural foramina
  narrowing without nerve root impingement
• Diffuse disc bulge L5-S1 with (B) neural foramina
  narrowing and possible (L) sided nerve root
  impingement

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Radiology Results Cont
Normal
HNP L5-S1
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Radiology Results Cont
Axial View of a normal L4 disc
Axial view of a 4mm L5 HNP
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To Image or Not To Image?

• Lifetime prevalence of LBP 80
• Often relieved by analgesics and activity
  modification with no further workup needed
• In 80 of cases of LBP, imaging does NOT affect
  the treatment
• Can lead to unnecessary additional testing due to
  the discovery of incidental benign lesions or
  degenerative processes
• Ex In one study, MRI scans revealed herniated
  discs in approximately 25 percent of asymptomatic
  persons less than 50 years of age and in 33
  percent of those more than 50 years of age.

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American College of Radiologys Criteria to Justify Further Evaluation with Imaging for Low Back Pain
Recently significant trauma Unexplained weight loss Unexplained fever Immunosuppression History of cancer IV drug use Prolonged use of corticosteroids Age gt70 Duration gt 3 months
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Additional Clinical Indications for Advanced Imaging in LBP
Radiating pain Symptoms of nerve root compression/cauda equina syndrome (B) LE weakness Urinary retention Saddle anesthesia
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Rationale For Use of Imaging Studies for Mr. F

• Incapacitating LBP gt 1wk
• Unrelieved by analgesics/activity modification
• () SLR indicating space occupying lesion
• Signs of possible nerve root compression
• Motor weakness
• Sensory changes

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Choice of Imaging Modality

• X-Rays Screening tool to detect abnormalities of
  bone
• i.e abnormalities of the spine, fx/dislocation,
  ankylosing spondylitis, RA, OA, tumors,
  osteoporosis, Pagets disease
• Discs not visualized on X-Ray but DDD is
  suspected whenever there is IV disc space
  narrowing
• Most cost effect modality for spinal imaging
• MRI used to delineate abnormalities
• Superior visualization of soft tissue and bone
  marrow
• Sagittal view best to delineate herniation of
  nucleus pulposus through annulus fibrosis
• Transverse images best to define compression of
  thecal sac and nerve root
• Costs approximately 2x as much as CT imaging

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Choice of Imaging Modality

• Myelography requires injection of radio-opaque
  dye in subarachnoid space via lumbar puncture
• Offers good visualization of nerve roots
• Excellent for diagnosing diseases of spinal cord
  and canal
• HNP seen as a defect in the normal filling of the
  dye
• Formerly gold standard for spinal cord
  radiography
• Falling out of favor as it is more invasive and
  less accurate than MRI or CT
• CT Scan best modality for looking at bone
• Delineates anatomy and pathology better than
  myelography
• Used to diagnose occult spinal fx, determine the
  extent of fx and localize vertebral fx fragments,
  especially those displaced into spinal canal
• Can determine presence of intervertebral disc
  disease

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Narrowing in on Mr. F

• Signs and symptoms pointing to suspected nerve
  root compression
• Standard AP and lat radiographs inexpensive
  screening tool to rule out tumor/fx fragment as
  sources of compression
• X-Rays also revealed presence of osteophytes and
  disc space narrowing
• MRI best option for visualizing soft tissue
  (nerve roots, IV discs) leading to our ultimate
  dx of multiple level HNP and nerve root
  impingement

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Implications to PT Plan of Care

• MRI results coupled with neurosurgery consult
  identified patient as potential surgical
  candidate
• Discussion with pt and surgeon revealed
  willingness to explore conservative PT while
  surgical work-up in progress
• PT focus on
• Restoring functional mobility
• Relief of nerve root compression through
  stretching, positional distraction and manual
  techniques
• Instruction in self-management of pain and HEP

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Patient Outcomes

• Patient D/Cd from Hospital X on 1/27 with
• Neurosurgery follow-up appt
• Recommendation for outpatient PT pending outcome
  of neurosurgery appt
• Patient lost to follow-up as he normally receives
  care at Hospital Y, which is closer to his home
• Patients neurosurgeon operates out of both
  Hospital X and Hospital Y.
• Pt has not yet appeared on OR list for Hospital X
  to date.

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Questions?
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References(for facts and figures)

• Erkonen WE, Smith WL, eds. Radiology 101 The
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• Gillard DM. How To Read Your MRI or CT. 2002.
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  5 April 2005.
• Jensen MC, Brant-Zawadski MN, Obuchowski N, Modic
  MT, Malkasian D, Ross JS. Magnetic resonance
  imaging of the lumbar spine in people without
  back pain. New England Journal of Medicine, 1994,
  33169-73.
• Kraus G. Radiology of low back pain. 2005.
  http//www.lowbackpain.com/radiology.htm. 5
  April 2005.
• Miller JC. When is Imaging Helpful for Patients
  with Back Pain? MGH Radiology Rounds serial
  online January 2004 Volume 2, Issue 1.
• Palmer, W. Spine Imaging Modality Approach
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  course)
• Pfirrmann, CW, Resnick, D. Schmorl Nodes of the
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  and Correlation with Degenerative changes of
  1,650 Spinal Levels in 100 Cadavers. Radiology.
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• Richardson, ML. Radiographic Anatomy of the
  Skeleton- Lumbar Spine. 1997. http//www.rad.washi
  ngton.edu/RadAnat/Lspine.html. 5 April 2005.