Gary Rea MD PhD Gary Rea MD PhD Medical Director Medical Director - - PowerPoint PPT Presentation

Gary Rea MD PhD Gary Rea MD PhD Medical Director Medical Director OSU Comprehensive Spine Center OSU Comprehensive Spine Center

1.

• 1. What should I order?

What should I order? 2.

• 2. When should I order it?

When should I order it? 3.

• 3. What in the hell is the radiologist saying and is

What in the hell is the radiologist saying and is any of it important? any of it important?

• 1. Few reasons to get x
• 1. Few reasons to get x-
• rays

rays -

• no reason to get before

no reason to get before 4 4-

• 6 weeks, unless looking for fracture

6 weeks, unless looking for fracture

• 2. MRI
• 2. MRI -
• best tool

best tool

• A. If progressive weakness, numbness, cauda
• A. If progressive weakness, numbness, cauda

equina concerns, pain not controlled with usual equina concerns, pain not controlled with usual methods methods

• B. If Red Flags
• B. If Red Flags
• C. I use often to rule out anatomic problem
• C. I use often to rule out anatomic problem

• D. Insurance companies want (sometimes)
• D. Insurance companies want (sometimes)

(1) 4 (1) 4-

• 6 weeks of activity alteration

6 weeks of activity alteration (2) PT, NSAIDs,and/or oral steroids (2) PT, NSAIDs,and/or oral steroids Positive SLR, numbness, weakness, Positive SLR, numbness, weakness,

• r reflex changes
• r reflex changes
• 3. CT
• 3. CT-
• virtually never necessary

virtually never necessary

• used to evaluate fractures, fusions

used to evaluate fractures, fusions

• do not order just because it is cheaper

do not order just because it is cheaper

• significant radiation

significant radiation

1.

• 1. Normal aging characteristics

Normal aging characteristics

• DDD

DDD -

• starts in teens, twenties, by 60s it

starts in teens, twenties, by 60s it is seen in 100% of x is seen in 100% of x-

• rays, mri scans

rays, mri scans

• Stenosis

Stenosis -

• product of aging

product of aging-

• more than 8mm

more than 8mm is is usually assymptomatic usually assymptomatic

• Disc space narrowing

Disc space narrowing -

• no relationship to

no relationship to pain pain

• Bulging discs

Bulging discs-

• ”

”just like wrinkles on the face just like wrinkles on the face” ”

• 2. What I tend to ignore on the report
• 2. What I tend to ignore on the report-
• hemangiomas, disc degeneration, disc

hemangiomas, disc degeneration, disc

• collapse, disc bulging, foraminal stenosis,

collapse, disc bulging, foraminal stenosis,

• mild stenosis, stenosis of 9mm or more

mild stenosis, stenosis of 9mm or more

• 3. What I do not ignore on the report
• 3. What I do not ignore on the report-
• fractures, spondylolisthesis, stenosis <8mm,

fractures, spondylolisthesis, stenosis <8mm,

• disc herniations, disc fragments, discitis,

disc herniations, disc fragments, discitis,

• tumor

tumor

• Incidence of important radiographic findings on

Incidence of important radiographic findings on patients with LBP patients with LBP-

• fracture .7%,infection .4%,

fracture .7%,infection .4%, tumor .7%,stenosis 3%,symptomatic stenosis tumor .7%,stenosis 3%,symptomatic stenosis 3%,DDD 3%,DDD-

• 90% in patients >65

90% in patients >65

• Multiple studies

Multiple studies-

• poor correlation between back

poor correlation between back pain and MRI findings pain and MRI findings

• 32% assymptomatic patients have abnormal MRI

32% assymptomatic patients have abnormal MRI

• 47% LBP patients have normal MRI

47% LBP patients have normal MRI

• 45 year old female with

45 year old female with long history of low back long history of low back pain. pain.

• Long history of

Long history of

• xycontin use 240mg
• xycontin use 240mg

per day per day

• Significant tenderness,

Significant tenderness, multiple positive multiple positive Waddell Waddell’ ’s signs s signs

Electrodiagnosis in Spinal Disorders

• Dr. Fran Pulver

Why obtain EDX testing in patients with spinal disorders?

• To establish and/or confirm diagnosis
• Radiculopathy vs. entrapment neuropathy vs.

polyneuropathy

• Localize a lesion
• Nerve root vs. plexus vs. peripheral nerve
• To correlate findings noted on physical exam

and imaging studies

• To determine extent, severity, and/or chronicity
• f a nerve injury

What are the limitations of EDX in patients with spinal disorders

• During the first 2-4 weeks after the onset of symptoms,

EDX findings may be difficult to detect

• Needle EMG detects motor axon loss and does not

detect sensory axon loss or demyelination

• Can be technically difficult in patients who are morbidly
• bese or with significant lower limb edema
• Poor patient tolerance

Other patient considerations

• EDX can be performed in patients on

anticoagulants or have pacemaker/defibrillator

• If patient has a stimulator, this needs to be

turned off for the test and can be turned back on after test is completed

• Some patients may have some mild discomfort

after the testing.