anne daly - health.vic - home€¦ · ppt file · web view · 2017-03-27mri features of disc...
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Neurosurgery Case Presentation
Uyen Phan Musculoskeletal Physiotherapy Stream Leader Melbourne Health
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43M presents to Neurosurgery clinic• Referred from ED 4 months ago.
“Low back pain, shooting, L4/5 compression, CT done in the community report summary in the notes.”
Timeframe: Urgent 1-8 weeks.
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ED Discharge Summary• LBP 3-4 months ago, treated in community with analgesia• CT showing:
- Degenerative disc changes L3/4, L4/5, L5/S1.- L3/4 disc bulge causing moderately severe spinal canal stenosis- L4/5 right foraminal disc bulge likely compressing right emerging nerve root.
• No red flags• Examination unremarkable• SLR 40-50° on the right side• Normal sensation, power, gait• Advised weight reduction• Analgesia• OP neurosurgery follow up
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S/EHOPC• 12 months gradual onset of LBP, right groin and right anterolateral
thigh pain to knee.• Past 6 months bilateral anterolateral thigh pain, rarely past knee,
not into feet. • No P&N, N, B & B, saddle paraesthesia, ataxia
Agg• Walking (10’), standing (<60’), bending, stairs
24/24• No significant night pain. Both legs stiff in morning 60’
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S/EGeneral Health• NIDDM• Hypertension• Hyperlipidaemia• High BMI (47)• No red flags
Medications• Metformin Hydrochloride• Telmisartan and Amlodipine• Proxen• Endep• Lipitor
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Management to date• Seen private Neurologist• Lx MRI
L3/4 posterior disc bulgeL4/5 posterior disc bulgeL5/S1 posterior disc bulge containing annular tear centrally
• Dx: L3/4 right discogenic sciatica
• MedicationsPrednisolone 5mg 2/52ProxenEndep
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Differential Diagnosis• LBP and right L3/4 radiculopathy• LBP and L3/4 central canal stenosis• LBP and L3/4 bilateral foraminal stenosis• LBP and peripheral neuropathy • LBP and bilateral meralgia paraesthetica• Hip referral • Inflammatory arthropathy?• Infective?• Vascular?• Metabolic?
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O/E• Obs: Obese• Gait: Antalgic • Lx AROM: Mild stiffness reproducing LBP• Sensation: NAD• Strength: NAD• Reflexes: NAD• Tone, clonus, plantar reflex: NAD• SLR R = 50° groin pain, L = 60°• Palpation: Nil significant tenderness lumbar, groin• Vascular Ax: Good pulses in lower limb
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Differential Diagnosis• LBP and right L3/4 radiculopathy• LBP and L3/4 central canal stenosis• LBP and L3/4 bilateral foraminal stenosis• LBP and peripheral neuropathy • LBP and bilateral meralgia paraesthetica• Hip referral • Inflammatory arthropathy?• Infective?• Vascular?• Metabolic?
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Indications for Imaging (ACP)• Immediate imaging in patients with acute LBP who have high risk
factors for cancer, spinal infection, cauda equina syndrome, severe/progressive neurological deficits
• Imaging after a trial of therapy in patients with minor risk factors for cancer, inflammatory back disease, vertebral compression fracture, S & S of radiculopathy, symptoms of symptomatic spinal stenosis
• Repeated imaging only recommended in patients with new or changed low back symptoms
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Imaging OptionsX-rays• Cheap, quick, accessible• Radiation• Poor sensitivity
CT• Cheapish, quick, accessible• Radiation• Poor evaluation of disc, cord, nerve roots, soft tissue tumours
MRI• Expensive, long, less accessible, contraindications• No radiation• Evaluates all elements – marrow, joints, disc, cord, nerve roots
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Disc Definitions• Bulge: >50% circumference• Protrusion: Focal <25% circumference
Broad based 25-50%• Extrusion: Herniated disc material
diameter > annulus defect• Migration: Movement of extruded disc
away from disc level• Sequestration: Migrated fragment is
separated from main disc• Annular tear: Focal defect in annulus
containing nucleus pulposis
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Disc Lesions
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Disc Extrusion
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Jensen et al 1994• 98 asymptomatic subjects (50M, 48F, 20-80 yrs, mean 42 yrs)• 2 independent blinded neuroradiologists• MRI defined as normal, bulge, protrusion, extrusion• 36% had normal disc at all levels• 52% had bulge at at least 1 level• 27% had a protrusion• 1% had extrusion• 38% had abnormality of more than 1 disc• 14% had annular tear• 8% had facet arthropathy• Prevalence of bulges (but not protrusions) increased with age• Findings similar in women and men.
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Boos et al 1995• 46 symptomatic subjects with moderate LBP/sciatica vs. 46
asymptomatic matched controls (age, sex, occupational risk factors)• 2 independent blinded neuroradiologist• MRI defined as disc herniation (normal, bulge, protrusion, extrusion,
sequestration), disc degeneration, neural compromise• Disc herniation had a substantially high prevalence (76%) in
asymptomatic subjects (96% symptomatic)• Individuals with minor disc herniations are at a very high risk that
their magnetic resonance images are not a causal explanation of pain because a high rate of asymptomatic subjects (63%) had comparable morphologic findings
• The only highly significant difference between the study group and the control group regarding morphologic findings was the criteria of a nerve root compromise.
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Cheung et al 2009• 1043 Chinese volunteer subjects aged 18-55 • Reason for volunteering not made clear. • Questionnaire on back pain (>2/52), questionnaire on lifestyle, MRI• MRI features of disc degeneration, disc herniation, annular tears,
Schmorl’s nodes
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Cheung et al 2009
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Cheung et al 2009• LDD was common occurring in 40% of subjects under 30 years of
age, with prevalence increasing up to 90% at the age of 50-55 years.
• Age is related but not the only factor• Disc degeneration is relevant to LBP. A significant association
between LDD and symptoms was observed.• The more severe the degeneration and the more levels involved
increased likelihood of pain
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O/E continued• Hip Flexion = 80° bilaterally, pain• Hip Abduction = 10° bilaterally• Hip ER = 20° bilaterally• Hip IR = 0° bilaterally, pain
• Knee ROM full pain free range bilaterally
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• No history of hip injury, trauma, pain• Oxford Hip Score 15/48 (severe)• Already tried weight loss (dietician x 3)• Difficulty with exercise/walking• Greatly impacting on QOL• Referred to Orthopaedic surgeon• On wait list of THR
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Reflection• Beware of confirmation bias• Match radiology findings to clinical findings• Importance of thorough, systematic assessment• Used case to advocate AMP role