MRI Diagnosis for Persistent Back Pain

MRI Diagnosis for Persistent Back Pain

It gives me great pleasure to have this opportunity to talk to you about something that’s very important
to the field of spondylitis. It’s really transformed the evaluation of this condition and it’s really enabled us to make a lot of advances in the field. So for a lot of people, including physicians, MRI’s, a little bit of a black box, in that we know it gives us
some important information but exactly what it tells us and how it helps in the assessment of a patient isn’t really very clear. So that’s what I hope
to do in this webinar is to discuss the advances in the field. And so what I am going to do is to first of all just outline some of the important unmet needs in the field of spondylitis. So one of the problems and challenges that physicians have is that
of course back pain is extremely common
in the general population. And it’s often very difficult to do an evaluation, a clinical evaluation that easily distinguishes
between spondylitis and all the other causes of back pain. So for example, somebody
with a slipped disc can experience a lot
of the same symptoms as a patient with spondylitis. And then when we look at the labs that are used to evaluate
patients, the tests that we get that are available do not specifically indicate whether a patient
has spondylitis or not. The B27 test, for example, and many people will be familiar
with the importance of the B27 gene towards the diagnosis. This is a gene that in fact occurs
in the normal healthy population, in about 10 percent of North American Caucasians. So it’s a normal healthy gene, but it is present
much more frequently in patients with spondylitis. So we don’t really have any tests that really clearly specifically
distinguish spondylitis from all the other causes of back pain. If we rely on x-rays,
this just is not good enough, they’re not sensitive enough. It often takes quite a while before you can see definite changes of spondylitis on an x-ray. And of course, a patient may suffer
with a lot of symptoms for many years before the diagnosis
becomes apparent on an x-ray. Moreover, there are changes in x-ray that can mimic spondylitis. So, for example, women
who have had children will have changes
in the pelvic bones in x-ray that look a lot like spondylitis and so, this can be a problem. And increasingly it’s been recognized that as for many conditions, early treatment is the best treatment. That’s when we get
the best treatment responses. So we really do want
to identify patients early. We want to recognize
the cause of symptoms early, so that we can provide
appropriate treatment. Then once a patient’s diagnosed and we know
that the patient has spondylitis, we often also want to monitor
the effects of treatment. And so we rely on what people tell us about the severity of their symptoms. But of course just because a patient has spondylitis doesn’t mean that they can’t get
a muscle sprain or a prolapsed disc or some other back problem. And sometimes it can be hard to tell if a patient’s symptoms and let’s say, increasing severity of symptoms, is due to the spondylitis
or some other cause of back pain. And so it’s important for us to have the ability to monitor patients
in an objective way with tools and tests that allow us to distinguish
active spondylitis from other causes of back pain. This is a problem right now because we don’t really
have that many tools to monitor people. We have a lab test called
the C reactive protein or CRP for short. But this just isn’t sensitive enough and about 50 to 60 percent of people have a normal CRP, both at the time of diagnosis and during follow up. And it may also for this reason be difficult to determine when’s the best time
to start a biologic. We, of course, want to start a biologic when a patient has active disease. But we also want to be sure that the severity of the symptoms are not due to some other problem, for example, like a slipped disc. So it’s important to have
these objective tools and tests that really tell us that a patient has spondylitis and that the spondylitis is active. And then increasingly
what we really want to know is which patients are more likely to get severe disease over follow up. And the sooner that we can make
that determination, the better for the patient. You can well imagine that if we can make this determination very early on then
we might then be in a position to introduce effective treatment
right from the start instead of waiting
for the disease to get worse. This is what we mean
by precision medicine. Everybody’s disease course is going
to be a little bit different. Some people are going to have
a mild disease and others may have more severe disease. So we really want to be in a position to practice precision medicine. And of course, the Obama administration has recognized this and has talked about supporting research into tools and the development of tests that will allow physicians
to practice precision medicine. The right treatment
for the right patient at the right time. And our current labs and x-rays for spondylitis really do not allow us
to practice precision medicine because they really
don’t tell us anything about the future course of spondylitis. So here’s a good example of the challenges of evaluating spondylitis
using an x-ray. And I’ve shown this x-ray
during workshops to a lot of rheumatologists. And I ask them, do you think
that the patient has spondylitis? Yes, no and I often get
a 50/50 response. Some people, some rheumatologists say yes and some rheumatologists say no. And if you look on the left side, what you should see
in a normal healthy joint and that is what we in fact see and that’s two nice parallel lines that indicate that the joint is healthy. On the right side however, you can see that those nice parallel lines
are not as evident. Things look a little bit fuzzy and this is very early spondylitis on the right side but not on the left side. On the left side the joint looks normal. It’s a beautiful x-ray that shows the difference
between abnormal and normal. And as I just indicated,
it’s often very difficult indeed in such an early case of disease for rheumatologists
and radiologists to make a clear-cut distinction between what’s normal and what’s abnormal. So that’s the problem with the x-ray. And this patient has already
had symptoms for six years. And of course it would have been nice to have treated this patient with the kind of effective therapies that we have so that they would not have suffered all this time with back pain and could have had
a normal quality of life with the kind of treatments that we have now available. So I’m going to discuss
the basics of MRI. What is it and I’m going
to show you some examples of MRI. And then how we use the MRI in patients to help understand their disease and provide appropriate treatment. Now I’m sure
many of you on the webinar understand something
about picture formats on a computer. And so we have, for example, a JPEG image. I think many of you will have heard of what a JPEG image is. So we send family photos around as attachments to emails. Probably many of you who are savvy with social media
don’t bother with that. But a JPEG is an example of a picture format that’s very easy to attach to an email and send around to family and friends. Some of you may also be familiar with a TIF picture format, which is a very high resolution picture format that’s used in publication to all kinds of journals. Now the kind of picture format that we use for MRI
is completely different. It isn’t something that a regular computer can show on the screen. You need special software to show a medical image. And the name
of that picture format is DICOM and that stands for digital imaging and communications in medicine. Hospitals all over the world now, for images that they store, the images that they create from x-rays and CT scans and MRI, they are all in this DICOM image format. And what happens in hospitals
all around the world is that there are
these electronic PAC systems. PAC stands for picture archiving and communication and what it is basically
is an electronic library and the software
in these systems allows medical images in DICOM format to be stored in hard drives, allows images to be retrieved,
for example, when a radiologist wants
to take a look at an image and report it. It’s something that can be seen
on an electronic medical record. When I see patients
in the clinic, in the outpatient clinic, I pull up the DICOM image
from that patient and I can show the image to the patient. And we can discuss it. I can show the spine. I can show the sacroiliac joints. We can talk about what it shows. Does it show spondylitis or not? Or alternatively, does it show
some other cause of back pain? And I do this as a routine in my clinic from one patient to the next. And this provides patients
with much more information and allows them to make
much more informed decisions about treatment and how they should manage
their condition. And so these DICOM images
are readily available. And they can be sent using a broad band communication to doctors in other locations
for second opinions, for example, to evaluate images. Now these are very large files and you cannot attach these to an email and send them by email for example. They are only transmitted
through secure broadband connections to maintain patient privacy. These are available
to communicate between specialists at different hospitals, for example. So that’s what MRI first is. And this is now just still
regular pictures. This isn’t DICOM yet. I’ll come to a DICOM format picture very shortly. But I just wanted to show you what an MRI image
shows compared to an x-ray. So this is a young man with two years of back pain. And on the left hand side
here is the x-ray of this patients sacroiliac joints. And the x-rays actually
look completely unremarkable. But when you look at the MRI, and there are typically
two types of MRI. One type of MRI’s
very sensitive to water. We call this a STIR MRI. So there’s the STIR picture, the STIR MRI. And its sensitivity
to water is important and it’s an important tool because water accumulates
wherever there’s inflammation. So, you know when you get
a swollen joint, that’s typically a reflection
of a lot of accumulation of water because blood vessels
in the joint become very leaky because of all the inflammation
and fluid accumulates in the joint. The sacroiliac joint’s no different. But where the fluid accumulates is in the bone around the joint. That’s why it looks so bright in this joint, the sacroiliac joint. So even though the x-ray
looks quite normal, the MRI is already very, very abnormal and shows the accumulation
of water related to inflammation. Now a second type
of MRI we call at T1 MRI. This tells us a lot
about damage to bone. This is an erosion. It’s telling us the inflammation is so intense that we’re starting to see
irregularity of the bone as the severity of the inflammation starts to chew away and dissolve the bone. And this is what we see already happening in very early disease. And eventually erosion of the bone, the dissolving of the bone can become quite severe. So we use two types of MRI and what we call a T1 MRI, which tells us about
the disillusion of bone, an erosion of bone
and the STIR MRI which is very sensitive to water which tells us
in a very sensitive way when inflammation has started even before an x-ray becomes positive. I think we should review the cases and then perhaps do a few more questions once we’ve gone through the cases. Just before I review the cases,
I should just mention that a lot of rheumatologists are not very familiar with the concept of DICOM imaging, evaluation and interpretation of MRI’s, not something that is taught in medical school for rheumatologists or in specialty training programs and that’s something
that we’re trying to change. And in particular, we have been working
with the Spondylitis Association to organize workshops to help train rheumatologists and help them to become familiar with DICOM imaging
and the assessment of MRI. This also applies to radiologists. And our first workshop in Los Angeles was very successful indeed. And we had a great deal of interest and very positive feedback and confirmation that this really was indeed
a very important unmet need that was being fulfilled by the SAA. So let’s move on to our first case. This was a very interesting young man who is a male champion marathon runner. And he was having
increasing difficulty running and found increasing difficulty even with simple tasks like sitting and standing
for prolonged periods. He was starting
to feel quite disenchanted with over-the-counter therapies. Went to see his family doctor who had tried naproxen and diclofenac. So these would be agents such as Arthrotec, another name for diclofenac and naproxen, the active ingredient of Aleve. So these are typical anti-inflammatories that a family doctor might use as first line treatment for spondylitis. He had a physical exam
which was completely normal. And he was tested for B27 and he was shown to be positive. And he had the test for active inflammation
that I mentioned earlier. The blood test is CRP and his CRP was normal. So what we’re going to do now is just switch to his x-ray. And this is his x-ray. And you can see on the left hand side his left sacroiliac joint
was completely normal. The right side
showed some questionable abnormalities, certainly not decisive and this x-ray was
in fact reported as normal and he was continued
on anti-inflammatories and then was referred
for rheumatologist assessment and this is when he had an MRI. This is his.
I’m going to show you some of the remarkable capabilities that I’m able make move the image around. I’m interested in some particular – I’m interested in something over here. I’m going to have to ask you to use your imagination a little bit and think of slicing through salami. And think of all those slices. Those consecutive slices of salami. And so imagine making
those cuts from the front to the back of the joint. So right now I’m going to start off see some white bits here
at the front of the joint. And we often see fluid
on the right hand side. This is the water sensitive MRI. And on the left hand side here, this is what tells us about bone. So I’m at the front of the joint now. And I’m going
to go from slice to slice. From the front x-ray through the joint you just get a 2D image. But here I’m going from front to back and back to front and I can do a very,
very detailed assessment. I’m going through all the slices to the back of the joint. And what I can see in this joint,
I’m going to show you what the abnormalities are in a minute. But I just wanted to go
through the principles of MRI so that you can understand
what it allows us to do. So it allows us to look
through a lot of thin slices. Each slice is
only three to four millimeters in thickness. So you can see that as I go from front
to back there are, what? About 10 or 12 slices. Slices. All very thin slices. The salami slices of the joint from front to back. So that’s the first advantage that the MRI gives us. The second is the ability to magnify and look
at exquisite detail in the joint. I’ve already mentioned how MRI
detects these abnormalities before pelvic x-ray. And in addition, your the image, clearer picture of what is happening. That I can download from PC or a Mac. So this viewing software, or as we call it DICOM viewing software, allows the radiologist
or the rheumatologist to now look at medical images that are based on DICOM format. And we can manipulate these images in ways that I’ve shown you. Look at all these thin slices of these MRI images going
from the front of the body to the back of the body. And so as you can see, we can evaluate
about 20 or so slices from the front to the back. So you can see
that’s an enormous advantage over the single image that a pelvic x-ray provides. Now what I’m going to now show you is some of the very
specific abnormalities. So, the first thing that we see is there’s already
this irregularity of the bone and we can see the bone is – there’s a gap in the bone. It’s like it’s been chewed away so, these are what we call erosions. You can see another gap here. This is another erosion and see more erosion on this side here. So, in fact, this person, this patient, has already developed this erosion of the bone in the sacroiliac joints. He doesn’t have too much inflammation. You can see on the water sensitive MRI. Because the inflammation probably
happened already several months back and what we see is the consequences
of the inflammation, the damage to the sacroiliac joints. You can see just how irregular this is. I’m going to blow this up
and you can see how irregular that bone
has now become, okay. So this is really bone
that’s really been chewed away by the inflammation. Now there is a happy ending
to this story. This patient received treatment
with a biological therapy because the diagnosis
was unquestionable based on the MRI. This patient is now back
to marathon running. So I’m going to now
describe another case. This has a definite
Canadian context to it. This is a Canadian
Royal Mounted Police Officer who’s 32 years old, who fell off his horse. They don’t normally go
around the streets of Canada on horses. But this was a parade. The horse became a little too excited. And ever since then, he’s had trouble with back pain. And he’s been told
that, you know well, you fell off a horse,
what do you expect? He was told that this was due to injury. He went to see his family doctor and had a lot of complaints. Mainly he couldn’t sit for very long, was feeling stiff, couldn’t really
walk very much on the beat and had some response to, again, the anti-inflammatories
we’ve discussed before. Now his pain had become so severe that he’d gone off work on disability. Really wasn’t too much to find
on physical exam and in fact, even his B27 test was negative. He had the inflammation test done, the CRP, this was just borderline normal and he had an x-ray
that was reported as normal. Basically because he was now
on disability and really had exhausted a lot
of the options for treatment, he was referred
to a rheumatologist. So this is his x-ray. And again, it’s an x-ray that shows
that on the right side he’s got nice clean margins
to his joint. On the left side, it looks like
there might be some irregularity there but here’s a problem. So, what you see
are these shadows. That’s actually gas in the bowel. And of course bowel sits in the pelvis and often overlaps
the sacroiliac joints. And it can really cause problems with interpretation
of the sacroiliac joint. So this is actually
difficult to interpret because there’s
some overlying gas shadow. So the x-ray, not surprisingly, was reported as normal. Let’s just have a look
at what his MRI shows. Now we’re again at the front. And we’re going
to go to our slice to the back of the joint. And on the right hand side
is the water sensitive MRI. You can tell it’s
the water sensitive MRI cause you can see the normal fluid, the water in the spinal canal. We’re right at the back
of the body here and I’m going to the front of the body, what was abnormal in this patient that led to the correct diagnosis. Now I’m going to make the image just that much. So now we have a much nicer looking detail to clearly understand
what the problem is. So now what we have on
the water sensitive MRI here, the right hand side you can see this bright signal here. Bright area. This is telling us
this patient has inflammation here. So through the next, to the next slice and we’re going to see
this bright signal. And then to the next slide, now we see more of this bright signal over here and over here and in the bone here. So on both sides of the joint – this is the dark line is the margin of the bone
of the joint. So we see this bright area here. That’s signifying this patient
has active ongoing inflammation. There’s a little bit
on this side as well but it’s mostly on this right side here. We go to the next salami slice and here we see even more inflammation in this joint on this side. Here on the next slice, there’s about five of these slices that have inflammation in the joint. So, again, this was a patient who was diagnosed. I’m going to show you what the spine looks like here. So the spine, the salami slice
is a little bit different. There the slices go from left to right. So you can see the individual vertebrae. Okay. This is
the water sensitive MRI because you see the signal from the fluid
in the spinal canal. So each one of these are
lumbar spine vertebra. And lo and behold,
we have a bright area here in one of the lumbar vertebrae that has this signal
indicating inflammation in the vertebra. So this patient had inflammation not just in the sacroiliac joints but also one
of the vertebral corners here. So this patient had
inflammation in both locations. What this looks like, see that bright signal of inflammation in the patient’s sacroiliac joint, I don’t know if he’s back
to riding a horse or not, but he certainly is back to work and he’s continuing his work as a police officer. So this is what it looks like
after inflammation has resolved. You can see the enormous detail that we get and how we can be confident with the diagnosis and what happens after treatment
to inflammation once it’s properly recognized, diagnosed and appropriately treated. So we are going to go back to just one more case. So, ice hockey
is a big deal in Canada. And yesterday was a fantastic game that I saw between the Edmonton Oilers and the New York Rangers. Happy to say
the Edmonton Oilers won six-five. So this was a case of a 42 year old male hockey referee. He had acute back pain after falling on the ice and he presented several months later because he was developing
numbness in his leg. His back pain
had actually improved somewhat but was still there and was still troubling him
from time to time. He was taking over
the counter Aleve, which as I mentioned before, the active ingredient is naproxen. He was concerned that maybe he’d trapped a nerve or had some nerve root impingement in the spine. So he had an x-ray done
in the x-ray department and the x-ray
of the lumbar spine was normal. He had a blood test
called the sed rate which some of you may have had done. It tells us something
about inflammation. His sed rate was a little high, it should be less than 20
and his was 32. So he was referred to a rheumatologist for further evaluation. This is what his x-ray looked like. The rheumatologist
was a little bit concerned. The rheumatologist was me and I was a little bit
concerned about this because while I thought his left side looked normal on the x-ray, I was really rather concerned that his right side did not look normal. He tried several anti-inflammatories and he was still getting
a lot of back trouble. I was really thinking
that he would probably need to go on a biological treatment to get adequate relief. So what did his MRI look like? I’m just going
to, again, optimize this. So that you can see the end picture a little bit brighter. On this side, salami slices. Little bit sharper a little bit brighter. And as we go from front to back through all of the slices
too dramatic. But we do see a little bit of faint signal, bright signal, on the water sensitive MRI and I talked to the patient about treatment and the fact that I thought he had inflammation
in his joints and that he might benefit
from a biological treatment. So we looked at this MRI scan
together in my clinic. He wasn’t all that
impressed with his MRI and he’d gone to the internet after we had our discussion and he read about some
of the side effects about biological therapies and he decided that he wasn’t gonna
go ahead with treatment and that maybe he wasn’t ready
at this point to start treatment
on a biological therapy. We had a discussion over the phone and I reassured him
that the latest information was very reassuring about the safety
of biological therapies, but he really wasn’t
ready yet for treatment and he decided he was going
to try conservative treatments like more exercise. He was going to lose
a few pounds in weight and he was going to stop smoking. I encouraged him
in all of these endeavors because certainly smoking
is a major risk factor for severe spondylitis. And then he came back
to see me in six months’ time and he said, you know, I’m really not getting any better. You know, I’ve lost 15 pounds, tried to do exercise but it’s hard for me to exercise
when I’m in pain and I’m not sleeping well. I’m waking up in the later hours of the morning and my quality of life
has really become quite poor. So we repeated the x-rays and he said, you know I’m still
worried about these biologics. We repeated the MRI now. So, again, so we could see these follow up images are brighter. Don’t really need to inflammation. We reviewed the image the inflammation now is obvious. And we can see a lot
of bright signal on this water sensitive MRI and it’s really very obvious on lots of slices now. On at least six slices, where we see this bright signal in the bones around the joint, it’s really become very obvious. We sat down and looked at this image on the MRI. He said, you know
we’re gonna go ahead and we’re gonna start treatment. He really did very well indeed. His pain really improved substantially. I’m happy to say
that he continued with changes to his lifestyle, very positive changes to his lifestyle. He’s lost weight,
he’s stopped smoking, and his symptoms
are much better controlled. He can exercise now, whereas he couldn’t before. And it’s really made a huge impact on his quality of life. And the imaging really
was very important in helping to reassure him that this really was
an appropriate treatment step for him. And this really was the way to go. So all of these have an important
and happy ending. They show how we can change management and how we can improve people’s lives with appropriate recognition
of this disease, it’s severity and provide appropriate treatment.

3 comments on “MRI Diagnosis for Persistent Back Pain

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