Oh my aching back

1. Oh my aching back Application of diagnostic imaging studies to Physical Therapy in the acute care setting By: Nicole M. Boyko, MSPT

2. 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

3. Overview: Mr. F’s 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

4. 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

5. History & Physical Exam Cont’ • History of Present Illness: • 1/19: presented to Hospital Y with same complaints; received injection in ER and was D/C’d home with appt for ortho follow-up • 1/21:Had 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/C’d home on Skelaxin and Percocet with min relief. • 1/24: MRI as outpatient at Hospital Y. Results unavailable but pt reports “two herniated disks.”

6. History & Physical Exam Cont’ • Admitting MD’s 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

7. PT/OT Initial Examination 1/25 * X-Ray & MRI results not yet available at time of initial exam * • Subjective: “I can’t 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.

8. 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

9. 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

10. 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

11. 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

12. 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.

13. PT Goals x 3-4 days: (I) HEP (I) sup sit via logrolling (I) sit stand (I) amb > 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 Initial Therapy Goals

14. 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. Radiology Results Example of claw osteophyte (white arrows) Example of traction osteophyte (white arrow)

15. Radiology Results Cont’ Lateral View: Normal

16. Radiology Results Cont’ AP View: Normal

17. Radiology Results Cont’ Degenerative changes to the lumbar spine (lateral view)

18. 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

19. Radiology Results Cont’ Normal HNP L5-S1

20. Radiology Results Cont’ Axial View of a normal L4 disc Axial view of a 4mm L5 HNP

21. 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.

24. Rationale For Use of Imaging Studies for Mr. F • Incapacitating LBP > 1wk • Unrelieved by analgesics/activity modification • (+) SLR indicating space occupying lesion • Signs of possible nerve root compression • Motor weakness • Sensory changes

25. 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, Paget’s 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

26. 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

27. 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

28. 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

29. Patient Outcomes • Patient D/C’d 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 • Patient’s neurosurgeon operates out of both Hospital X and Hospital Y. • Pt has not yet appeared on OR list for Hospital X to date.

30. Questions?

31. References(for facts and figures) • Erkonen WE, Smith WL, eds. Radiology 101: The Basics and Fundamentals of Imaging. Philadelphia, PA: Lippincott-Raven, 1998. • Gillard DM. How To Read Your MRI or CT. 2002. http: www.chirogeek.com/003_CT-Axial_Tutorial.htm. 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, 331:69-73. • 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 Spectrum of Cases. MGH Dept of Radiology. [Prepared as PowerPoint presentation for this course) • Pfirrmann, CW, Resnick, D. Schmorl Nodes of the Thoracic and Lumbar Spine: Radiographic- Pathologic Study of Prevalence, Characterization and Correlation with Degenerative changes of 1,650 Spinal Levels in 100 Cadavers. Radiology. 2001, 219: 368-374. • Richardson, ML. Radiographic Anatomy of the Skeleton- Lumbar Spine. 1997. http://www.rad.washington.edu/RadAnat/Lspine.html. 5 April 2005.