3/3/2017

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William Hsu BSc DC DACBR

March 4, 2017

T - Trauma

R – Range of motion

A – Alcohol/smoking

U – Unresponsive to care/unusual natural history/symptoms

M – Motor/sensory/reflexes

A - Age

49 year old woman with acute onset of low back

pain and left groin pain after pulling a 90lb cart

full of fish – work related injury.

Referred by her MD to A local chiropractor.

Courtesy of Dr. Philip Browne.

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Slight loss of lumbar range of motion.

Left SLR painful in the left groin and low back at

60 degrees.

Tenderness over the AIIS/ASIS.

Avulsion fracture of the AIIS or rectus femoris

strain on the left

Possible disc herniation in the lumbar spine with

referral pain.

Plain films of lumbar spine and pelvis

Ordered by the MD.

Not available at initial chiropractic consultation.

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Soft tissue therapy for lumbar spine and left

anterior thigh and gluteal muscles.

Obtain x-ray and report from the hospital.

Minor degenerative changes in the lumbar spine.

Patient’s low back and gluteal pain improved with soft tissue therapy for the first several days, but left groin pain increased – now patient requires a cane for ambulation.

Further physical examination reveal extremely tender left groin muscles and muscle wasting of the left thigh.

What would you do?

Ordered new film of the pelvis.

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June 19/06

An ill-defined large lytic lesion in the left ilium

with pathological fracture.

MD radiologist admitted missing the lesion on initial

pelvis on June 6/06.

Ordered bone scan

To see if this is a solitary or if there are multiple

lesions.

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CT Scan – Aug. 11/06

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A large ill-defined lytic lesion involving almost all the ilium Extending from AIIS to iliac fossa and posteriorly to the

iliac articular margin of the left upper sacroiliac joint.

Soft tissue extension

Atrophy of gluteus maximus

Differential diagnosis Lymphoma

Lytic metastasis (patient is a chronic smoker)

Solitary plasmacytoma

Likely a plasmacytoma due to the cold spot in the

left ilium, adjacent to the pathological fractures

(hot spots).

81 year old woman presented as a patient to CMCC clinic for her niece who is a chiropractic intern

She is a reluctant historian

has chronic LBP

has not seen a family physician for 60 years

Physical findings do not fit the history

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81 year old

Reluctant historian

No physical check up for 60 years

Physical examination does not fit the history

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A large ill-defined lytic lesion involving the left

lateral half of sacrum with destruction of the arcuate

lines at S1 and S2 and indistinct lateral border of the

sacrum

Differential diagnosis:

Lytic metastases

Plasmacytoma

Lymphoma

Chordoma

Referred to the emergency room

Physical examination

Inverted right nipple with shrunken right breast

Diagnosis

Breast cancer with bony metastasis to the sacrum

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Be wary of reluctant historian

Is he/she hiding something from you?

Look at the films.

Don’t be afraid to re-x-ray if the patient is not improving.

Expand your list of differential diagnosis.

You only make a diagnosis that you know.

Take a good history and physical examination.

It will guide you to the correct area to image.

Plain films are still very useful, but know its limitation.

34 year old male network administrator with one year of episodic pins and needles sensation in his lower back, buttocks and posterior thighs.

Competitive gymnast from age 14 to 21.

Retraining now.

MRI of the lumbar spine

One year ago

Submitted for second reading

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Proton density

Axial

T2 Axial

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Focal marrow edema at the anterosuperior corners

of T12 to L2 with suggestion of vertebral

squaring.

Marrow edema adjacent to the sacroiliac joints

with widening of joint space and blurring of iliac

margins; suggestion of ankylosis of the superior

sacroiliac joints.

No disc herniation

Sero-negative spondyloarthropathy such as

ankylosing spondylitis.

Recommend plain film for confirmation.

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In addition to pins and needles sensation, there

was stiffness and tightness of the lower back.

Onset at age 25, progressive.

Tunnel vision

MR will show more than discal problem

Marrow edema

Intraspinal mass

Plain films still should be the first imaging

modality

Cheap, easily accessible

Specific

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67 year old East Indian man presented to CMCC

clinic with 6 weeks of progressively worsening LBP

Past history

Long term diabetic

Kidney stones with subsequent bladder infection 7 weeks

ago; bedridden for 10 days

Seen MD 2.5 weeks ago; x-ray lumbar spine which was read

as normal

Progressively worsening LBP

Long term diabetic

Bladder infection 7 weeks ago; bedridden for 10

days

Films taken 2.5 weeks ago

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Mild disc space narrowing at L3-4

Did you see osteophytes?

Oblique views were available.

Endplate erosions at the superior endplate of L4

What is your diagnosis?

What would you do next?

1. Try to convince the MD radiologist that he has

missed the diagnosis?

2. Send the patient to the Emerg.?

3. Re-x-ray the patient?

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Films at CMCC clinic

Further narrowing of the L3-4 disc with bony

erosions of the adjacent endplates and

retrolisthesis

Diagnosis

Infectious spondylodiscitis at L3-4 (Salmonella)

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Be wary of disc narrowing without osteophytes!!!

Endplate erosion in infection may be very subtle.

Even the best radiologist has bad days!

Fever and chills not always present in spinal infection.

Elevated WBCs not always present (particularly with TB)

May be it is not a bad idea to re-x-ray your patient if the patient is not getting better.

45 year old business man with recent onset of

acute low back pain.

Can not recall any traumatic event; however, the

patient is an avid basketball player.

MRI of the lumbar spine

Courtesy of Dr. S. Injeyan

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Semi-circular hypointense T1 and hyperintense

T2 marrow signal at the upper 1/3 of the L2

vertebral body (Modic type I change).

This is accompanied by an oval depression at the

superior endplate of L2.

Recent traumatic Schmorl’s node at L2 superior

endplate.

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Symptomatic

Modic 1 changes

Hyperintense T2; Hypointense T1

Similar marrow change to acute compression fracture

Weaken endplate with trabecular microfractures

T1 WI

hypointense

T2 WI

hyperintense

New compression fractures

of T12, L1 and L2

54 year old woman with insidious onset of low

back pain over right sacroiliac joint and right

anterior thigh pain after left hip replacement 11

months ago for longstanding developmental hip

dysplasia.

Denies any low back pain prior to the surgery.

Courtesy of Dr. Johanna Carlo

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Films

5 months

ago

Severe disc narrowing with vertebral sclerosis at

L4-5.

= hemispheric spondylosclerosis (Modic III)

Spatulated transverse processes with accessory

articulation to sacral ala

= Lumbosacral transitional segment at L6.

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MRI of lumbar spine

5 months ago

Severe disc narrowing with diffuse annular disc bulge with foraminal encroachment at L4-5.

Hypointense T1 and T2 marrow change adjacent to L4-5 disc

= Modic type III change.

Hypointense T1 and hyperintense T2 marrow change in the vertebral bodies of L4 and 5 beyond the Modic type III change

= Modic type I change.

Hypermobile severe degenerative disc disease at

L4-5 with superimposed Modic type I and III

changes and foraminal stenosis.

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55 year old male with severe low back pain and

urinary retention and bowel motility dysfunction.

Courtesy of Dr. Scott MacNeil July 2007

Extreme pain over the sacrum/sacroiliac joints.

Painful gait due to low back pain.

Referred to hospital for plain films of the lumbar

spine.

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Loss of right 1st and 2nd sacral arcuate lines (upper

anterior sacral foraminal margins).

Lytic destruction of the anterior sacral cortex from

S1 to S3 with presacral soft tissue swelling.

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Aggressive lytic lesion of the sacrum with soft

tissue mass.

Differential diagnosis

Lytic metastasis.

Multiple myeloma.

Chordoma.

20 year old female professional wrestler with recurrent LBP for 2 years since a wrestling injury where she was pinned and heard a pop in her back.

Right worse than the left.

Seen PT, DC, sports medical doctor and acupuncturist with mixed results.

Two MRI studies – all read as normal.

Courtesy of Intern Abbott/Dr. Chris DeGraauw

April 3, 2013

Right side

7/10 – 10/10

Constant

Aggravated by lumbar ROM, esp. bending and twisting.

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Kidney stones, UTI, appendicitis

Nurse aid work.

MVA’s at age 5, 17, 18. No significant injury.

Past treatments

Physiotherapy – SMT, mobilization, traction

Sports MD – 2 MRI’s

Chiropractor – SMT 6-8x over 2 months

Acupuncturist – 2-3x

Initial injury

Nov. 2011

Increase pain by

Jan. 2012 due to

wrestling tours

Off work for 1

month due to lifting

injury May 2012

Trying to retrain Jan.

2013

CMCC clinic

March 22, 2013

1st

MRI study

March, 2012

2nd

MRI study

December, 2012

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Discogenic low back pain

Mechanical

Sacroiliac syndrome, facet syndrome, myofascial strain

Inflammatory spondyloarthropathy

Kidney stones

Pars fracture

Bilateral pes planus

L/S ROM – mild limitation due to muscle

tightness in all range; painful and limited

extension.

- ve nerve root tension sign; - ve Maigne

Normal neuro.

+ ve Right SI compression

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Hyperintense T2 and hypointense T1 signals in the right pedicle, transverse process and inferior articular process with an irregular gap in the right L5 pars interarticularis.

No compensatory hypertrophy of the left lamina and pars.

Associated with slightly atrophied multifidus muscle.

Normal disc hydration and height from L2 to S1.

The spinal canal and lateral recesses patent with no neural compression.

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Recent right L5 pars fracture with adjacent marrow edema and slight atrophy of adjacent multifidus muscle.

The follow-up MRI study dated December 22, 2012 shows fatty marrow conversion of the right L5 pedicle next to the pars defect. No stress hypertrophy of the left L5 pars/lamina is seen. No disc herniation is seen.

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Mar 5/12

Hyperintense T2

Hypointense T1

Dec 22/12

Hyperintense T2

Hyperintense T1

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April 24, 2013

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Case series 2005

13 young athletes less than 20 y.o. with unilateral

spondylolysis.

CT and MR studies.

Model study

Sairyo K, Katoh S, Sasa T, Yasyi N, Goel VK, Vadapalli S, Masuda A, Biyani A,

Ebraheim N. Athletes with Unilateral Spondylolysis are at Risk of Stress Fracture at

the Contralateral Pedicle and Pars interarticularis – A Clinical and Biomechanical

Study. Am J Sports Medicine. 2005;33, 583-590.

Early stage

No contralateral sclerotic change or stress fracture.

Progressive stage

One has contralateral pedicle stress fracture

One has stress fracture of contralateral pars.

Terminal stage

All 5 showed stress reaction of contralateral peidcle (1

stress fracture and 4 bone sclerosis.

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All 13 cases were treated with bracing corset for 3

– 6 months.

6 early, 2 progressive and 5 terminal stages.

7 showed bony fusion with or without surgery.

1 – bilateral terminal spondylolysis

5 – unilateral terminal spondylolysis

All 6 early stage patients formed bony union after

3-6 months bracing.

All 6 early stage patients formed bony union after

3-6 months bracing.

All 2 progressive stage patients, bracing did not

lead to bony fusion at the pars defects.

Results:

6 early, 2 progressive and 5 terminal stage defects.

3 (23.1%) showed contralateral stress fracture.

2 belonged to progressive and 1 to terminal stage

spondylolysis group.

4 of the 5 terminal stage group showed stress reactions,

such as sclerosis of the contralateral pedicle.

Model showed increase load to contralateral pars as

high as 12.6-fold compared to the intact spine.

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Subtle cortical thickening at the right L5 pars,

medially and dorsally with no overt lucency.

Healing pars fracture of right L5.

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23 year-old male with 10 years of low back pain after a fall.

Courtesy of Dr. Wiltshire

January 6, 2015

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A lumbosacral transitional segment is visualized at L5 with spatulated transverse processes.

A triangular bony fragment is observed at the posteroinferior corner of L4 vertebral body measuring 7mm x 5mm with a similarly sized bony defect at the vertebral corner.

It has displaced into the spinal canal.

Mild disc narrowing is noted at L4-5.

Minimal facet sclerosis is evident from L3 to L5.

A large type II old posterior limbus bone at L4 posteroinferior vertebral corner with likely central stenosis and mild degenerative disc disease.

Minimal facet arthrosis from L3 to L5.

Type IB lumbosacral transitional segment at L5.

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34 year-old male with chronic low back pain for 15 years.

Right side at L4-S1 mainly with occasional left SI joint.

Tight achy quadriceps occasionally.

Reduced right lateral flexion and forward flexion.

No specific injury.

Play cricket.

Smoker for 16 years.

Courtesy of Dr. Asgharifar

May 29, 2015

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Congenital block vertebra at L4-5 with a rudimentary disc and anterior wasp-waist deformity.

Sclerotic left L5 pedicle with vertebral rotation of L5.

6mm anterolisthesis at L5-S1.

A mild left lumbosacral scoliosis.

Mild disc narrowing with bone spurring at L3-4 and minimal at L5-S1.

Mild facet sclerosis with hypertrophy at L3-4 and L5-S1.

A congenital block vertebra at L4-5.

Mild degenerative disc disease at L3-4 and minimal at L5-S1.

Grade 1 isthmic spondylolisthesis at L5-S1 with sclerotic left L5 pedicle. This is most likely secondary to a pars defect at right L5. Differential diagnosis should include agenesis of the right L5 pedicle. Oblique views of the lumbar spine and an AP tilt-up sacroiliac joint view are recommended for confirmation.

Mild facet arthrosis at L3-4 and L5-S1.

35 year-old male with left low back pain and left calf (radiculopathy in the S1 and S2 distribution).

Courtesy of Dr. J. DeGraauw

January 23, 2015

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S2

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A large left paramedian disc extrusion at L5-S1 with inferior displacement, posterior displacement and compression of the left S1 and S2 nerve roots.

68 year-old male with low back pain.

Previous chiropractic care helped with his low back pain.

Not this time.

Courtesy of Dr. Charbonneau

December 17, 2015

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Indistinct cortical borders of right L3 and left L4 pedicles on the AP view.

10% anterolisthesis at L4-5 with intact pars.

Mild to moderate disc narrowing at L4-5; Anterior bone spurring from T9 to L1.

Facet sclerosis from L3 to S1.

Mild axial joint narrowing of the left hip.

Suggestion of lytic destruction of right L3 and left L4 pedicles. Differential diagnosis should include lytic metastasis and multiple myeloma.

Grade 1 degenerative spondylolisthesis with degenerative disc disease at L4-5.

Mild to moderate facet arthrosis from L3 to S1.

Mild DJD of the left hip joint.

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Patient’s symptoms worsened after SMT.

Check into hospital

Further imaging show lytic destruction of thoracic,

lumbar spine and pelvis with primary lesion in the chest

– bronchogenic carcinoma.

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72 year-old Korean woman with 3 weeks of acute low back pain after falling on her buttock while zip lining on a homemade zip line on a farm.

Courtesy of Intern Cruickshank/Dr. C. DeGraauw

August 7, 2015

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The bone density is moderately diminished.

Moderate anterolateral wedged deformity of L1 is visualized with near 50% loss of anterior height and right lateral height.

A band of condensed trabeculae is observed.

a 6.5mm anterolisthesis at L4-5.

Mild disc narrowing with bone spurring is noted from L1 to L5.

Mild facet sclerosis with hypertrophy is evident from L1 to S1.

Moderate osteopenia with recent moderate compression fracture of L1.

Mild degenerative disc disease from L1 to L5.

Mild facet arthrosis from L1 to S1.

Grade 1 degenerative spondylolisthesis at L4-5.

Mild degenerative joint disease of both sacroiliac joints.

Arteriosclerosis of abdominal aorta.

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42 year-old female with spina bifida occulta and low back pain.

Courtesy of Dr. Wiltshire

March 16, 2015

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Non-union of neural arches from L4 to whole sacrum.

Abrupt increased in the interpediculate distances from L2 to L3.

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Spina bifida occulta at L4 and L5 and large sacral hiatus.

Hint of intraspinal canal pathology with abrupt increased interpediculate distances from L2 to L3.

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Low lying conus medullaris at L3 inferior endplate.

Two asymmetric hemi-cord from L2-3 caudad to L3 inferior endplate within one thecal sac.

No midline fibrous or bony septum.

Cauda equina and filum terminale are in contact to the dorsal thecal sac from L4 to L5.

No thickening of filum terminale or lipoma.

No meningocele, sinus or lipoma.

Bony defects at the dorsal arches from L4 to S2.

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Type II split cord malformation with tethered cord and possible tethering arachnoid band to the dura.

Also known as diastematomyelia or

A rare spinal anomaly with a sagittal division of the spinal cord into 2 symmetrical or asymmetrical hemicords.

Occult spinal dysraphism.

Pang et al. classification

Type I

the hemicords are invested with individual dural sacs and the medial walls of the sacs always ensheath a rigid (bony or cartilaginous) midline spur.

Type II

Hemicords within a single dural sac and the midline septum is composed of nonrigid fibrous or fibrovascular tissues.

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Associated abnormalities

Soft tissues

Tethered cord (90%); lipomyelomeningocele, meningocele, occult intrasacral meningocele, filum terminale lipoma, lipoma, dermal sinus tract, dural ectasia, syringohydromyelia, teratoma, neurenteric cyst, dermoid cyst, epidermoid cyst, arteriovenous malformation, epidural venous angioma, and arachnoid cyst.

Bony anomalies

block vertebra, hypoplastic vertebra, kyphosis and fused ribs.

Pang D. Split cord malformation: Part II: Clinical syndrome.

Neurosurgery 1992; 31: 481-500.

Symptoms and Signs

Back pain and leg pain (59%)

Leg weakness and/or numbness (54%)

Scoliosis (45%)

Leg-length asymmetry

External manifestations

hypertrichosis, hemangioma, hyperpigmentation, and subcutaneous lipomas (45%)

Pang D, Dias MS, Ahab-Barmada M. Split cord malformation: Part I: A unified theory of

embryogenesis for double spinal cord malformation. Neurosurgery 1992; 31: 451-480.

Development of symptoms Most experience neurological deterioration during childhood

or adolescence.

Occasionally, sudden and catastrophic neurological deterioration was associated with normal sports activities or minor injuries.

Occasional normal child who reaches adulthood is at risk for deterioration in later years.

Childbirth may be associated with "precipitous" neurological decline as a result of normal obstetric positioning.

Hazard of neurological deterioration is significant and surgery should be considered prior to development of neurological deficits.

Kilickesmez O, Barut Y, Tasdemiroglu E. MRI features of adult tethered cord

syndrome. Tani Girisim Radyol 2003; 9: 295-301.

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Clinical study of 254 patients with SCM Skin stigmata found in 60%

Hypertrichosis (32%);

Asymmetrical lower-limb weakness (68%)

Sphincter disturbances (33%)

15% asymptomatic.

With surgery, 39% showed improvement in motor power, 57.9% experienced sensory improvement, and 27.3% regained continence.

Risk of injury to the hemicords is highest with type I SCM.

Risk of neurological deficits developing increases with age.

all patients with SCM should be surgically treated prophylactically even if they are asymptomatic.

Mahapatra AK, Gupta DK. Split cord malformations: a clinical study of 254 patients

and a proposal for a new clinical-imaging classification. J Neurosurg. 2005 Dec;103(6

Suppl):531-6.

11 year-old boy with 3 days of low back pain after being checked in a hockey game.

Unable to play further.

Courtesy of Dr. Ruttan

March 25, 2014

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A hazy zone of oblique lucency at the L5 pars interarticularis on the lateral view with a sclerotic left L5 pedicle.

Wilkinson’s syndrome at L5.

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2016

2014

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48 year-old female with severe tenderness in the lumbar spine after falling on her buttock.

X-ray at hospital and read as no compression fracture.

Chiropractor disagrees and needs confirmation from us.

Courtesy of Dr. Robert Rodine

November 24, 2014

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New compression fracture of L1 with anterior

wedged deformity with step defect and zone of

impacted trabeculae.

Moderate DDD from L2 to L4.

Chiropractors are MSK specialists.

Patients us for MSK issues.

We should able to question MSK diagnosis from

other healthcare practitioners, especially when the

patient’s symptoms do not fit the diagnosis.

Trust your instinct!