Low back ache and disc disease

Q1. What are the available imaging procedure for low back ache? What is the utility of each of these procedures?

CT or MRI are typically ordered for patients with severe or prolonged pain, focal neuro deficits or history of cancer or febrile illness.

• MRI and CT scans are commonly used to identify an abnormality of the disc or bony spine.
  • MRI is more accurate and allows visualization of the spinal cord and nerve roots and comparison of nerve roots in the neural foramins.
• X-rays are widely available to rule out gross fractures or spinal instability.

Case 1:

22 y/o patient complains of one week of back pain. The pain started the day after he helped his friend move to a different apartment. It does not wake him from sleep, and is alleviated with NSAIDS. The pain is slowly improving, and he is able to go to work without significant discomfort.

• Q: What is your working diagnosis?
  • A: Muscle sprain
• Q: Does he need imaging studies?
  • A: No.

Case 2:

A 49 y/o female reports three weeks of lower back pain. The pain is not associated with any specific incident. The pain radiates into her left buttock and posterior thigh. There is mild weakness of left foot dorsiflexion and toe extension. The patient has a few fasciculations is her left dorsal foot. Pinprick sensation is decreased over his left dorsal foot. There is no Babinski sign. Her pain can be reproduced with passive flexion of the hip.

• Q: What is your working diagnosis?
  • A: L L5 radiculopathy, possible disc herniation
• Q: Which imaging procedure would you order?
  • A: MRI (lumbar)

Herniated Lumbar Disc A & B: Sagittal and axial MR images show a large herniation of intervertebral disc at L4-L5 with compressed thecal sac and nerve roots (black arrows). There is also a second herniation at L5-S1 seen on the sagittal image.	C: Another case showing a large herniated disc at L5-S1 with compression of thecal sac and nerve roots (black arrows).

Case 3:

• 70 y/o male who has been diagnosed with prostatic cancer, which has metastasized to his lymph nodes. For the last month he has had sharp, shooting pain in his lower chest and back which increases with coughing or straining. He is incontinent with normal strength.
• Q: What is your working diagnosis?
  • A: Metastasis to vertebrae, possibly compressing nerve roots.
• Q: Which imaging procedure would you order?
  • A: MRI (thoracic & lumbar) with and without contrast.

Sagittal T 1 wtd. MRI of the lumbar spine	Post contrast (C+) sagittal T 1 wtd. MRI	Sagittal T 2 wtd. MRI	Axial T 1 wtd. MRI (C+)
Bony Metastasis and metastasis to the Spinal Cord Findings: : Bony metastasis (yellow arrow in A, B, C) is seen involving the T 12 vertebral body. Intramedullary location of metastasis within the distal thoracic cord, is verified on post contrast sagittal image (red arrow in B) and axial image (red arrow in D). Edema (green arrow in C) within the thoracic cord is best shown on T 2 wtd. image C.

Case 4:

40 y/o male has 1 day of spastic weakness in his legs, and one episode of incontinence. His knee and ankle deep tendon reflexes are increased (3+) bilaterally, but 2+ elsewhere. The upper limbs are normal. Pinprick and temperature sensation are decreased below mid-torso.

• Q: What is your working diagnosis?
  • A: Thoracic myelopathy
• Q: Which imaging procedure would you order?
  • A: MRI (thoracic) with and without contrast

Post contrast (C+) sagittal T1 wtd. MRI	Sagittal T2 wtd. MRI of thoracic spine	Precontrast sagittal T1 wtd. MRI	Axial CT image of the thoracic spine
Classic example of calcified intradural meningioma Findings: : An intradural enhancing meningioma (arrow in A), the ventrally located tumor has produced cord compression and with displacement of the thoracic cord (red arrow in D) to the right side. Calcified nature of the tumor is identified on sagittal T 2 wtd. image as an area of dark signal intensity (yellow arrow in B) and confirmed by CT imaging (yellow arrow in D) as an area of high attenuation density.

Case 5:

82y/o thin female with back pain for several months. Her back pain began after a minor fall that she had several months ago. She stated that she just fell into a sitting position on her couch. Her neurological exam is normal.

• Q: What is your working diagnosis?
  • A: Osteoprosis with vertebral compression fractures
• Q: Which imaging procedure will you order?
  • A: Plain films

Osteoporosis Compression fracture of spine