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Chronic Low Back Pain Is a Common Problem in Primary Care

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Chronic Low Back Pain Is a Common Problem in Primary Care ` MAGNETIC RESONANCE IMAGING EVALUATION OF LOW BACK PAIN IN ADULT NIGERIANS AT THE NATIONAL HOSPITAL ABUJA, NIGERIA BY DR UMERAH Chinwe Kenechukwu (MBBS ENUGU) DEPARTMENT OF RADIOLOGY, NATIONAL HOSPITAL, ABUJA BEING A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP OF THE MEDICAL COLLEGE IN RADIOLOGY (FMCR). NOVEMBER 2014 1 CERTIFICATION FROM THE PROJECT SUPERVISOR This is to certify that the research project titled Magnetic Resonance Imaging Evaluation of Low Back Pain in Adult Nigerians at the National Hospital Abuja, Nigeria, was carried out by Dr Umerah, C.K in the Department of Radiology NHA and that I supervised the work. PROJECT SUPERVISOR .......................................... DR. AKANO, A. O [FMCR] Chief Consultant Radiologist Radiology department, National Hospital Abuja, Nigeria. Date……………………….. 2 ATTESTATION I confirm that this project work was carried out entirely by Dr Umerah C.K and duely supervised in the Radiology Department of the National Hospital Abuja. --------------------------------------------------------------------------------- Dr A.A. UMAR [FMCR] Head of Department Radiology department, National hospital Abuja, Nigeria. DATE………………………………. 3 DECLARATION It is hereby affirmed that this work titled “MAGNETIC RESONANCE IMAGING EVALUATION OF LOW BACK PAIN IN ADULT NIGERIANS AT THE NATIONAL HOSPITAL ABUJA, NIGERIA” was carried out by me at the Department of Radiology, National Hospital Abuja. In addition, the work is original and has not been presented to any other college for any reason nor for publication elsewhere. DR UMERAH, Chinwe Kenechukwu 4 DEDICATION In loving memory of my hero, my mentor, my dear father, late Prof Ben C.Umerah, who remains my inspiration 5 ACKNOWLEDGEMENT Special thanks to Almighty God for His abundant blessings without Whom nothing is possible. Thank you to my lovely sisters, aunties and entire family who constantly support me, my supervisor Dr A.O Akano for his tutelage and guidance and all my teachers for their collective efforts and individual contributions. I am grateful to all the staff of radiology department of National Hospital Abuja for their support. 6 TABLE OF CONTENTS 1. Title page…………………………….......................................i 2. Certification ……………………………………......................ii 3. Attestation ………………………………………………........iii 4. Declaration…………………………………………….………iv 5. Dedication ………………………………………………..…...v 6. Acknowledgements ………………………………….….……vi 7. Table of Contents………………………..…………..………..vii 8. Summary…………………………………………..……..........2 9. Introduction……………………………..................................4 10. MRI Anatomy of the lumbar spine….....................................6 11. Justification …………………………............................17 12. Objectives …………………..................................................19 13. Literature review….…………….……….……………………20 14. Materials and methods…..………………………….………...37 15. Results ………………………………………………..……… 43 16. Discussion...……………………………………………………63 17. Conclusion………………………………................................72 18. Recommendations ……………………….……………............73 19. References.………………………………….……….…………74 7 20. Appendix I copy local HERC approval ...……….………...82 21. Appendix II consent form………………..............................83 22. Appendix III Study data sheet………………………….……..84 23. Appendix IV departmental MRI questionnaire…….…………86 The following terms and definitions were applied to this study: 1. Adult: individual aged 18 years and older. 2. Low back pain: Low back pain is usually defined as pain localized below the line of the twelfth rib and above the inferior gluteal folds 3. Musculoskeletal disorder: Affecting the muscles and/or skeleton of the spinal column eg lumbar spondylosis. 4. Incidence: is the rate of new (or newly diagnosed) cases of the disease. It is generally reported as the number of new cases occurring within a period of time. 5. Spinal disc herniation informally and misleadingly called a "slipped disc", is a condition affecting the spine, in which a tear in the annulus fibrosus of an intervertebral disc allows the nucleus pulposus to bulge out. Tears are almost always posterolateral in nature owing to the presence of the posterior longitudinal ligament in the spinal canal. 6. TSE-Turbo Spin Echo 8 SE-Conventional spin echo MSMA-Multi stack multi angle [used mainly for axial cuts] TIRM-Turbo inversion recovery magnitude FS-Fat Saturation Summary Introduction Low Back Pain(LBP) is a common problem affecting both genders and most ages for which about one in four adults seek care within every six-month period. It results in considerable direct and indirect costs, which could be financial, workforce and social amongst others. Care-seeking behavior varies depending on cultural factors, the intensity of the pain and the extent of activity limitation and the presence of co-morbidity. Magnetic Resonance Imaging (MRI) has proven invaluable in the assessment, management and follow-up of LBP. Aims and Objectives This study aims at describing the patterns of low back pain and their MRI changes in the cohort study. Methodology This is a prospective, descriptive study carried out at the Department of Radiology of the National Hospital Abuja using open MRI 0.2T Magnetom Concerto 9 (SIEMENS, Germany 2004) Syngo. Plain and contrast MRI images of the lumbar spine were acquired in both T1 and T2 weightings Study duration was 2 years from January from 2012- December 2014.Informed consent was obtained from patients and/or their relatives.Patients’ demographic history was taken from their case notes, request cards and from the patients themselves. The MRI findings were cross tabulated with age group, gender, severity of pain and duration. The result was analyzed using the Statistical Package for Social Sciences. Results A total of four hundred patients were evaluated, there was a male preponderance (54.5%). Their ages ranged from 21-81yearswith peak at the fifth decade. The incidence of degenerative disease was very high, 84% relative to other spinal abnormalities. Osteophytes, loss of disc signal and exit nerve root compression were the most common specific degenerative finding. Other MRI findings included vertebral body destruction, disc herniation, Modic changes of the vertebral bodies as well as narrowing of the spinal canal. MRI continues to be the gold standard for imaging in the evaluation of low back pain .This study conclusively shows the high sensitivity of MRI in low back pain and is in accordance with data from other studies. 10 There is need for an increase in availability and affordability of MRI for patients with low back pain to benefit from the sensitivity of this investigation. INTRODUCTION Back pain has affected humans throughout recorded history. The oldest surviving surgical text, the Edwin Smith papyrus from 1500 BC, includes a case of back strain. Two key ideas in the nineteenth century laid the foundations for the modern approach to back pain: That pain came from the spine; and that it was due to injury. There is however no evidence that back pain has changed1. Low Back Pain is the most prevalent musculoskeletal condition and the most common cause of disability in developed nations2. A global review published in 2000 suggested that only one African study was available for inclusion 3. A recent publication in 2003, reports a much larger group of relevant African studies of which 67% were methodologically sound. This review indicates that there is little difference in the prevalence of Low Back Pain among Africans compared with that in developed countries4. 11 The lifetime prevalence of Low Back Pain (at least one episode of Low Back Pain in a lifetime) in developed countries is reported to be up to 85%4. Low Back Pain results in significant levels of disability, producing significant restrictions in usual activity and participation, such as inability to work4. Musculoskeletal complaints are the second most common reasons for consulting a doctor and constitute, in most countries, up to 10–20% of primary care consultations 5. In the Ontario Health Survey, musculoskeletal complaints were the reason for almost 20% of all health care utilization.2They were the most expensive disease category in the Swedish Cost of Illness Study, representing 22.6% of the total cost of illness; the greatest costs were indirect costs related to morbidity and disability6. The total direct cost for use ofhealth services that results from musculoskeletal conditions was 0.7% of the gross national product in the Netherlands, 1.0% in Canada, and 1.2% in the USA 7,8. The indirect costs of musculoskeletal conditions (loss of productivityand wages) were much greater than the direct costs, corresponding to 2.4% and 1.3% of the gross national products of Canada and the USA, respectively4. The purpose of this study seeks to describe the MRI findings in patients with low back pain in an attempt to provide better understanding of the characteristics of 12 patients identified with a diagnosis of lowbackpain, and the estimation of healthcare utilization and costs. MRI ANATOMY OF THE LUMBAR SPINE The lumbar vertebrae are the largest segments of the movable part of the vertebral column and are characterized by the absence of the foramen transversarium within the transverse process, and by the absence of facets on the sides of the body. They are designated L1 to L5, starting at the top. This area of the spine is the source of much body motion and supports most of the body
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