Lumber Spine Disc Prolapsed in MRI - Annotated Bibliography Example

 Introduction: The spine has an important physiological role as a support for the body. As cited by Ballinger (1986, 286) it is known otherwise as the backbone or the vertebral column. It is made up of the vertebral bones together with discs formed from fibro cartilage. It is made up of five different sections – the cervical spine in the neck region, the thoracic spine which extends the length of the chest. This then continues down the lumber and sacral spine and ends with the bones of the coccyx. Within the lumbar spine are 5 vertebrae named as L1 (Lumber One) to L5 (Ballinger 1986, 268). The painful and incapacitating prolapse of a lumber spine disc or discs is one of the commonest problems which can affect the spinal column in humans. (Dhir 2007, 250). The main cause is poor posture and many people with this condition are older people. There are of course many other spinal conditions such as spinal injuries, tumours and innate abnormalities. Any or all of these will result in pain and possible incapacity. Many of these abnormalities are related to the particular area of the lumbar spine. Such people become hospital patients and need the best possible treatment that modern medical knowledge and technology can provide in order that they recover as quickly as possible ,and can return to their normal activities as soon as possible without adverse side effects. (Ballinger 1986, 268). In modern day medical practice in western style hospitals, three different methods of medical imaging are used. A patient who attends with a suspected lumbar spine disc prolapse will usually undergo CT scans or preferably MRI. (Fayad et al. 2009, 1) considered the latter to be the most useful method as it best exposes spinal lesions and so points to the most obvious reason for the symptoms experienced. (Kamath et al. 2008, 353). Lakshminarayanan (2009, 199) gives the example of a possible symptom as numbness and tingling sensations in the patient’s limb Magnetic Resonance Imaging or (MRI) is a modern medical imaging technique that has to a large extent superseded most other imaging modes in suspected cases of lumber disc prolapse. It is a safe method, as it does not expose either the patient or health workers to the possibility of harm from ionizing radiation as occurs with x-rays. Instead it is based upon the resonance or movement of hydrogen atoms. MR imaging uses a large magnetic field to produce an image for further analysis (Tamraz et al.2002, 1).The technology is based on helium and a coil system. It is capable of providing images of the body’s soft tissues with a high degree of accuracy with high resolution isotropic 3D-acquisitions (Sorantin 2008, 227).This means that MRI is the method of choice when it comes to the investigation of spinal disorders. The use of the method is on the increase and (Kamath et al. 2008, 353) has become the leader in the field. The method has a number of advantages including the important factor of a very high degree of diagnostic accuracy. (Fayad et al. 2008, 3).There has been a survey of 125 lumbar discs and in every case the results were found to be dependable. (Runge 1992, 150) cites it as the preferred imaging method in cases of lumber spine disease. (Weishaupt et al.2001, 424) point out how MRI imaging has proved to be both useful and accurate when it is necessary to show lumber disc displacement and when abnormalities and degeneration are suspected in the spine. CT scanning is a somewhat more invasive technique than MR imaging and creates more inconvenience for patients. With MRI the patient is simply escorted into the room where they then lie down on a comfortable padded couch which then slides into the scanner so that images can be formed. 1.2 Methodology: I was looking at how MRI technology is used as a diagnostic tool in diagnosing lumbar spine disc diseases. A bibliography was compiled on the subject of the significance MR imaging in the diagnosis of lumbar spine diseases. This was done by searching for relevant articles in electronic journal data base within Curtin University library and on some medical web sites as well as hard copy books and journals. I began my search on Lumber Spine Imaging. I also searched the World Wide Web for useful medical sites in order to find suitable articles. This gave me a wide range of studies to consider. I then skimmed through the result of this search and picked out articles which discussed LS disc imaging using MR imaging modality. After reading various abstracts I was able to determine the articles most relevant to my research. This were then summarized, critiqued and their potential significance noted. Bibliography Afzal S. and Akbar, S., Magnetic Resonance Imaging of Lumber Intervertebral Discs in Elderly Patients with Minor Trauma.,21st December 2007, European Journal of Radiology 70 (2009) 352–356 Article Summary The authors point out how common fractures of the vertebrae are after minor trauma in the elderly. They had reviewed MR images of 37 elderly patients aged over 65 who had had a single vertebral fracture (the fracture group), those with multiple fractures at various levels being excluded as were those with more than minor trauma. Another group (the stenosis group) consisted of patients who had no previous history of lumber fractures who had been diagnosed with lumber stenosis, that is a narrowing of part of the spine which results in pressure. The results of this particular piece of research were that obvious differences were found upon considering images of both groups. Among those in the fracture group high density zones were observed in 23%, whereas among the second stenosis group the number was as low as 3%. In some patients a high density zone was also discovered in those discs with a low or iso density. This was seen among 47% of those with vertebral fractures. The conclusion of the researchers was that, among older patients, there is often injury in discs near to fractures which have resulted to relatively minor trauma such as can occur in cases of osteoporosis. They believe that haemorrhage is the most likely cause of the images seen. Such injuries in many cases quickly become asymptomatic. In other cases surgical intervention would be needed. They cite an article by Rao Singrakhia from 2003 which discusses how in some cases there is long term severe pain caused by such things as non-union of these fractures or collapse of the vertebrae resulting in neurological problems. For these reasons the authors feel that early diagnosis and subsequent intervention is important. MRI is an important tool for this. They discuss other research into unstable spinal fractures. No one had previously reported on changes in the MR I of intervertebral discs in cases of minor injury. Critic My main negative criticism of this particular piece of research is the supposition by the researchers that the cause of the anomaly is haemorrhage. Although this is almost certainly the cause, as is verified by the differences found between the two groups orf patients, the researchers were unable to prove this by cadaver study, as it is impossible to simulate bleeding once death has taken place. On the positive side they do stress the difference that early diagnosis can make. Significance This is new research which adds to knowledge on this subject, while being based upon work by earlier research, which is why I have included it as one of the 5 most important pieces of research among those under consideration. Also the cause cited, osteoporosis in elderly patients, is a relatively common condition, so knowledge on this subject will help a large number of people who may, with the correct early diagnosis and intervention, be prevented from further injury and pain caused by haemorrhage into adjacent discs. This would also have economic repercussions as it would cut medication and care costs. Fayad, F et al, Reliability of a modified Modic classification of bone marrow changes in lumbar spine MRI, Joint Bone Spine 76 (2009) 286e289 Article Summary Article Summary The objective of this research was to determine the reliability of intra- and interobserver modified Modic classification with regard to changes in bone marrow as seen using MRI. The research takes into account the mixed signals that might be received. The method used was the independent assessment of lumber MRI scans which had been done on 94 people who presented with low back pain. A senior reviewer (Intraobserver) evaluated the images twice with a three week interval between viewings. Another senior observer plus a junior also observed the images, but in this case only once (Interobserver) There was classification of the results as follows. Modic type I – Signal changes as a result of pure oedema endplate. Modic type II – These were pure fatty changes. Modic I-II These were a mix of types 1 and 2, but oedema was predominant. Modic II-I Again these were a mixture, fatty changes predominating. Intraobserver agreement was classed as excellent, whereas in the second case reliability was found to be dependent upon the experience of the person observing. It was concluded that using a modified Modic method of classification was reliable and could be used by observers at different levels of experience. MRI has been able to allow better study of degenerative disease of vertebral discs, because of the ability to contrast soft tissues and with regard to multiplanar imaging. The researchers felt that MRI was the method of choice in cases of low back pain. They conclude that further studies are required, but did feel that this modified way of classification was helpful. Modic changes were seen in up to 50% of patients presenting with low back pain. Subsequent treatment choices were affected.. Modic I and I-II was associated with severe pain which could be successfully treated with intra-vertebral cortico –steroid injections, whereas this was less likely to reduce pain after one month in cases which were classified as Modic II-I. They point out that observed Modic changes are used in clinical practice to enable physicians to decide both upon such medical treatment or the requirement for surgery. Critic The researchers could have suggested a follow on study. Some observations by interobservers were reported as being only of moderate reliability due to inexperience but did not consider ways in which these practitioners could be helped to increase their accuracy. They are however fully aware of the differences in reliability that inexperience brings. Significance The research is important because of possible clinical and therapeutic significance of mixed marrow alterations. The patients are more likely to receive the correct treatment at an early stage as a result. This would have personal repercussions for them in that they would be more likely to be pain free and able to get back to normal activities more quickly. It also has economic and resource implications for the hospital The research was based upon previous studies and extended knowledge on the subject which is why I have included it as one of the 5 texts chosen as important. Mitra,D., Cassar-Pullicin,V. and McCall,I., Longitudinal study of high intensity zones on MR of lumbar intervertebral discs ,Clinical Radiology (2004) 59, 1002–1008 Article Summary Again this was a study of the use of MRI in the lumber spinal region, in this case a study from the United Kingdom. The objective of these particular researchers was to study the temporal evolution of high intensity zones (HIZ) when MRI is the medium of choice i.e the way in which they alter over a period of time, in people who presented with degenerative disease of the lumbar vertebrae. Also to evaluate whether there is correlation between such evolution observed and the symptoms seen or perceived . Each of 56 patients had two scans at a variety of time intervals. Two observers then considered these, looking for any changes. The symptoms that the patients were complaining about were assessed using visual analogue scores (VAS). A VAS is usually a horizontal line of 100 mm long. There are word descriptions at each end such as no pain and intense pain. The patient marks the place that they feel best represents their situation, i.e. the degree of pain perceived. The Oswestry Low Back Questionnaire was also used, as was the patient’s subjective perception of any changes in symptoms felt. The results were very mixed when the follow-up MRI HIZ were examined by the observers. In 26.6 % of cases the HIZ were no longer present. In 14% there was improvement, worsening in 18.8% and in 40.6 % there was no perceptible change. The conclusion was that there was no correlation between changes in symptoms and changes in HIZ. In the majority of cases either the HIZ improved over time or did not change. This new research has superseded earlier findings by proving that there is no statistical relationship between alteration in perceived symptoms and the evolution of the zones. Any other MRI feature which could possibly explain changes in symptoms were counted as confounding factors Critic Because of the variation in the time intervals between the various pairs of scans, the researchers suspect that in some cases the patients concerned would find it difficult to recall what their earlier symptoms had been and so found it difficult to assess change with accuracy. Did the observers reports look at each result together and come to a joint conclusion? This is impossible to tell from the report. More positively it does state that this study of the natural history of HIZ is a fresh way of looking at the problem Significance I have included it in my five choices firstly because it expands on previous research and the researchers are objective and honest about the difficulties that arise when conclusions are based partly upon subjective findings i.e. how the patients perceive their condition and the amount of pain they felt they experienced. I also chose it because those concerned originally looked at a large number (650) cases and eventually only choose those they best felt fitted their research criteria. They were not wasting resources. Also this is a way of studying high intensity zones that has not been carried out before. Rankine et al ,The therapeutic Impact of Lumber Spine MRI on Patients with Low Back and Leg Pain, Clinical Radiology 1998 53, 688-693 Article Summary This study investigated the influence of MRI of the lumber spine on the treatment of patients with a clinical diagnosis of spinal neural compression.. At the time MRI was first requested their clinical features were compared with the management choices that followed. This meant the clinical signs that led originally to a request for MRI could be determined. At the time of the MRI request such things as the patient’s medical history, the findings on examination by the physician, including tests of function, and any psychological disability were recorded . After the MRI, and without any knowledge of the resultant findings, the patients were again assessed and the diagnosis and subsequent clinical management plan noted. Then the report and films were accessed and the diagnosis and management plans altered as required. These were then compared with the earlier diagnosis and care plan. 72 patients were included in the study, the majority (90.3%) had leg pain as the main feature of their condition. Neurological abnormalities were found in 43%. Of those who had surgery planned , 47% had the plan changed to conservative care as a result of the MRI findings. In 50% of cases the original diagnosis was altered. In some cases the MRI did not confirm the original diagnosis of compression of the neural roots and 17 patients in which no abnormality was discovered on neurological examination required surgical intervention, of which 12 required spinal fusion. There was a definite move towards more conservative treatment in many cases. It was found that neurological abnormalities found on clinical examination were not necessarily good indicators of the need for surgery. The majority of people who experienced chronic back and leg pain had degenerative conditions. Therefore MRI is an appropriate early step to take. Critic This research is now somewhat dated, as it was carried out in 1998 and knowledge about MRI and what it can and cannot do is constantly expanding. Because of the variety of possible diagnoses, it proved impossible to arrive at clearly defined guidelines for the use of MRI. These will require more extensive and up to date study. There needs to be consideration in the future as to why neurological findings are not good indicators of the need for surgery. Are the reasons purely subjective? On the positive side some patients will be saved from unhelpful surgery and pain as a result of this research. 72 patients were included in the study, the majority (90.3%) had leg pain as the main feature of their condition. Neurological abnormalities were found in 43%. Significance Although dated (1998), it is included among the chosen 5 because of the ways in which inappropriate surgery is prevented where it is not required, despite earlier clinical findings. The reverse was also true with two patients who would have been managed in a conservative way had their care plans changed to include surgery. All the patients concerned can be said to have received a better solution to their problems and had their pain relieved more quickly. They were therefore more speedily able to return to normal activities and did not take up unnecessary surgical beds or theatre time. Rothenburg,T. et al, Magnetic Resonance Imaging of the Lumber Spine After Epidural and Nerve Root Injection Therapy: Evaluation of Soft Tissue Changes , Clkincal Imaging 30 , 2006, 31-334 Article Summary The objective of this research was to evaluate changes in soft tissues after injections of the spinal nerve roots and epidural injections in cases of disease of the neural roots ( radiculopathy). The patients were given a series of injections in the epidural space. MRI was done in each case before and afterwards, using lumber spine sagittal images. In all cases there were no clinical signs of infection, both before treatment and afterwards, when followed up at 3 weeks and later after 6 weeks. The results were compared. In all patients there was observed, after the series of injections, some oedema in a diffuse wedge among the tissues surrounding the vertebral column. In two cases haemotomas were observed in the paravertebral muscle. There were no changes in the epidural spaces, abscess, or in lipodystrophy. The conclusion reached was that after such injections for lumber radiculopathy normal tissues changes include in some cases haemotoma and in all cases there develops wedge shaped oedema at the level of the injections. This may be because of reaction in the tissues to the anesthetic used and is unconnected with infection. Knowledge about what can be considered to be normal changes after injection will make it easier to diagnose infections such as spinal abscesses earlier and so realistic and helpful therapy decisions can be made. Although it is comparatively rare for infective organisms to be introduced into the body as a result of spinal injections, there had been reports of infections being introduced iatrogenically, i.e. as a direct result of such injections given by medical staff. The typical symptoms that accompany spinal abscesses are considered by the researchers. Without MRI imaging it is difficult to differentiate between such symptoms and any preexisting vertebral disc herniation. Critic Only 15 people were examined, which seems a very small number on which to base important conclusions. Also none of these actually had an abscess, so images of changes brought about in such a case were not considered. Could they not have found as least one or two such cases to deliberate upon and enable the observers to make proper comparisons? Perhaps that should be the next step. On the positive side because such injections are such a common occurrence the more that is known about possible changes the better in order to avoid the possible long term neurological problems that could result from an undiagnosed abscess. Significance This research project was chosen as being important, and so was included in my five choices, because of the frequency in modern times of spinal injections for various reasons, which therefore statistically must heighten the possibility of infectious organisms being introduced and spinal abscesses developing, even if great care is taken. Hospital introduced infection has become a very important issue in recent years and in some cases can have long term repercussions and even fatalities after relatively minor procedures. The other reason was the difficulty of arriving easily at a correct diagnosis of spinal abscess without accessing MRI facilities. Conclusion MRI has become the imaging method of choice when investigating many different conditions and diseases in recent years. There has been time for a large amount of research, some of it concerned with scans of the lumber spine, the reasons for doing so, and the reliability and significance of results. References Aprill C, Bogduk N. “High intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging” British Journal of Radiology, 1992, 65 361-9 Fayad,F et al “ Reliability of a modified Modic classification of bone marrow changes in lumbar spine MRI,” Joint Bone Spine 76 (2009) 286e289 Mitra,D., Cassar-Pullicin,V. and McCall,I., “Longitudinal study of high intensity zones on MR of lumbar intervertebral discs “Clinical Radiology 2004 59, 1002–1008 Rankine et al ,”The therapeutic Impact of Lumber Spine MRI on Patients with Low Back and Leg Pain”, Clinical Radiology 1998 53, 688-693 Rothenburg,T. et al,”Magnetic Resonance Imaging of the Lumber Spine After Epidural and Nerve Root Injection Therapy: Evaluation of Soft Tissue Changes “ Clinical Imaging 30 , 2006, 31-334 “The Oswestry Low Back Questionnaire“available from http://www.goodmedicine.org.uk/files/assessment,%20oswestry.DOC, accessed 17th September 2010 Read More