Are You Normal or if not

Are You Very Unusual?

Asymptomatic Scan Results, Pain Sources and Case Studies of Lumbar Spine, Cervical Spine,

Shoulders and Knees

Sean Dadswell

2015

Introduction

How do you justify to patients not to get investigations done?

Do you know what scans of normal patients look like?

Pressure on investigation budgets?

GP ordering scans prior to arriving in Physio.

Have you ever been guilty of changing your practice because of a scan result that doesn’t correlate with what you have found clinically?

If you don’t know what’s normal how can you know what is abnormal?

Personal experience of back pain and subsequent MRI results.

Aims Identify different

investigation results for the Lumbar Spine, Neck, Shoulders and Knee in Asymptomatic patients.

Give clinicians an appreciation of the prevalence of different changes in normal patients in relation to demographic characteristics and activity levels etc

Discuss research/experimental relating to sources of pain in all mentioned areas and the presentation of this pain.

Case Studies of things that are unusual (just to confuse things).

Based on 40+ Journal articles

Draw your own conclusion

Dispel some myths

Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain (Jensen et al 1994)

98 Pt’s no episode of back pain lasting >48 Hours and never had radicular symptoms.

50:48 male: female

Age 20-80 (Mean 42.8)

Recruited by flyer

27 symptomatic MRIs interspersed

Diagnosed as disc bulge, protrusion and extrusion

Results

Change Percentage of Asymptomatic Subjects

Normal all levels 38

Bulge at least 1 level 52

Protrusion 27

Extrusion 1

Abnormalities > 1 level 38

Schmorl’s Node 19

Annular Tear 14

Facet degeneration 8

Spondylosis 7

Stenosis (Central/Lateral) 7/7

Spondylolysthesis 7

Results cont

Most Abnormalities at L4/5 (30%) and L5/s1 (30%) Fewest L1/2 5% Prevalence of chages is significantly worse with age (P=

0.001) 67% of over 50’s had disc abnormalities at > 1 Level

compared to 27% under 50’s More Abnormalities in those who exercises than those

who are sedentary 16% compared to 4% (Small sample)

REMEMBER ALL COMPLETELY ASYMPTOMATIC

Conclusion: MRI results are COMPLETELY MEANINGLESS in isolation

Other Results of Note

Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations

(Brinjikji et al 2014)

Systematic review

33 Articles (1988-2014)

All subjects had never suffered any kind of back pain

No motor or neuro deficit, no trauma

Studies excluded if they did not specifically state pt’swere pain free

• With nearly 90% of 60+ year olds having disc degeneration and other changes then these could be considered age related changes rather than pathological changes

• As >50% of asymptomatic 30-39 year olds having disc degeneration then it may suggest that changes on MRI are incidental and not causative.

67 Pt Never suffered rom LBP or Sciatica (age 20-80)

Interpreted by 3 neurologist all blinded to Symptoms

Scans of Asymptomatic patients mixed with those of 33 symptomatic patients

Interestingly only 60% of scans had total agreement of all 3 neurologist but 99% had 2 or more (? Questions findings)

(Right: MRI 33 Year old man never had back pain)

Abnormal MRI Scans of the Lumbar Spine in Asymptomatic Subjects (Boden et al 1990)

Finding Age 20-39 40-59 60+

Herniated Disc 21% 22% 36%

Spinal Stenosis 1% 0% 21%

Results:

• Most disc herniations at L4/5 (35%) and L5/s1 (45%)

• In context: 1 in 4 normal patients will have abnormal MRI findings at any age!!!!

• Would you use a clinical test that was this inaccurate

• Author suggests to perform surgery based on an MRI alone would be a DISASTER!!!!!

75Year old man with bilat thigh pain for 3 years

Pain mainly getting up from chair

Severe loss PKB 90 degs bilat which progressed to 120 degs with stretching

Failed to progress pain so asked for MRI

ESP not seen many L2/3 disc bulge/stenosis so felt unlikelydiscussed with radiologist who suggested MRI

MRI showed L2/3 central stenosis

Asquier et al 1996 had only 100 pt to major hospital in france in 10 years with femoral neuralgia

Found L2/3 8%, L3/4 35% and L4/5 40%

Quick Case study to highlight higher Lsp involvement.

Loughnan et al 2002

Epidural analgesia and backache: An RCT comparison of IM Meperidine for analgesia during labour.

611 Mothers

310 received IM Meperidine

301 received epidural

Follow up at 6/12 with 85% follow up completed

Results:

Common Myth: I’ve had back pain since I had an epidural when I was pregnant!!

Epidural IM Meperidine

Any Back Pain 48% 50%

New Episode 29% 28%

Common Myth: Surgery doesn’t help Chronic LBP!!

Fritzell et al 2002

CLBP and Fusion: A Comparison of 3 Surgical Techniques: A Prospective Multicenter Randomised Study from The Swedish Lumbar Spine Study Group

Compared 3 progressively extensive spinal fusion techniques

294 Patients with at least 2 years therapy resistant LBP (Mean 8 Years pain)

All had L4/5 or L5/S1 spondylosis diagnosed on radiology

4 Groups (1 non surgical and 3 surgical all n=70-75)

Off work for mean of 3 years

Age 25-65

201 followed up for 6,12 and 24 Months

All treatment groups improved compared to control

P score reduced average 6.5 to 4.5/10 (P=0.0001)

Oswestry 47.5 to 36 (P=0.0001)

35% back to work across all treatment groups

60-68% reported “better” or “Much better” post Rx

In the 3 groups the complications increased from 6% to 31% with increased fixation.

Results

Congenital Vascular Malformations Present in 10% Autopsys and 14 % of over 60’s Only cause problem when they cause spinal cord

compression, hypertrophied bone, epidural hemorrhage or compression fracture.

Case 1: 54 year old progressive LL weakness over 1 year could ony

walk few steps with a walker +ve babinski Pain below mid chest CT showed T4 compression Rx Arterial Embolization (No Help) Scerlosing Ethanol 2 injections 10/52 apart Resolve symptoms in 6/12 back to work as ward sister

Common Abnormal Findings: Hemanginomas

Case 2:

64 Year old 3/12 HO Progressive LL weakness

Walking less than 6m

Weak prox leg muscles

MRI T12 compression

CT Hemanginoma

Same Rx of ethanol injections 10/52 apart

In 6 weeks walking 2 miles day

5/12 later MRI showed no compression

Biomechanics of back pain (Adams 2004)

Research well established re innervation of spine

Dorsal Rami of each spinal nerve divides into 3 and different parts supply Facets, interspinus ligs and muscles, skin, erector spinae and multifidus

End plates have spinal nerve so have potential to produce pain

Disc innervation (in health patients) is only in external few mm’s of nerve. Anybody know why?

Sources of Lumbar Spine Pain

Disc innervation controversial but possibly related to health discs having significant pressure through more central part of disc and less through outermost part.

Lack of hydrostatic pressure allows capillary formation which are required for neural infiltration.

Mechanism of pain from degenerative is that loss of structure reduces discs weight bearing properties and as pressure reduces more nerves can infiltrate discs (similar process to tendinopathy?)

Further evidence discussed that predisposition to back pain is genetic more than environmental based on twin studies

Mentions that 30% of chronic LBP comes from SI joint??? (Based on spurious claims and only related to pain below L5/S1)

Landmark paper in 80’s (would not be allowed now)

193 surgeries done with only local anesthetic then surgeon mechanically compressed various structures and pt described pain

All patients had been diagnosed with LBP with or with out leg pain due to disc bulge of stenosis

The Tissue Origin of Sciatic & Back Pain (Kuslich et Al 1991)

Structure Some pain Reproduced pain Site pain

Involved nerve 99% 90% Gluts leg foot

Normal nerve 11% 9% Gluts leg

Annulus of disc 73% 23% Back

Vert end plate 61% 9% Back

Facet 30% 3% Back

Normal Nerves generally no pain except sustained compression

Scar tissue from previous surgery usually asymptomatic unless compressing nerve

Annulus LBP side consistent and never gave leg pain although there was some buttock pain (1/3 v.tender, 1/3 tender, 1/3 no pain)

Facets took greater force to elicit any pain and always back pain (Remember sample)

Interesting findings from a study that wouldn’t get approved today!

120 Pts Chronic pain (>6/12) (Age 18-90)

No neural deficit

All failed conservative management

3 Stages to experiment

Evaluation of the Relative Contributions of Various Structures in Chronic LBP (Manchikanti et al 2001)

2 x Facet Injections

SI injectionProvocative Discography

Transforaminalinjection

Results: • 40% Facet joint pain• 26% Discogenic pain• 2% SI joint pain• 13% Nerve root

Bear in mind pt’s with LBP onlyDifficult thing to Ax but seem to have ried to limit flaws

500 pt’s age 18-90

P >6/12 (mean 83-106 months depending on area)

No radicular pain

Failed conservative management

Each had 2 injections of short and long lasting anaesthetic only +ve if both injections worked.

Results: (64-72% had bilateral involvement)

Prevalence of facet pain in Chronic Spinal Pain In Csp, Tsp and Lsp (Manchikanti et al, 2004)

Part of spine Facets Percentage

Cervical 140/212 55%

Thoracic 30/72 42%

Lumbar 124/397 31%

Case Study: Melanoma

67 Year old lady

HO 6/12 LBP followed by 2/12 of intermittent Claudication

Diagnosed as osteoporotic on X ray

Rx Meds and Physio => no Change

MRI = Epidural mass presumed to be hypertrophy of lig flavum

Even though pt had tumourremoved 13 years previous

Planned to fuse spine

Dark mass found during surgery found to be malignant melanoma

Bone scan revealed increase bone uptake L3 and SI Jt

Had radio and immunotherapy

All Clear 12/12 later

Apparently usual to miss these on MRI

497 Asymptomatic pt’s

Even spread 10 to >60

No Current or previous neck pain requiring medical intervention

Clear criteria for size and shape of abnormality

Results

MRI of Cervical Intervertebral Discs in Asymptomatic Subjects (Matsumoto et al 1998)

Abnomality 20’s 40’s >60

Disc Degeneration 15% 40% 87%

Post bulge 8% 18% 25%

Ant bulges 2% 8% 18%

Foraminal Stenosis 2% 5% 14%

50 Discs had posterior bulge with spinal cord compression mainly over 40’s

105 Asypt from 18-90

No previous neck pain

No Rheumatologic history

Not the best study in terms of report in but good images

Results

Evaluation of Age Related Changes in Cervical Spine in Saudi Arabian Adult Population: Using CT Scan Images (Hassan et al

2014)

18-35 years 36-55 56-90

Normal 20/35 3/35 1/35

Abnormal 15/35 32/35 34/35

63 Pts age 20-73

No Neck, shoulder or Radcular pain

37 Symptomatic scans interspersed

Multiple pothologies looked for (Spurs, < disc hieght, disc bulges, foraminal stenosis and cord impingement)

Catergories of mild/mod/severe and important/not important

Results:

Prevalence of cervical Spine MRI Pathology in AsymtpomaticIndividuals (Faubel 1990)

Abnormality <40 >40

Major Abnormality 14% 28%

Herniated disc 10% 5%

Foraminal Stenosis 4% 20%

Disc Degeneration 25% 57%

Cord Abnormalities 9% 1%

Highlights dangers of ordering surgery based solely on MRI

Longitudinal study (Although does not report difference in symptoms over time??)

Subjects 26 No Pain 40 sypmtoms of neck and/or sh pain for > 6 months

Age 17-19 then 24-26 Scanned 7 years apart

Not very high quality study but does highlight that changes on MRI are equally prevalent in young people when comparing symptomatic and asymptomatic subjects

MRI Changes of Cervical Spine in Asymptomatic and Symptomatic Young Adults (Siivola et al including Dr

Vanharanta 2002)

Change No Pain Pain

Disc Degeneration 11/15 9/16

Annular Tear 10 8

Disc Protrusion 13 11

Disc Herniation 0 4 (? Relevant)

No Findings 2 4

68 Consectutive patients

Chronic Pain >3/12 secondary toy RTA (54/12 mean)

Only 25% Normal Activity

34% off work because of pain

Given 3 injections one short lasting, one longer astinganasthetic and 1 placebo

Results:

Over 60% of Chronic neck pain could originate from facets

Most common levels C2/3 and 5/6

Sources of Neck PainChronic Cervical Zygapophyseal Joint Pain After Whiplash: Placebo

Controlled Prevalance Study (Lord et al 1996)

Type of pain +ve response -ve response

Headache 11 11

Neck pain 20 21

56 Pt’s Post Traumatic neck pain

Underwent provocative discography and facet joint blocks

Results:

Concludes that discography or Facet blocks not sufficient alone

Also discs and facets often pain generators following trauma

On The Nature of Neck Pain, Discography and Cervical Zygapophyseal Joint Blocks (Bogduk & Aprill 1993)

Structures involved Percentage

Disc alone 20%

Facet alone 23%

Disc and Facet 17%

No Segmental involvement 17%

170 pt’s (Although only 149 completed) with neck pain and/or radiculopathy

Age 15-83 (Mean 49)

No Duration of symptoms

Agreement between 3 radiologists

Results:

C4/5 level most commonly involved

TB Most Common Lsp

Cervical Spine MRI Findings in Patients Presenting with Neck Pain and Radiculopathy (Okedayo et al 2014)

Change Percentage

Normal 14%

Spondylosis alone 35%

Prolapse alone 10%

Spondylosis with Disc prolapse 33%

TB 3%

9 Health subjects

No previous neck pain

Electrical Stimulation of Medial Branch of Cervical posterior rami

Fluoroscopic guidance

Author appreciates that in chronic or severe neck pain referral patterns may vary due to central sensitisation/hypersensitivity

Electrcial Stimulation Induced Cervical Medial Branch Referral Patterns (Windor et al 2003)

2 Different studies referral patterns

51 Consecutively enrolled subjects

No Shoulder pain in each shoulder

Analyzed 3 Ultrasonographers

Age 40-70

96% Patients had an abnormality

Even when symptoms are present US results should be viewed with caution

Ultrasound of the Shoulder: Asymptomatic Findings in Men (Girish et al 2011)

Problem Percentage

Bursal Thickening 78

AC joint OA 65

Supraspinatus Tendinosis 39

Subscapularis Tendinosis 25

Partial Thickness tear 22

Labral Abnormalities 14

Calcification 4

Long Head Biceps prblem 4

96 Asymptomatic Shoulders

Exclusions no sh or neck pain or functional limitations

Age 19-88

Mixture of sedentary and active people in over 60’s Group

Abnormal Findings on MRI of Asymptomatic Shoulders (Sheret al 1995)

Problem Percentage

Any tear 34

Full thickness 15

Partial thickness 20

Over 60’s FTT 28

Over 60’s PTT 26

40-60 Any Tear 28

19-39 Any Tear 3

66% No tear

All problems increased with age

65% had evidence of AC joint OA

Other study cited reports that as long as Posterior cuff not damaged then it can still function

Chinese Study

644 out of 3117 members of the same village

Age 20-87 (Mean 69)

2:1 female to male

No one had ever had surgery

The Asymptomatic sh’s had never had sh pain

Symptomatic shoulders had pain at the time of the study

Prevalence of Symptomatic and Asymptomatic Rotator Cuff Tears in the General Population (Minagawa et al 2013)

Results:

In >50years old 50:50 ratio of Sympt: Asympt

In >60 years 2:1 Asymp: Sympt

Cuff tears significantly higher in manual laborers (38% forest workers)

Problem Total Symptomatic Asymptomatic

Full Thickness Tear 147 (22%) 35% 65%

Shoulder pain in 7-36% of general public 3rd most common MSK problem 94 Cases upper limb pain Exclusions of neck pain or previous multiple sh problems Diagnosis agreed on by 2 blinded Practitioners based on

tests including, apprehension, H&K, lift off Xrays, US Some patients had MRI and Arthroscopy Diagnostic injections were performed to confirm diagnosis

of AC jt pain, impingement and calcific tendinosis Pts were asked to map pain and rate intensity Young pt’s genereally diagnosed as instability (Mean age

34) Calcific tendinosis (Mean age 46 years) GH OA (Mean 69)

Sources of Pain in the ShoulderPain Mapping for Common Shoulder Disorders (Bayam et al

2011)

Severity pain worst in GH jt OA

Least variation in Ac jt distribution

Weak correlation between pain intensity and area

Interestingly no mention of frozen shoulder

Pain mapping in shoulder

Saline injections in to 15 health AC joints and 10 Subacromial spaces

AC joint Pain over joint, anterior lateral deltoid and supraspinatus

SA space Pain over lateral acromion, deltoid, forearm and fingers (Did not give any pain in neck or traps).

The Pattern of Pain by Irritation of the AC joint and the Subacromial Space (Gerber et al 1996)

Testing Scarf test whilst pain was present only increased pain in 13% of patients

Direct pressure to coracoid process reproduced AC jtpain in 87% of patients

Did not test after subacromial injection as movement seemed very limited so could not get to start positions

Systematic Review of 53 trials

Not limited to MSK but included trials Sh OA, Spinal surgery 6 studies, General OA 4 Studies, Plantar Callosities

Results:

72% of surgery resulted in improvements in both placebo and surgical groups

Only 49% of studies reported superior outcomes for Rx group

Rx effects were generally small

Use of Placebo Controls in Evaluation of Surgery (Wartolowska et al 2014)

5 Cases where shoulder joint malignancy diagnosis was delayed secondary being treated as frozen shoulder

Tumours are uncommon

Clinical history can be identical to frozen shoulder

Arthroscopic distention are strictly contraindicated with local oncological process is present

Can result in treatment being a limb preserving resection to a forequarter amputation

All 5 cases had prolonged conservative management and hydrodylation

2 had arthroscopic surgery

Lessons Learnt from the Painful Shoulder; Case series of Malignant Shoulder Girdle Tumours Misdiagnosed as Frozen

Shoulder (Quan et al 2005)

6 Year Old lady

18/12 HO worsening shoulder stiffness

Initially Rx with oral painkillers and steroid inj (No Help)

Then Hydrodylation (No improvement)

MRI showed large permeative tumour in scap

Case 1

42 Year old man

Sudden onset sh pain due to work

Originally diagnosed as Rot cuff tendinopathy and SAI

Had Physio and arthroscopic release (No Help)

2/12 later reduced ROM so hydrodylation (Worsened)

X ray Showed destructive lesion

Course of Chemo and en bloc resection

Case 2

50 Year old woman 6/12 HO episodic shoulder pain

Xray initially NAD

SAI injection

Arthroscopic distention

MUA

Arthroscopic debridment and acromioplasty

Lots of synovitis during arthroscopy which her symptoms were put down to

Xray 2 years after onset diagnosed large lesion in glenoid cartiledge

En bloc resection of tumour

Case 3

A initial X-ray B repeat X-ray

Other cases one initially responded to injection and distension but stiffness returned and ended up with palliative care

Last one had previous HO tumour, had arthroscopy and diagnosed rot cuff tendinopathy, repeat Xrayafter 1 year and showed destruction of glenoid and coracoid

10% of Xrays will be normal

2% of patients referred for MUA had chest wall tumours

Misdiagnosis has grave consequences

Should Xray be routine for frozen sh?

Further Ix if pain and restriction persist or are atypical

100 Pt’s age 18-73

45 Pts with traumatic HO pain

Ref by orthopadic surgeons, Rheumatologist, GP and general Surgery

Pt had Unilat knee pain and had never missed work or sport because of other knee

Results:

Patients with Suspected Meniscal Tears: Prevalance of Abnormalities Seen on MRI of 100 Symptomatic and 100

Contralateral Asymptomatic Knees (Zanetti 2003)

Type of Tear Symptomatic Asymptomatic

Any tear 57% 36%

Medial 50% 34%

Lateral 16% 8%

All patients with out meniscal tear on symptomatic side had normal Asymptomatic side

Prevalence of tears on Asymptomatic side in patients with symptoms was 63%

In this paper 57% clinically suspected Meniscal tears were confirmed on MRI

Very high prevalence in opposite knee

May be medial collateral more relevant and mimic meniscus

88% of those referred to the study were done so by Ortho Consultants

Problem Symptomatic Asymptomatic

Collat lig Abnormality 53% 6% (P=0.001)

Percapsular oedema 64% 12% (P=0.001)

Bone Marrow Oedema 36% 3% (P=0.001)

Necrosis or fracture 11% 0% (P0.001)

Pericapsular soft tissue abnormalities most common finding 62% (? Clinical relevant?)

Bone Oedema/Bruie very common 35%

14 NBA players (both knees)

Age 20-36

Include pt’s with previous knee injuries, 1 MCL tear and 1 meniscectomy

Results

25 knees (89%) had one or more abormalities

Only 3 knee no abnormalities

All players had something wrong with at least one knee

Jt effusion in30%

Patella tendinosis 40%

Not representative but highlights need to consider hobbies

Abnormal Findings on Knee MRI in Asymptomatic NBA Players (Walczak et al 2008)

220 knees with Asymptomatic OA

30 Bakers Cysts detected none of which were painful

The Reliability of Clinical Exam for Detecting Bakers Cysts in Asymptomatic Fossa (Akgul et al 2013)

320 Elite Athletes (Cricket, netball, basket ball and Australian rules) All Asymptomatic

27 non athletes (Controls)

Results:

22% athletes (Have Hydroechoic area) 4% Controls

30% Males 15% Females

32% Basketball Players 9% Other athletes

Patella Tendon ultrasound in Asymptomatic Active Athletes Reveals Hydroechoic Regions: A Study of 320 Tendons (Cook

et al 1998)

26 Basketball players (8 Male 18 Female)

2 Compatition days 1 year apart

All patients were asymptomatic at first competition

10 Pt’s had abnormalities at first competition

42 no abnormalities

Results:

3 of 10 (30%) subjects developed jumpers knee

3 of 42 (7%) controls developed jumpers knee

At follow up 1 year later 60% still had adnormalities

Prospective Imaging Study of Asymptomatic Patella Tendinopathy in Young Basketball Players (Cook et al 2000)

243 Subjects

90 Controls (No Knee pain No OA on Xray)

59 Knee pain

32 Asymptomatic but OA on Xray

62 Symptomatic OA confirmed on Xray

Results:

Sources of Knee PainSynovial Pathology Detected on Ultrasound Correlates With the Severity of Radiographic Knee OA More Than Symptoms

(Hall et al 2004)

Problem Controls Knee pain Asympt OA Sympt OA

Effusion 28% 19 81 92

Synovial hypertrophy

8 7 40 82

Bakers Cyst 12 9 21 39

Infrapat bursitis 0 6 0 8

Significantly higher effusion and synovitis in Symptomatic OA group compared to Asympt and controls

Pain correlated weakly but significantly with amount of synovitis

Synovitis not necessarily inflammatory but may give mechanical pain

401 patients with OA on Xray

351 with pain

50 with no pain

Mean age 67

Results:

Bone Marrow Lesions in 77.5% pts with pain compared 30% asymptomatic knees

Large lesions almost exclusively in painful knees (36%:2%)

However size of lesion does not correlate with severity pain

The Association of Bone Marrow Lesons with Pain in Knee OA (Felson et al 2001)

535 Pts (subset of larger study)

Sample 50-79

Mix of OA or at risk ie obese, previous knee pain etc

Only 454 included due to loss data

Found amount of synovitis strongly correlates with severity of pain measured with 2 different pain measures

Relation of Synovitis to Knee Pain Using Contrast Enhanced MRI (Baker et al 2010)

25 pts of 667 people with tumors referred to and ortho dept had previously been diagnosed with sports injuries

All had invasive procedures for intraarticularproblems

18 men 7 women

Age 15-55 (Mean 27)

21 Disagnosed as meniscus tear

1 ACL, 1 Patfem pain, 1 Synovial Cyst, 1 Synovitis

None MRI prior to surgery which would have diagnosed tumors

Tumors About the Knee Misdiagnosed as Athletic Injuries (Muscolo et al 2009)

Delayed diagnosis affected 6/11 pt’s with benign tumor as initially could have been treated with cureltage but had to be resected

9/14 malignant pts might have been treated differently as 8 could have been treated with intraarticular resection and 1 with extraarticularresection

Instead 3 had extra articular resection and 6 had amputation

Always consider clinical findings when evaluating scan results

Always consider that scan result findings may be incidental

Ensure you are aware of what are normal values/finding when ordering an investigation

Conclusions