Imaging degenerative disk Imaging degenerative disk
disease in the lumbar disease in the lumbar
spinespine
Elaine Besancon MS III
Dr. Gillian Lieberman
Learning ObjectivesLearning Objectives
Anatomy reviewAnatomy review
Pathophysiology of degenerative disc Pathophysiology of degenerative disc
diseasedisease
Common Common sequelaesequelae of disk diseaseof disk disease
–– HerniationHerniation
–– StenosisStenosis
–– InstabilityInstability
Imaging modalitiesImaging modalities
Clinical OutcomesClinical Outcomes
Anatomy of the three Anatomy of the three
joint complexjoint complex
Degenerative disk disease is a poorly defined term.Degenerative disk disease is a poorly defined term.
Often misused, but generally agreed to refer to pathology associOften misused, but generally agreed to refer to pathology associated with ated with
repetitive traumatic injury to the repetitive traumatic injury to the ““threethree--jointjoint--complexcomplex”” of the spineof the spine
EndplateEndplate--discdisc--endplateendplate
2 facet joints2 facet joints
Image courtesy of Dr. Rafael Rojas
Anatomy of the three Anatomy of the three
joint complexjoint complex
Degenerative disk disease is a poorly defined term.Degenerative disk disease is a poorly defined term.
Often misused, but generally agreed to refer to pathology associOften misused, but generally agreed to refer to pathology associated with ated with
repetitive traumatic injury to the repetitive traumatic injury to the ““threethree--jointjoint--complexcomplex”” of the spineof the spine
EndplateEndplate--discdisc--endplateendplate
2 facet joints2 facet joints
Image courtesy of Dr. Rafael Rojas
Pathophysiology of disk Pathophysiology of disk
injuryinjury
Failure of disks most Failure of disks most
common in regions with common in regions with
highest mechanical stress, highest mechanical stress,
especially lower lumbar especially lower lumbar
region.region.
Disc nutrition dependent on Disc nutrition dependent on
diffusion from marrow of diffusion from marrow of
bone or from blood vessels bone or from blood vessels
through annulusthrough annulus
Whether primary pathology Whether primary pathology
is usually metabolic or is usually metabolic or
mechanical is not known.mechanical is not known.
Image courtesy of Dr. Rafael Rojas
Pathophysiology of disk Pathophysiology of disk
injury continuedinjury continued
•Deformation of endplate and loss
of water in the nucleus can lead to
abnormal forces on annulus
•Small contribution from various
environmental factors like
exercise, trauma.
•Twin studies suggest large role
for genetic predisposition.
•Collagen
•Cytokines (IL-2)
Image courtesy of Dr. Rafael Rojas
Common featuresCommon features
Common Common sequelaesequelae of disk disease of disk disease
–– HerniationHerniation
–– StenosisStenosis
–– InstabilityInstability
Common featuresCommon features
Common Common sequelaesequelae of disk disease of disk disease
–– HerniationHerniation
–– StenosisStenosis
–– InstabilityInstability
Index Patient: Low back Index Patient: Low back
painpain
49 year-old woman presents for
evaluation of low back pain that radiates
down to her lower legs.
Do you image her?
When to image for low When to image for low
back painback pain
85% of people with LBP are never given a precise 85% of people with LBP are never given a precise pathoanatomicalpathoanatomical diagnosis, diagnosis,
even with imagingeven with imaging
Imaging findings and symptoms do not correlate precisely Imaging findings and symptoms do not correlate precisely
Indications of a more complicated status, often termed "red flagIndications of a more complicated status, often termed "red flags," include s," include
the following:the following:
–– Recent significant trauma, or milder trauma, age >50 Recent significant trauma, or milder trauma, age >50
–– Unexplained weight loss Unexplained weight loss
–– Unexplained fever Unexplained fever
–– ImmunosuppressionImmunosuppression
–– History of cancer History of cancer
–– Intravenous (IV) drug use Intravenous (IV) drug use
–– Prolonged use of corticosteroids, osteoporosis Prolonged use of corticosteroids, osteoporosis
–– Age >70 Age >70
–– Focal neurologic deficit with progressive or disabling symptoms Focal neurologic deficit with progressive or disabling symptoms
–– Duration longer than 6 weeksDuration longer than 6 weeks
Index Patient: Persistent Index Patient: Persistent
low back painlow back pain
49 year-old woman presents for
evaluation of low back pain that radiates
down to her lower legs.
Do you image her?
Initially, no.
However, she returns with
continuing pain after 6 weeks.
Imaging ModalitiesImaging Modalities
Plain filmPlain film
MRI MRI
– Most accurate modality for assessing
intervertebral disk disease.
CTCT
–– CT CT myelogrammyelogram
Imaging Modalities: Plain Imaging Modalities: Plain
FilmFilm
Plain filmPlain film
–– ProsPros
FastFast
Low CostLow Cost
Good for bony abnormalitiesGood for bony abnormalities
–– ConsCons
Poor visualization of disksPoor visualization of disks
Radiation exposureRadiation exposure
Most abnormalities seen on xMost abnormalities seen on x--ray can be better ray can be better
characterized on CT or MRI.characterized on CT or MRI.
Imaging Modalities: MRIImaging Modalities: MRI
MRI MRI
–– Pros:Pros:
Most accurate modality for assessing intervertebral disk
disease.
Excellent for soft tissue abnormalities
No radiation exposure
– Cons
Less useful for bony abnormalities
Higher costHigher cost
Contraindicated in patients with ferromagnetic objects in Contraindicated in patients with ferromagnetic objects in
their bodies, or patients with implanted electronic devices. their bodies, or patients with implanted electronic devices.
Claustrophobia or inability to hold still for long periods of Claustrophobia or inability to hold still for long periods of
time may prevent patients from completing the MRI.time may prevent patients from completing the MRI.
Imaging Modalities: CTImaging Modalities: CT
CTCT
–– Only indicated for imaging of disk disease in patients who Only indicated for imaging of disk disease in patients who
have contraindications to MRI.have contraindications to MRI.
–– Pros:Pros:
Faster than MRIFaster than MRI
Good for abnormalities of bony cortexGood for abnormalities of bony cortex
–– ConsCons
Radiation exposureRadiation exposure
Poor soft tissue differentiationPoor soft tissue differentiation
–– CT CT myelogrammyelogram
CT plus injection of CT plus injection of intrathecalintrathecal contrastcontrast
Pros:Pros:
–– Much better imaging of disk pathologyMuch better imaging of disk pathology
Cons:Cons:
–– InvasiveInvasive
–– Many contraindications, including all contraindications for lumbMany contraindications, including all contraindications for lumbar ar
puncture and those for IV contrast.puncture and those for IV contrast.
Index Patient: Disk Index Patient: Disk
HerniationHerniation on MRIon MRI
49 year-old woman presents for
evaluation of low back pain that radiates
down to her lower legs.
Disc bulges seen at all lumbar levels.
Classic history is pain that
increases with flexion.
Pain with straight leg raise seen on
exam.
Index Patient MRI and Index Patient MRI and
Normal ComparisonNormal Comparison
Index Patient: Index Patient: OsteophytesOsteophytes
and Marrow Changes on and Marrow Changes on
MRIMRI
Companion Patient: Companion Patient:
Annular Tear on MRIAnnular Tear on MRI
35 yo male with history of LBP and R
sided radiculopathy and groin pain.
Image courtesy of Dr. Rafael Rojas
Radial annular tear seen as hyperintensity
at L5/S1
Companion Patient: Disk Companion Patient: Disk
Disease on Plain FilmDisease on Plain Film
76-year-old female with a
longstanding history of low back
pain, and a more recent history of
radiating left leg pain provoked by
walking.
•Note signs of disk
disease:
•Decreased
intervertebral
height
•Endplate
sclerosis
•Osteophyte
formation
Common featuresCommon features
Common Common sequelaesequelae of disk disease of disk disease
–– HerniationHerniation
–– StenosisStenosis
–– InstabilityInstability
Index Patient: Spinal Index Patient: Spinal
stenosisstenosis on MRIon MRI
•Constriction of canal and
foramina commonly caused by:
•Anteriorly
•herniated disks
•Posteriorly
•enlarged ligamentum
flavum
•Facet hypertrophy
•Symptoms improve with flexion
and worsen with activity
(“neurogenic claudication”).
Spinal stenosis:
Index Patient: Spinal Index Patient: Spinal stenosisstenosis
on MRI with normal on MRI with normal
comparisoncomparison
Common featuresCommon features
Common Common sequelaesequelae of disk disease of disk disease
–– HerniationHerniation
–– StenosisStenosis
–– InstabilityInstability
Companion Patient: Companion Patient:
spondylolysisspondylolysis on plain filmon plain film
Companion Patient: the Scotty Companion Patient: the Scotty
dog sign on plain filmdog sign on plain film
Companion Patient: Companion Patient:
SpondylolisthesisSpondylolisthesis on Plain Filmon Plain Film
•• SubtypesSubtypes
•• DegenerativeDegenerative
•• SubluxationSubluxation at facet at facet
jointsjoints
•• Normal or narrow Normal or narrow
canalcanal
•• IsthmicIsthmic
•• Due to Due to spondylolysisspondylolysis
(seen in (seen in
6% of adults6% of adults
•• Widened canalWidened canal
Companion Patient: Companion Patient:
SpondylolisthesisSpondylolisthesis on CTon CT
Reasons to order CT:Reasons to order CT:
–– Better for bony cortexBetter for bony cortex
–– OsteophytesOsteophytes
–– TraumaTrauma
–– MRI contraindicationsMRI contraindications
68 year old man with LBP after a fall
Anterior displacement of L5 on S1
Index Patient: Instability on Index Patient: Instability on
plain filmplain film
•Leftward listhesis
•Disk space narrowing
•Due to ligament
laxity and
degenerative joint
disease
Clinical OutcomesClinical Outcomes
So you see degenerative disk disease on imagingSo you see degenerative disk disease on imaging……now now
what?what?
–– Studies have found 25Studies have found 25--64% of asymptomatic patients 64% of asymptomatic patients
have disk have disk herniationsherniations
–– 2/3 of patients with symptomatic disc 2/3 of patients with symptomatic disc herniationherniation have have
significant resolution of symptoms at 6 months.significant resolution of symptoms at 6 months.
–– Radiologic findings do not correlate well with surgical Radiologic findings do not correlate well with surgical
outcomesoutcomes
–– Surgery may be useful in symptomatic patients with Surgery may be useful in symptomatic patients with
signs of nerve root compression or severe canal signs of nerve root compression or severe canal
narrowing if conservative therapy has failednarrowing if conservative therapy has failed
Take Home PointsTake Home Points
Imaging not indicated for LBP unless more than 6 weeks have Imaging not indicated for LBP unless more than 6 weeks have
past or a past or a red flagred flag is present in the historyis present in the history
Imaging of choice for DDD is Imaging of choice for DDD is nonnon--contrast MRIcontrast MRI
Common complications of DDD include disk Common complications of DDD include disk herniationherniation, spinal , spinal
stenosisstenosis, and joint instability, and joint instability
Imaging findings do Imaging findings do notnot correlate well with symptom severity correlate well with symptom severity
or surgical outcomeor surgical outcome
In the majority of cases, conservative management will lead to In the majority of cases, conservative management will lead to
significant resolution of symptomssignificant resolution of symptoms
ReferencesReferences
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AcknowledgmentsAcknowledgments
Dr. Gillian LiebermanDr. Gillian Lieberman
Maria Maria LevantakisLevantakis
Dr. Rafael RojasDr. Rafael Rojas
Dr. Jay Dr. Jay PahadePahade
Imaging degenerative disk disease in the lumbar spine
Learning Objectives
Anatomy of the three joint complex
Anatomy of the three joint complex
Pathophysiology of disk injury
Pathophysiology of disk injury continued
Common features
Common features
Index Patient: Low back pain
When to image for low back pain
Index Patient: Persistent low back pain
Imaging Modalities
Imaging Modalities: Plain Film
Imaging Modalities: MRI
Imaging Modalities: CT
Index Patient: Disk Herniation on MRI
Index Patient MRI and Normal Comparison
Index Patient: Osteophytes and Marrow Changes on MRI
Companion Patient: Annular Tear on MRI
Companion Patient: Disk Disease on Plain Film
Common features
Index Patient: Spinal stenosis on MRI
Index Patient: Spinal stenosis on MRI with normal comparison
Common features
Companion Patient: spondylolysis on plain film
Companion Patient: the Scotty dog sign on plain film
Companion Patient: Spondylolisthesis on Plain Film
Companion Patient: Spondylolisthesis on CT
Index Patient: Instability on plain film
Clinical Outcomes
Take Home Points
References
Acknowledgments