0:02

Hello and welcome to Noon Conference, hosted by modality

0:05

Noon Conference connects the global radiology community

0:08

through free live educational webinars that are accessible

0:11

for all and is an opportunity

0:13

to learn alongside top radiologists from around the world.

0:16

You can access the recording of today's conference

0:18

and previous noon conferences by creating a free account.

0:22

Today we are honored to welcome Dr.

0:24

Wendy Gibbs for a lecture entitled, impactful Assessment

0:28

of the Degenerative and Postoperative Spine.

0:31

Dr. Gibbs is an associate professor of neuroradiology

0:35

and the director of Spine Imaging

0:36

and Intervention at Barrow Neurological Institute.

0:40

She's immediate past president of the A-S-S-R-W-N-S

0:44

and Chair of the A SNR Education Committee.

0:47

She recently joined the A CR Neuroradiology Commission

0:50

serving as chair of the education committee

0:53

and holds positions in the R-S-N-A-A-C-R-A-S-N-R

0:57

and subspecialty and regional neuroradiology societies.

1:01

She has focused her research, service

1:03

and education efforts on spinal ecology intervention

1:06

and pain management radiology reporting in Alzheimer's

1:09

disease, neurodegenerative, and CSF disorders.

1:13

At the end of the lecture, please join Dr. Gibbs in a q

1:16

and a session where she will address questions you

1:18

may have on today's topic.

1:19

Please remember to use the q

1:21

and a feature to submit your questions so we can get to

1:23

as many as we can before our time is up.

1:25

With that, we are ready to begin today's lecture.

1:28

Dr. Gibbs, please take it from here.

1:31

Here we go. Well, thank you so much.

1:34

I really appreciate the chance to be here.

1:36

We are talking a little bit yesterday about what a fantastic

1:39

platform this is, where we can share education

1:42

with people from all over the world.

1:44

A lot of people who don't always have access to this stuff.

1:47

I love it that we can give it to them for free, all

1:49

of you out there right now, and also

1:52

whenever people wanna see it later and go to the website

1:55

and see these free new conferences.

1:57

I can't wait to watch more myself.

1:59

I don't like to watch them as well. Our fellows watch them.

2:01

So this is just such a great organization.

2:04

So impactful assessment

2:05

of the degenerative and postoperative spine.

2:07

Well, that's kind of a tall order I've given myself

2:10

high bar here to reach,

2:12

but hopefully I can show you some cases, some things

2:15

that I have learned along the way since I was a

2:18

resident, since I was a fellow.

2:20

All of my lectures are built on things

2:22

that I've learned the hard way

2:23

that I didn't know, and I ran into it.

2:25

I'm like, oh my gosh, what's this?

2:26

So hopefully I can save everyone here.

2:28

A little bit of trouble and pain. We'll see.

2:30

All right, so let's start off with this case.

2:33

67-year-old with back and leg pain and weakness.

2:36

I was talking to one of my fellows boy last Friday, I think,

2:40

and she was saying in that, you know,

2:41

we had a ton in her fellowship where I work now,

2:44

we have a ton of spine imaging

2:46

and she said she has even more now in her kind

2:48

of outpatient, regular, uh, private practice.

2:52

It's so much of what we all do in outpatient and inpatient.

2:56

It's just degenerative spine.

2:59

So it's important to know what to do so

3:02

that we can make a difference for our patients.

3:04

And I'm gonna give you, that's

3:05

another thing about this platform.

3:06

We a chance to get on my soapbox

3:08

and give you my opinion about spine imaging.

3:11

Um, so 67-year-old back and leg pain and weakness.

3:15

Now, this poor guy's, like so many people we see every day,

3:19

the vast majority of everyone is gonna be like this someday

3:23

80% of people are gonna suffer debilitating bouts of back

3:27

or neck pain, some kind

3:29

of spinal degenerative disorder in their lifetime.

3:33

So keep your core strong, take care of yourself.

3:36

What we see here is a sagal MRI image.

3:41

This is gonna be a T two weighted image.

3:43

We have an axial T two and we have an axial ct,

3:46

and we see the very typical findings

3:48

that we see in every degenerative spine.

3:50

So we see multi-level mild degenerative listhesis on the

3:54

sagal image, which are causing, you know, mild compression

3:57

of the thecal sac, some serpiginous nerve roots

3:59

where it's being compressed.

4:00

Here on this axial image, we see kind

4:02

of this diffuse annular disc bulge.

4:05

We see facet arthropathy, ligamentum flam, buckling.

4:08

We see that is really kind of narrowing the canal.

4:10

It's compressing the thecal sac.

4:11

All those nerve roots are bunched up in the middle.

4:14

And here on ct, we see typical osteophytes come in these

4:17

from these degenerated CETs ligamentum, um,

4:21

flame calcification ossification, kind of

4:24

that nplate osteophyte from the disc.

4:27

So blah, blah, blah, what can I teach you about this?

4:29

So I'm gonna switch gears. This is my soapbox here.

4:32

How do you report this? How do you report it?

4:35

How do your partners report it?

4:36

How does someone across town,

4:37

someone across the world, report this?

4:40

So what is important for this man to make him better?

4:43

That's what I think is important.

4:45

We focus on, so this, i,

4:48

I put in some extra slides here at the beginning

4:50

so I can kind of share with you

4:51

before I make you listen

4:52

to all this degenerative post-op stuff.

4:54

I want you to know why I think

4:55

it's important you listen to it.

4:57

This is one of my friends who's a spine surgeon at

5:00

Mallinckrodt, and he came to one of our spine meetings

5:02

and he got up on stage and he said, why do you report level

5:04

by level and make my patients go crazy?

5:06

And by him as well, he said, you're, you know,

5:10

we're reporting all these things.

5:11

This is a big report from one of his patients

5:13

who had nothing surgical.

5:15

He had all these so-called degenerative changes, um,

5:19

but none of it were, you know, none of them.

5:20

He had to go through it all with him

5:21

and say, you know, this is what this means.

5:23

This is what this means, but none of it is really causing

5:25

what is wrong with you.

5:27

And so he said, you know, this, I, this just, he's wasted,

5:31

you know, an hour of his time.

5:32

It's not really a waste, but you can

5:33

see what the problem is here.

5:35

So many of our spine reports look like this,

5:37

and is that really the right thing to do?

5:39

This is another thing. Um, one of my friends from, um,

5:42

Switzerland, Alex Ami,

5:44

who's a fantastic spine surgeon, same thing.

5:46

He had this quote that he posted, I can't remember

5:48

where he posted this line, but he shared it with me.

5:50

But he said, you know, we're all doing

5:52

standardized reports now.

5:54

And he tells the patients, you know, don't look at those.

5:56

That's for the radiologist, not

5:58

for the surgeon or for the patient.

6:00

And that really spoke to me

6:02

because I'm thinking it's for the radiologist.

6:04

You know, that's, that shouldn't be the way we're reporting.

6:07

That doesn't necessarily add value

6:09

for the surgeon or for the patient.

6:11

One more. So this is my friend Brian Lee who works with me,

6:14

and he came to our spine meeting and had this as well.

6:17

He said, you reported all this stuff, but

6:19

because of the way you reported it, not me personally,

6:23

I'm not going take credit for that, but

6:24

because of the way it was reported,

6:26

the insurance company denied the patient's surgery even

6:28

though they really, really needed it,

6:30

because, you know, it was a lot of words

6:32

but not the right words.

6:35

So imaging in back pain

6:36

and spine surgery, again, just, this is a lot

6:38

of a lot of stuff.

6:39

But again, I wanna tell you why

6:40

I think this stuff is important.

6:42

Why? I'm gonna show you what I'm gonna show you.

6:44

So our job really, when we're looking at imaging

6:47

for back pain is to identify undiagnosed systemic processes.

6:52

I'm gonna show you what that means in a minute.

6:53

Up in the right hand corner, you can see a patient

6:55

who actually has, you know, cancer, that was a patient

6:58

who came in with back pain.

6:59

It wasn't degenerative, it was cancer.

7:01

So that by diagnosing that, we've added value.

7:03

But if you look at these numbers from our friends at Mayo in

7:07

the primary care setting, only, you know,

7:09

less than 1% have cancer, less than 0.1% have infection.

7:13

About 4% have osteoporotic fractures.

7:15

That's a little bit higher. But in general,

7:17

that means all the rest of spine or imaging that we do.

7:21

Really, were not identifying systemic processes.

7:23

So are we adding value spine surgeons don't think so.

7:27

So they say, you know, for their literature, these,

7:29

this was a study that came out not too long ago.

7:31

There's no difference in outcomes for these patients

7:34

based on our reads.

7:36

So we are not providing any additional information.

7:39

If anybody out there, I know my fellows,

7:41

despite everything we've said,

7:42

are still worried about being replaced by ai.

7:44

If there's a reason, if we're going to be,

7:46

this is why we're not adding information

7:49

that the surgeon don't already have

7:50

and we're not adding value to improve patient outcomes.

7:54

This, I'm gonna show you pictures soon for the next hour.

7:57

So one more word slide here.

7:59

This is something I saw not too long ago

8:01

and I talked about at our A SSR, our spine Society meeting.

8:05

This is kind of the, the, um, hierarchy

8:08

of value in medicine.

8:10

And this is where radiology is focused at the top.

8:13

We wanna have good images that have like good contrast

8:15

or good signal noise, whatever,

8:17

or that reduce, you know, uncertainty of good positive

8:20

or negative predictive value, good accuracy,

8:22

but in reality that doesn't add a ton

8:24

of value for patient care.

8:26

We wanna be down here, um, a little bit down on my list.

8:29

It's actually going toward the top of the pyramid here.

8:31

We actually wanna be making changes to

8:34

what the clinicians think or how they treat the patients.

8:37

And ultimately we wanna reduce harm,

8:40

decrease their morbidity, their mortality,

8:43

increase their benefit for an individual patient

8:45

or at the very top for all patients.

8:47

So I wanted to say these things.

8:49

I wanna have you keep these in mind as we're going

8:51

because this is why we're doing spine imaging.

8:54

So everybody, as you know, we've heard this a million times,

8:57

has findings that look degenerative on their images.

9:00

That doesn't mean they're causing symptoms.

9:03

It really depends on what the patient's symptoms are

9:05

to know whether the findings we're seeing

9:06

make a difference or not.

9:08

And further, I'm gonna talk about this more in a minute.

9:11

You know, what we see on our supine imaging on our cts

9:14

or on our mrs, that position is not the position the patient

9:17

lives in unless they're bed found.

9:19

So really what we're seeing, you know, that level

9:21

of stenosis compression,

9:23

whatever isn't necessarily accurate.

9:25

So keep all those things in mind.

9:26

Our role, like in this picture right here, our role was not

9:28

to, well that's finally pretty good,

9:30

but was not to identify degenerative changes.

9:32

Our role here was

9:33

to say this person has an osteoporotic compression fracture,

9:37

you know, at L one, that's correct, pulse from the canal,

9:39

it's, you know, little al sac compression, whatever,

9:42

but they're now gonna get treated for their osteoporosis,

9:44

prevent further fractures.

9:46

So we're adding value to that patient.

9:47

We're gonna prevent further morbidity and mortality

9:50

and help them right now.

9:52

So all that, now let's go to degenerative

9:54

and not degenerative spine.

9:55

So back to this man,

9:57

67-year-old really paying back paying weakness.

10:00

So when you think about how he's standing,

10:02

you remember your, your, um, netter book from,

10:05

from medical school where the man is leaning forward over a

10:08

shopping cart, he's like hunched over.

10:10

And that was to relieve his spinal stenosis in the setting

10:13

of neurogenic claudication.

10:14

That's what he has. So leg pain, numbness, weakness

10:17

after standing, you know, for 15, 20 minutes or whatever.

10:20

That's the problem that so many people have.

10:23

So that's what we're seeing in these images

10:26

and that's what I'm gonna talk about first.

10:28

'cause obviously very, very most common.

10:30

So decompression

10:32

for these symptoms is the most common spine surgery

10:34

in older individuals.

10:35

Anybody over 55, at least in the us

10:38

I'm speaking international audience, but in the US at least.

10:41

So the reason the PA people have these symptoms is

10:44

because there's vascular congestion.

10:46

This compression, um, compresses not just the nerve roots,

10:50

but also the vessels.

10:51

So after you've had chronic compression

10:53

of the blood vessels, you have blood nerve barrier

10:56

disruption, you end up having these nerves, um,

10:59

they're damaged for a long time, then they start to deely,

11:02

they atrophy and they die.

11:03

You also, if you have severe enough stenosis,

11:05

have disruption of your CSF flow to the lumbar spine.

11:08

And CSF is not just water, it actually has a lot

11:10

of proteins, a lot of nutrients that are necessary

11:13

for healthy auto equate.

11:15

So all these things, um,

11:17

are happening when you have spinal stenosis.

11:19

And this justifies surgery in my mind.

11:23

So a lot of people are very opposed to spine surgery.

11:25

I have to admit that when I was a fellow, I had, you know,

11:27

everybody was saying, I won't say who won't name names,

11:30

but very famous people are saying spine surgery is the

11:32

worst thing that can happen to people.

11:33

And maybe it wasn't as good.

11:35

You know, that wasn't that long ago.

11:36

But I think that's, um, a little bit exaggerated.

11:39

And I actually, you know,

11:40

that's what I was trying to believe.

11:41

But now after working with spine surgeons

11:44

and doing this for, you know, eight,

11:45

nine years now, I believe the opposite.

11:47

I think spine surgery is vital and they do a very good job.

11:50

It's never really indicate, or almost never.

11:53

So we have good evidence level two evidence showing

11:56

that laminectomy infusion works better

11:59

to treat people's symptoms of canal stenosis than, um,

12:02

conservative approaches like medicine,

12:04

physical therapy, things like that.

12:06

But it's very complicated.

12:07

So that's what I'm gonna talk about a little bit.

12:10

This is part of the value thing.

12:12

How do we know what's important to talk about?

12:14

I asked you to think about that.

12:15

When we're seeing these cases, it's important to understand

12:19

how these patients are treated, what will help them.

12:21

We have to understand the surgery

12:22

and what the surgeons are considering

12:24

and what is important to report.

12:26

So the principles here, let me show you this figure,

12:29

and we get to real cases very soon.

12:31

I'm gonna show you a ton of them, but a little bit more

12:33

principle here in the background.

12:34

So this beautiful figure, which I love from radiographics,

12:38

um, shows what is happening when you're standing up.

12:41

So your center of gravity is actually in the front

12:44

where your ribs are here.

12:45

These forces of gravity are pulling you

12:47

to fall on your face, your posterior tension band,

12:50

your SuperSPIN ligament in spinous ligament, you know, set,

12:53

um, capsules, all these things.

12:55

They're actually counteracting that force

12:57

to hold you upright.

12:59

So when they're doing surgery, you know,

13:01

or originally they're,

13:02

they're more minimally invasive surgeries now,

13:04

but they would take out the posterior s

13:06

and they would disrupt this posterior tension band.

13:07

So they have to balance having, um, too much decompression,

13:12

which takes away the stabilizing force.

13:14

So you're gonna fall on your face or too little so

13:16

that they don't actually address the problem.

13:20

So let me just show you this, this, um,

13:22

because it's, it's kind of mandatory.

13:24

I was told by um, my friends who run a lot of conferences,

13:28

I have to show you

13:29

stenosis and we're gonna get back to that.

13:30

This is kind of a grading system we use just

13:33

so we're all on the same page,

13:34

at least from the lumbar spine.

13:36

If you have, um, a little bit of distortion

13:39

of the anterior CSF space, that's usually mild stenosis.

13:42

If you have a little bit more aggregation

13:44

of the nerve roots, but still have a little

13:46

bit of csf, that's moderate.

13:47

If you have these things ventral disc dorsal, um,

13:51

pathy limb, me thickening,

13:53

and you have no CSF between the nerve roots, that's severe.

13:55

So that's also in general.

13:56

So we can all kind of say the same thing.

13:58

But like I said, when we're on our backs,

14:00

that's not necessarily how the patient lives in real life

14:02

when they're sitting up, when they're standing up.

14:04

So it might not matter. And like I said at the beginning,

14:07

there's poor correlation between all this

14:09

and what the symptoms actually are.

14:11

So person who have severe stenosis

14:12

but no symptoms, they could look like this

14:14

mild and have symptoms.

14:16

So while we grade these things, I wanna keep that in mind.

14:19

We can do all the level by level, we can grade everything,

14:21

but does grading really matter?

14:23

And a little, it's a little bit controversial.

14:25

Everybody wants to put questions in the QA about that

14:28

and maybe exaggerating that a little bit.

14:30

But I'm not really big on saying I I,

14:33

I don't think things we report are that important.

14:35

Um, we should say in general

14:37

how much stenosis protrusion protrusion,

14:40

but that's not the primary reason that we're doing this.

14:44

All right, so let me skip to another case.

14:45

So 42-year-old left leg radiculopathy.

14:49

So this one little bit younger patient, I mean, again,

14:52

for people who are newer, I just wanna

14:53

show you some of the sequences.

14:54

I also found out recently my first trip to ECR R in Europe,

14:57

that not every place in the world does the same imaging

15:00

that we do in the US in a lot of places.

15:02

Found out don't do stir.

15:04

So fat saturated T two, we know this is a SAG T two

15:06

because the CS F is bright

15:08

but there's not bright fat in the back.

15:10

So this has been saturated out fat saturated T two

15:13

or this was a stern.

15:15

So we have, um, normal bright discs at most levels.

15:19

This transversely oriented line

15:21

through the disc is a nice beautiful healthy disc.

15:23

This is the interclear cle,

15:24

which usually we only see when people are relatively

15:27

younger, you know, super healthy.

15:29

Down here we've lost that T two signal.

15:31

So four, five and five one.

15:33

We have T two, um, more hypo intensity.

15:36

And here at five one you can see

15:38

there's nplate irregularity.

15:39

You can see there's a disc herniation.

15:40

So on our axial T two, this one is a real T two

15:43

because the CSF is bright, the fat is bright, we see this,

15:47

um, left central disc, maybe protrusion, maybe extrusion.

15:51

It's a herniation regardless.

15:53

And here's the um, you know, L five has come out already.

15:57

These are the L five nerves.

15:58

S one is coming down and this disc is impacting a dorsally

16:01

displacing, probably compressing the

16:03

descending left S one nerve.

16:06

So what they did, this is another,

16:07

this is a little surgery story.

16:09

So they had, um, surgery, they had really bad, bad symptoms.

16:13

There was nothing they could do, they

16:14

couldn't walk severe pains.

16:15

The surgeons went in there. This, I'm sorry,

16:17

I'm showing you a different uh, uh, sequence,

16:20

but they got a microdiscectomy after this.

16:21

This is their postoperative study right here.

16:25

Um, again, these are different sequences, but it's the same.

16:28

Uh, I have to show you the principle. This is all I had.

16:32

You see this disc herniation here at five one.

16:34

It looks exactly like the pre-op,

16:35

even though it did a microdiscectomy.

16:37

They took out as much of that disc as they could

16:39

with a minimally invasive approach.

16:40

Here this axial, this one you can see here,

16:44

there's this left central disc,

16:46

just like the pre-op it had been taken out.

16:48

So this is a recurrent disc protrusion or herniation.

16:52

This person has failed back syndrome.

16:54

So I'm showing you this to show

16:55

you both the principles of surgery.

16:56

You don't wanna do too much or too little,

16:58

but also to introduce this term, which I learned

17:00

as a resident, I'm not sure people are learning it anymore,

17:03

but that's if you have the same symptoms.

17:06

So when had a um, left S one radiculopathy,

17:09

if you have the same symptoms, either they persist

17:11

after surgery or they come back after surgery.

17:15

That is failed back like up to one year.

17:17

And there are a number of causes,

17:19

but this is one of the most common.

17:21

So in this case,

17:22

so this person came out the exact same symptoms,

17:25

severe intractable pain.

17:26

This is the one I just showed you, the,

17:28

the post microdiscectomy.

17:30

So now they had to do the definitive surgery.

17:32

So they had to do a real discectomy, they put in a graft.

17:34

And here you can see here this a**l ct.

17:37

I'm sure you, I'm keeping you on your toes,

17:38

keep myself on my toes, showing you all these

17:40

different sequences for the same thing.

17:42

But this is to show that, you know, the first time

17:45

they did too little, they wanted to keep

17:46

that posterior tension band intact and minimally invasive,

17:49

but they had a recurrent disc failed back.

17:52

So this time they had to do more surgeries.

17:54

So they actually had to take out the whole disc.

17:56

That's kind of the difficulty with spine surgery.

17:58

That's what we have to keep in mind

17:59

when we see these things.

17:59

It's not easy, it's not just one size fits all.

18:02

It's for any individual patient.

18:03

It's a balancing act between um, what their pathology is,

18:07

what their symptoms are, and what is the best surgery for

18:10

that level for that problem.

18:13

Oh, I showed you this. So this is

18:14

where I put in more slides at the beginning.

18:16

So I'll I'll um, skip past this

18:18

'cause this is what I showed you already.

18:19

It's just a review. So we wanna keep that push attention mat

18:22

as attacked as possible to prevent you from losing

18:24

it and falling on your face.

18:26

But um, not too low. I get a return disc like that.

18:30

So does everybody need surgery? No, not everybody does.

18:33

So a lot of people have huge disc. This was an amazing case.

18:38

I saw, let's see, I think it was right in my first year on a

18:40

fellowship when I was a staff huge um,

18:43

disc here on the right.

18:44

This uh, was a relatively young patient

18:47

in just a matter of months.

18:49

That disc resolved on its own.

18:51

You can't even tell it was there.

18:53

This is not uncommon, especially

18:54

for bigger discs and younger people.

18:57

So discs decrease or resolve a third of people at six weeks.

19:00

The body deals itself or two thirds of people at six months,

19:03

which is just really incredible.

19:05

So that's why we start with rest and pain medication

19:09

and steroids and physical therapy.

19:10

We don't just always go straight to surgery

19:12

unless it's intractable pain that the person has

19:15

to have it right then if they fail,

19:17

that they get epidural steroid injections.

19:18

Oftentimes, at least here in the us that was a big part

19:20

of my practice before.

19:22

Um, and the, the steroid injection is

19:24

to basically treat their pain to get them

19:26

through till the body heals themselves.

19:29

You know, it isn't healing the herniation at all.

19:32

It's just to help them get back to work

19:34

or back to the physical therapy.

19:36

But if that doesn't work, they need surgery.

19:39

Okay, let's go on to this poor case.

19:41

Okay, 65-year-old, she was healthy except she kept falling.

19:46

Another really common thing, so it had actually been um,

19:51

referred to my friend who's a neurosurgeon

19:52

and they said this person, you know, had their MI read

19:56

as um, infectious or inflammatory or possibly tumor.

20:00

And so this is a sagittal T two of the cervical spine.

20:04

Um, not a bad spine actually you can see there's a little

20:07

bit of degenerative change here in the mid cervical spine

20:10

here on the um, stir image or fat saturated T two.

20:13

You can see there's some edema here in the cord below

20:16

that level of degeneration right there.

20:19

This is a post contrast

20:20

and you can see there's patchy enhancement.

20:22

So this is why they wondered if it was infectious

20:25

inflammatory or tumor.

20:26

So I'm showing you this for a couple reasons.

20:28

Um, I'm gonna have a principle about this

20:30

but also show you um, something that's extremely common.

20:35

So when we have abnormal T two signal within the cord

20:37

and enhancement, we often for what we think is degenerative,

20:40

don't get post contrast.

20:41

So we don't see this, but if, if there is contrast

20:44

for any reason, this can be a fool

20:46

or it can be scary to a lot of people.

20:48

But we see a very interesting appearance on the axle images.

20:52

So this thing, whatever it is, the abnormal T two,

20:55

the abnormal enhancement is very symmetric on each

20:57

side of the cord.

20:59

And you can see it here too a little bit.

21:00

It's very faint here, but

21:01

it's a little bit of enhancement on each side.

21:02

A little bit T two signal on each side.

21:04

Very symmetric, not mass like um, this is actually,

21:09

oh, so let's go a little bit further.

21:10

There's no expansion of the cord like a tumor.

21:13

It's on both sides. We call this pancake enhancement only.

21:18

I'm gonna show you another case,

21:19

probably tell you what it is.

21:19

Okay, this was another one. This is a

21:20

little bit younger patient.

21:21

So exact same thing, very minor degenerative changes

21:24

but had this area

21:25

of T two hyperintensity within the cord on the stir

21:28

image here on the axial.

21:29

So this is C one level, this is C four C five,

21:32

this is five six where this is right here.

21:34

You can see it's T two signal on both sides. Very symmetric.

21:37

Each lateral aspect of the cord,

21:39

it's called a butterfly in appearance.

21:41

And this is cervical spondylotic myelopathy.

21:44

It's chronic, um, degenerative change

21:46

or chronic, um, degeneration of the cord secondary

21:49

to compression from discs,

21:51

fibro region degenerative changes in the cervical spine.

21:53

And this was actually in a re in a patient who had ms.

21:56

So this first one was actually for their ms.

21:58

If you were, you probably saw this up here,

22:00

this lesion is not degenerative, this was an MS lesion.

22:02

But we were wondering what this lesion was.

22:04

So was this MS or was it degeneration?

22:07

It was cervical spondylolytic myelopathy.

22:10

So when we have cervical stenosis,

22:12

we have a little bit different picture than we have in the

22:15

lumbar spine because in the cervical spine you're not

22:17

holding up the whole weight of your body, just of your head.

22:20

Um, the discs.

22:21

So for that reason the discs in the cervical

22:23

spine don't have to be as big.

22:24

They're smaller. They're usually T two hypo intenses.

22:27

They're not juicy discs like you see in the lumbar spine.

22:30

And more oftenly more often,

22:32

more often we have radicular pain

22:34

because of osteophytic changes.

22:36

Disc osteo ridge on vertebral pathy than big acute discs

22:41

coming out like I just showed you in the lumbar spine.

22:44

So when people have this very characteristic, uh,

22:48

constellation of symptoms,

22:49

decreased hand dexterity gain imbalance.

22:51

So the poor woman who is falling more often in sensory motor

22:53

disturbance, this all falls under the category of um,

22:57

degenerative cervical myelopathy,

22:58

which can be cervical spondylitic myelopathy,

23:00

that compression I just showed you.

23:02

Um, degenerative disc disease

23:03

or things like ossification

23:05

of the posterior longitudinal ligament.

23:07

Anything that's chronically compressing the spinal cord.

23:09

I love this figure from this article if you want.

23:11

Look this up. This is such a great review shows all the

23:14

possible things that can go wrong to, to compress the cord

23:17

and cause these symptoms.

23:20

This is the most common spinal cord, um,

23:22

disorder in adults over 55 years old.

23:24

You know, this isn't, I think in

23:25

the US I don't know about the world.

23:27

Um, and usually people start to get symptomatic when their

23:31

canal stenosis is about 50% or more.

23:35

Now everybody, and again, our imaging doesn't always show

23:37

what the person looks like when they're upright.

23:39

We only see what they're looking

23:40

like when they're laying down.

23:42

But it's um, it's actually pretty complex.

23:45

So static mechanical, the quote static, um,

23:48

mechanical is just, you know, the compression itself.

23:51

What we see in these pictures dynamic is

23:53

'cause the, when the person is upright,

23:55

they're actually moving their head around

23:56

and the cord, if you can imagine is moving

23:58

over these ridges.

23:59

It's being stretched, it's being, you know,

24:01

when you're extend stretching the other way.

24:03

It's hitting the front whenever you're moving your head.

24:05

And then there's also ischemia, which I described, um,

24:08

for the uh, neurogenic claudication, same thing.

24:11

You're having your vessels along the the cord which are

24:14

feeding the cord super important even though we

24:15

rarely ever see them.

24:17

And they're also being compressed.

24:18

So there's ischemia that's also adding to this.

24:22

Um, this uh, like blood nerve

24:25

and blood cord barrier causing demyelination

24:28

and um, eventually this cavitation and loss of function.

24:34

All right, so those are some principles.

24:35

Now how about this case?

24:36

Is this like the S I've shown you 20 ute back pain

24:39

and CLO Aquinas symptoms.

24:40

We heard that from the ER all the time.

24:43

So bowel and bladder dysfunction, severe pain, weakness.

24:46

So when she came in, this is her sagal CT 20-year-old.

24:50

Didn't really expect to see much

24:51

although she seemed like she was in a lot of pain.

24:53

This CT is actually great.

24:55

My resident picked it up right away.

24:56

This, she said this, you know this person

24:58

has these huge discs in their lower lumbar

25:01

spine, which is really weird.

25:02

Biggest one here at four five.

25:04

I don't know, hopefully you can see that it's kind of faint

25:05

but it was faint for us too.

25:07

But I would argue that really you can see things well in our

25:09

cts these days 'cause the CT technology is so much better

25:12

here on the axial image.

25:14

So when we're looking at our axis, these are just again,

25:16

just a little problem solving how we approach these

25:18

for people who aren't so used

25:19

to seeing this stuff, we're just learning.

25:22

We have this huge, so we have a diffuse disc bulge which is

25:25

uncommon for a 20-year-old, but this is

25:26

what we see in people with diffuse bulge.

25:28

And then we've got this triangle coming out of us.

25:30

This is a disc herniation,

25:31

this is our normal thecal sac, which is a triangle here.

25:34

We've got our facets, we've got our ligamentum flavum.

25:37

Always look for this dorsal epidural fat

25:39

because if that's not there, there's something wrong.

25:42

We should also always see dark fat in the frame it.

25:46

And that's again problem solving.

25:47

So um, this,

25:49

these are things you wanna look at

25:50

when you're looking at your ct.

25:51

Anyway, big disc there

25:52

because this was a young person, very unusual, severe pain.

25:57

They went ahead and they got an MRI her marrow on the sagal.

26:00

T one is very, very dark.

26:02

So we know it's T one 'cause the CSF is is dark

26:04

but the fat is bright.

26:06

Dorsal epidural fat is bright, very dark marrow on T one

26:09

because she is young so that's okay for her, that's normal.

26:12

Here's our T two CSF is bright, dorsal fat is bright

26:15

and we can see the big disc herniations

26:16

I just showed you on ct.

26:18

Now this is maybe a little bit more advanced for people

26:21

who do look at this all the time.

26:23

Um, is this degenerative? I'm gonna ask you.

26:26

Well maybe she has a little degeneration

26:27

but that's not really what this is gonna be.

26:29

This looks just like our ct, this axial T two.

26:32

So you can see normal thecal sac here.

26:34

You can see this big triangle coming just like we saw in our

26:36

CT of disc herniation.

26:38

But how many times do you see a disc herniation coming

26:41

straight back into the canal all the way to the back?

26:43

So this is the dorsal epidural fat.

26:44

So that means this is the dorsal aspect of the dura.

26:48

It's coming straight back. Most extrusions we know come out

26:51

of the annulus, they go up

26:52

or down under the posterior longitudinal ligament sub

26:54

ligamentous extrusions.

26:56

So something else is going on here.

26:58

Oh, I mean, so I put a little principles here,

27:01

sorry I'm surprising myself here.

27:03

So when, this is just a little aside, Coquina syndrome.

27:06

So um, and I'll tell you what it is, which is a surprise.

27:09

This person had chronic quinine dysfunction

27:11

of the lumbosacral nerve roots causing symptoms of bowel,

27:13

bladder incontinence, saddle anesthesia,

27:16

back pain, lower extremity weakness.

27:17

So again, we hear this all the time, well

27:20

the ER kind of puts us in things.

27:22

We see this indication a lot, a lot of times we're skeptical

27:25

and that for good reason has low prevalence

27:27

but it's highly litigious.

27:29

So if something is missed, that person,

27:31

you know, somebody's gonna get sued.

27:32

So it's very important that we take these all seriously.

27:35

We look at them and um, try to figure out what's going on

27:37

and we want to not miss anything severe.

27:40

The most common cause is a lumbar disc herniation, 45%.

27:43

So that's what we just saw there.

27:44

So she did indeed have caught Quin syndrome

27:46

and now let's go back to the case.

27:47

Alright, so this is a blow up of that.

27:50

Again, I'm showing you this,

27:51

how it's going back instead of up and down.

27:53

Um, you can kinda see also it has an unusual shape here.

27:56

So it's coming out,

27:57

it's a little divot and then it's coming back.

27:58

It's kind of like a snowman.

28:00

This is the, this is a T two, this is a T one.

28:03

So this is an intradural disc herniation.

28:05

And I'm showing you this. I said at the beginning,

28:07

all my lectures, uh,

28:08

the things I learned the hard way

28:10

I'd heard about this when I was a resident.

28:11

I read it, the book or something, what I read books.

28:14

Um, I didn't believe it could happen.

28:16

Like how could that possibly happen? I don't believe it.

28:18

And it wasn't actually until a couple years ago,

28:21

I'd been staff for gosh, three or four years

28:24

before I saw this.

28:25

And we actually had a run of them.

28:27

And um, so it was really important.

28:29

So the surgeons actually asked me to write this up with them

28:32

because they hadn't seen it very much either.

28:33

And we all of a sudden we're seeing a bunch.

28:35

So it's one of those things that might be more common than

28:37

we think, but if you haven't seen it, you don't even know.

28:40

You don't uh, know it if you don't know it.

28:42

Is that how you say that? So this is a nice figure showing

28:45

um, what is actually happening here.

28:47

So when you have a disc herniation,

28:49

so when you have your disc annulus, it has to get

28:51

to the disc tear, whatever air tear of the annulus,

28:55

the nucleus pulis comes out.

28:57

Usually it's stuck by the posterior longitudal ligament.

29:00

You have sub ligamentous extrusions up and down.

29:02

But if it goes through the um,

29:05

posterior longitudinal ligament for some reason there's um,

29:08

usually very tight apposition of the annulus,

29:13

the posterior lung ligament and the dura.

29:15

And, but if there's any kind of like, you know, some kind

29:18

of inflammation or prior trauma, something happens there

29:20

or just the injury itself, they, they can get weak

29:24

and the disc can actually go through it.

29:25

So it has to go through the annulus, it goes

29:28

through the PLL, it has to go through the dura

29:31

and it has this very characteristic wasting here waist,

29:35

a waist like a snowman or whatever neck like a snowman.

29:38

Um, where it is splitting the era white

29:40

and the dura which are also tightly opposed.

29:42

So that's why it's causing this shape.

29:45

So when you see the shape, this was another case.

29:48

This was like the same month.

29:49

This person actually had two,

29:50

you see this very character thing

29:51

where the disc is coming all the way toward the back

29:53

and it's kind of got this snowman snowman on its

29:55

side appearance.

29:57

And here on this AAL you can see this very

29:58

typical huge triangle.

30:00

This is a nice picture from the Mayo group from

30:01

Radiographics showing

30:03

how it's not compressing the thecal sac,

30:04

it's actually going in and

30:06

because it's going in there's not much

30:08

resistance inside the dura.

30:09

So it's compressing all those nerve roots.

30:11

And these people are way more symptomatic than normal disc

30:14

herniations oftentimes because compressing from the

30:17

inside basically if you can imagine

30:18

that is really compressive in addition to being inflammatory

30:22

because your nucleus pulposus is um, immune privileged,

30:26

organ immune privileged.

30:28

So it hasn't seen your immune system basically.

30:30

So when it escapes through a tear

30:32

and into your thecal sec, your immune system was like,

30:35

well everywhere

30:36

around there your immune system is like well what is this?

30:38

And a bunch of, you know, inflammation starts

30:40

as your body tries to fight this kind of foreign thing

30:43

that it's not used to seeing.

30:46

Anyway, that's true of all disc herniations.

30:48

So here's another one. This is where our third case,

30:50

that was like in six weeks or something like that.

30:52

This had been mistakenly called a tumor, possibly a tumor.

30:55

And you can see why 'cause it had gotten contrast

30:58

for some reason and it was marginally

30:59

enhancing and been there a while.

31:01

And so the margin was enhancing coming like straight

31:04

out like I showed you the others.

31:06

This is the axial

31:07

and you can see why people would be worried about this.

31:08

Why is this, you know, filling the thecal sac

31:11

with abnormal enhancement.

31:13

This is fat saturated post um, contrast.

31:16

So this one too, this was a T two.

31:19

Um, so the, the dorsal drill fat is bright,

31:22

dors fat is bright because I know what's T two,

31:24

this looks like a normal fecal sac

31:26

but there should be CSF in it but it's gray.

31:28

That's 'cause it's filled blood and disc material anyway.

31:31

So watch for that snowman on its side

31:34

coming straight out to the back.

31:35

Keep that in mind. And it's important that we mention it

31:38

because when the surgeons go in there, it,

31:40

this is a very different surgery than a normal

31:42

um, disc surgery.

31:44

And if they go in there and don't know it can be uh,

31:47

you know, it's, it's way more complicated.

31:48

It can be a problem. And actually I've seen

31:50

that happen a couple of times

31:51

and even further these are often calcified as in this case.

31:55

And so when they get in there there's a calcified disc.

31:57

This calcification actually like usually sticks to the dura.

32:01

So this one they actually,

32:02

they treated one, he had to abandon it.

32:04

She's like I've gotta treat the rest another time.

32:06

It dorsally decompressed rather than to get the disc

32:08

because this was stuck to the drill,

32:10

there was not really much they could do

32:12

to relieve the symptoms.

32:14

So not all disc herniations are created equal

32:17

interoral discs produce more symptoms

32:19

more severe than I expected.

32:20

So if it's a weird shape,

32:22

like I said snowman on its side coming straight back,

32:25

consider this, remember this.

32:26

Now that you've seen it much harder surgery

32:28

so we should say it, we had a watch for it.

32:30

And also CT is very useful

32:32

because if it's calcified that adds a whole additional level

32:36

of complexities of the surgery.

32:39

All right, on that note, let's skip to another.

32:40

Not all discs are created equal case.

32:43

This is in the thoracic spine.

32:45

So this is a 40 yard

32:46

with increasing lower extremity weakness and back pain.

32:49

Now usually you don't get,

32:51

you get little discs in the thoracic spine.

32:53

You see when you're going down little ones,

32:54

you know they're on usually off right side or left side

32:56

and then just a little bit indenting tocal sac.

32:58

You rarely get big ones though.

33:00

And that's because you don't have a lot of micro promotion

33:02

or instability in the thoracic spine

33:04

because you've got stabilization with your ribs and sternum.

33:07

So when you do get a big disc

33:08

and thoracic spine, very unusual.

33:10

That's not, not regular degeneration.

33:13

So this one, you know this is a sagittal stir.

33:17

So the CSF is bright but the fat is not bright.

33:20

So stir fat, saturate T two see this big

33:22

disc radiation coming out.

33:23

There was abnormal cord signal.

33:25

Even though this was a chronic process, it was um, you know,

33:28

gradually causing pain and more and more dysfunction.

33:31

And this is the um, myelogram.

33:33

So you can see also I said MRI

33:35

and CT are useful in a lot of cases it was calcified.

33:38

So not necessarily degenerative.

33:40

Actually this disc space are pretty nice, right?

33:42

This doesn't look like degenerative spine.

33:44

So how do we do surgery? How do we help these people?

33:48

That's what I'm gonna show you in a minute.

33:49

These are things I just said.

33:51

If um, the tho thrust uh, stabilization with ribs

33:55

and stern making them less common calcification,

33:57

like I said can adhere to the dura,

33:59

which makes it very difficult.

34:00

So these are important. It can cause CSF leaks

34:03

because they try

34:04

to pull it off cause a big hole in the dura very hard

34:06

to repair anywhere but especially in the thoracic spine it's

34:09

hard to get in there and their

34:10

approach is totally different.

34:11

So it's very hard to fix those.

34:13

And when you have these big calcified thoracic discs,

34:15

a third of those people are gonna have severe com.

34:17

Well some kind of complication which is a mess usually.

34:22

So this is something I'm showing

34:23

you in case you ever see it.

34:24

People internationally, I don't know if you'll see it, um,

34:26

people in our in US you might see it more and more.

34:30

I have no idea what this was

34:31

again, that's why I'm showing it to you.

34:32

When I first saw it, I'm like wow,

34:33

what is, what is happening?

34:35

In this case this person had this large um,

34:38

calcified thoracic disc causing severe canal stenosis

34:42

and compression of the thoracic cord

34:44

after surgery I saw this ct,

34:45

I'm like what is happening here?

34:46

So this looks like fat signal, this is the sagal.

34:49

Um, it looks like a little bit of that discus left.

34:52

I'm like wow, did they accidentally leave that?

34:54

So what they do actually is they do a partial ectomy

34:58

because you can't just go in there easily from the front.

35:01

They go in from the side, they took out a bone, part

35:04

of the bone and that vacuum, that space kind of pulls back

35:08

that herniation a little bit.

35:10

Um, and then also they leave a little bit of the edge

35:14

that's connected to the dura there

35:15

because if they've relieved the mass effect

35:17

by taking out some of the bones, everything comes back a

35:19

little bit, they can leave a little bit

35:22

so they don't cause a dur tear in the CSF leak.

35:24

So if you see this, it's not a mistake.

35:27

That's actually what they meant to do.

35:29

Um, and here it is on MRI.

35:31

This is actually the way I first saw it, which is crazy.

35:33

I'm like what is happening here?

35:35

But this um, this is the fat

35:37

that they packed within the ectomy.

35:39

This dark thing is the little bit of disc they left

35:41

that corresponds with this part of the ct.

35:43

So that's normal. That's good treatment.

35:45

They fix that patient and it's um, it's like I said it's,

35:49

it is a relatively new technique I think.

35:50

Uh, it's kind of something that they do here a lot.

35:53

It's a specialized procedure Ryan,

35:54

but it's getting out all over.

35:57

Uh, spine surgery is getting more

35:59

and more advanced so you might see it all right, so,

36:02

oh gosh, so many stories.

36:04

I've gotta make sure that I um, don't talk too long here.

36:07

I'm not gonna make it through this whole thing

36:09

but that's okay 'cause I think I've shown you the most

36:11

important parts of degenerative

36:12

and post-op concepts already.

36:14

This is a 48-year-old with back and leg pain.

36:17

So is this degenerative stenosis and what is the treatment?

36:20

So on this axial T two CSF is bright dorsal dorsal,

36:24

dorsal subq fat is bright.

36:26

Um, I told you a little grading scale, there's a little bit

36:29

of a basement that's mild stenosis.

36:31

If there's a little bit like an oval

36:33

where the nerves a little more aggregated

36:34

but you can see CSF, that's moderate stenosis.

36:37

So that's what you might call this moderate stenosis.

36:40

Um, here on the SAG T one good alignment.

36:44

There's not a lot of DYS space eye loss maybe a little bit

36:47

the thecal sac here though this bright stuff in the back.

36:50

Dorsal epidural fat is really compressing the thecal sac.

36:54

Here is the T two. This stuff right here.

36:57

This is the fat, it's bright on T two it saturates out on

37:00

SAT fats three T two or stir.

37:02

You can see there's severe thecal sacs in the nose

37:05

or compression really a lot right here at four five.

37:08

So it's this degenerative.

37:10

Is that a disc herniation causing

37:11

that is men flavin Buckley it's not.

37:14

So this is epidural lipoma mitosis.

37:16

So what I'm talking about adding value,

37:18

you know not everything is degenerative

37:20

that's causing stenosis

37:21

and symptoms of that we think

37:22

of when we think of canal stenosis.

37:24

Secondary degeneration, this is pretty common

37:26

and it can be actually a very bad,

37:29

I'm gonna call it a disease, a bad disease to have

37:31

because it's very, very hard to treat usually.

37:34

So when we have overgrowth of fat in the canal,

37:37

usually this has caused either, you know,

37:39

it's either a high BMI

37:40

or if people are on like steroids

37:42

for different inflammatory uh conditions, things like that.

37:45

It can cause overgrowth of this fat

37:47

because that's the reason it develops.

37:50

If they, you know, usually what you first try

37:52

to do is you um, try have weight loss

37:54

or surgery that'll help you lose weight

37:56

or you stop those medications if you can.

37:58

Not everybody can but if it doesn't go away with that

38:01

'cause it's cause severe radiculopathy, it's compressing

38:03

that thecal sac like I just showed you.

38:05

Severe thecal second depression,

38:07

then sometimes rarely they have to do surgery.

38:09

They don't want to because just like calcification fat

38:11

sticks to the dura when they try

38:13

to peel it off, that closes dural tears.

38:14

CSF leaks, it's a huge, huge mess

38:16

and know the cord can get tethered and uh, it's horrible.

38:20

So something is benign

38:21

or innocuous as fat can be a big, big problem.

38:25

But this is something that's not often I like,

38:27

you know I'm saying this 'cause I see this

38:30

cause called degenerative.

38:31

Like they say oh degenerative spine whatever

38:33

canal does thecal second impression.

38:34

But this is not degenerative in any way.

38:37

Um, so it's important to realize what is causing the

38:42

stenosis or that's not really stenosis,

38:43

it's the equal sac compression.

38:45

So this is um, very under-reported and underestimated

38:49

and underrecognized.

38:51

So watch out for that. How about this one 45-year-old

38:54

with increasing neck pain and myelopathy.

38:57

So upper extremity and lower extremity weakness.

38:59

Um, is this degenerative? Will surgery help this person?

39:04

So we see um, when we're going through this on the sagal ct,

39:07

so good alignment DYS space height are pretty good really.

39:11

There's some maybe a little anti osteophytes a little bit,

39:14

but are they really doing much?

39:15

I don't know. So here on the sty two CCF is CSF is bright,

39:20

subq fat is bright, um, this part looks okay, right?

39:24

That's what you think of a normal cervical spine.

39:26

But here in the mid and lower there's not a lot

39:28

of CSF in front despite their not

39:29

being terrible degenerative changes.

39:31

And here on this axial like merge

39:33

or something, you see there's no CSF in the front or back

39:35

and this cord is really really flat.

39:38

So this is congenital stenosis.

39:41

Um, this is usually caused by having short pedicles

39:45

and we can recognize this as being, you know, congenital.

39:47

One of the clues is it's usually multiple

39:49

levels rather than just one level.

39:51

And it's important to recognize it

39:52

because when everybody's gonna, not everybody

39:56

but most people end up getting degenerative changes in their

39:58

cervical spine that'll cause symptoms.

40:00

But these people get it earlier

40:01

because they already didn't have enough room.

40:03

So when the degenerative changes do get worse,

40:05

they have zero room.

40:07

Also even maybe more important they have increased risk

40:09

of cord injury even with minor trauma.

40:12

So like ground level falls and things like that.

40:14

Your CSF in front of the cord is um,

40:17

is a buffer to protect your cord.

40:19

So you can imagine you fall, you know the cord is,

40:21

it usually has the CSF to protect a tiny bit

40:24

but if it's just hitting those bones,

40:26

it's gonna be injured more easily.

40:28

So indeed these people do get surgery.

40:31

Um, and the surgery is typical is typically um,

40:35

posterior decompression to give that um,

40:37

to open up the canal, give the cord more room.

40:40

The question is when, so they don't wanna do surgery

40:43

to early because as we know,

40:45

anytime you get spine surgery you're altering the

40:47

biomechanics, which means uh,

40:50

other injuries are more you're, you're more prone to injury

40:54

again more easily

40:55

'cause you've got altered biomechanics in your spine.

40:57

But also the degenerative changes

40:58

that develop later will come

41:01

what sooner The junctional levels.

41:04

So that's kind of a hard thing to figure out they need,

41:06

they don't wanna wait too long till the person falls

41:08

and has a cord injury but they don't wanna do it too soon

41:11

'cause nobody wants to have the surgery too soon

41:12

as we know the levels above and below to generate faster.

41:16

People ask me if I give measurements,

41:17

I never measure things.

41:19

I just, when I look at it

41:20

and it looks like there's no CSF despite very um,

41:24

little degenerative change.

41:25

That's what I call it. And I kind

41:28

of also support my argument with the literature

41:31

'cause it this nice article from radiology talks about

41:34

how you know, everybody's different depends on your sex,

41:36

your age, your height, all these things that um,

41:40

will influence how big your, your canal is.

41:43

So what about this one, this 56-year-old neck pain.

41:46

You can see there's obviously something here in the canal

41:48

causing canal stenosis, but what is it

41:50

and is it degenerative?

41:51

And will surgery help? So we know what this is,

41:54

this isn't too hard I think,

41:57

although I think it's super under called

41:58

and again this is called degenerative all the time.

42:01

But look at the, so normal alignment,

42:03

look at the disc space heights, you know,

42:04

little loss but not much.

42:05

This is not really degenerative case at all.

42:08

But you have this huge block of bone in the anterior aspect

42:11

of the canal causing, you know, severe canal stenosis.

42:14

Certainly cord compression, it's been growing forever

42:17

so the cord is accommodating to it.

42:19

But um, but it's also important to mention

42:22

for the same reasons as I just talked about.

42:24

So increased risk cord injury even in minor trauma

42:27

'cause you've got no extra CSF, you've got no room.

42:29

So your cord is right up there.

42:30

So if you're hitting it, if you fall your cord hits this big

42:33

block of bone, it's gonna get injured more easily.

42:35

So it grows super slowly, your cord accommodates

42:38

but they still wanna do surgery a lot of times

42:41

to protect the cord for those reasons.

42:43

It also continues to grow this in dish.

42:46

They continue to grow like one

42:47

to three millimeters per year.

42:49

Um, up and down 0.3.

42:51

I found that in paper I was super, super interested in this.

42:54

I didn't know that. I think it's actually quite fascinating.

42:57

There are a bunch of different patterns

42:58

and we had great keys last night.

43:00

Um, I'm so excited and I, the residents

43:04

and folks trying to think I'm crazy

43:05

because I'm so excited about OPLL.

43:08

But it's very, very interesting.

43:09

So you can have like this long

43:11

contiguous like we're seeing here.

43:13

You can have it just behind the vertebral bodies kinda

43:15

segmental or mixed

43:16

or it can sometimes mimic um, the uh, disc osteophytes.

43:21

So here just more cases, we see this all the time.

43:23

It used to be that they would say that this was certain um,

43:27

populations like these certain

43:29

countries in the world had this more than others.

43:30

Now I know that's not true

43:31

because I see this in every people from every country age,

43:35

gender, everything.

43:36

So again, big blocks of bone

43:38

and they they, oh I used to think they only used

43:40

to do dorsal decompression until recently.

43:44

And then I found out actually sometimes they do an anterior

43:46

approach to preserve that posterior tension band.

43:48

Like I said, you um,

43:49

when you lose this you're losing the stabilizing thing

43:52

that keeps you back, keeps from falling on your face.

43:54

Um, but you can do anterior

43:56

or posterior approach nowadays you can do

43:58

corpectomy and take it out from the front.

44:00

So you might see either one to those of you

44:02

who asked me about that not too long ago.

44:04

You might be much this one. Um, oh, another one. Yes.

44:09

So you can see this person, again,

44:11

this is not a degenerative case.

44:13

So this person has OPLL kind

44:15

of the segmental like I said, or mixed pattern.

44:17

So it's behind the bodies

44:18

but it's also, you know, at disc level.

44:20

But behind the body, behind the body causing canal stenosis,

44:23

they also got fusion in the front from diffuse idiopathic

44:26

skeletal hyper OSTs.

44:27

So I'm showing this one 'cause there's no way they could

44:29

treat this one from the front.

44:30

So they had the dorsally decompressed

44:32

'cause they wouldn't have been able to take

44:33

out all this stuff.

44:35

This one was super excited about a young patient.

44:37

This was a trauma case but I was still super excited

44:39

'cause this is a 38-year-old

44:41

and um, it was the free limb said degenerative change,

44:46

you know, maybe age accelerated 'cause they were so young.

44:48

I said that's not actually degenerative

44:50

because look at this very characteristic bow tie pattern.

44:53

And this is a type of early opioid just so you know,

44:56

DYS space high or preserved, there was no degenerative.

44:59

Alright, oof gu I have 45 minutes

45:03

so I'm only gonna show a little bit more here.

45:04

52-year-old man with chronic

45:06

but increasing neck pain and stiffness.

45:09

So I just showed you a case like this. Is this degenerative?

45:13

Uh, they might have a little bit

45:14

of degenerative change down here in the lower cervical

45:17

spine, but up here this looks pretty nice.

45:20

A little bit of maybe os osteoid or is that OPL.

45:22

But here you see the fusion ally

45:24

and this is diffuse osteopathic skeletal hyperos ptosis.

45:27

Now why am I talking about this?

45:28

Because there's often caused de all degenerative,

45:31

but it is not and it's treated differently

45:34

and you can have no degeneration have

45:36

dish or you can have both.

45:38

It's um, abnormal bone formation, you know, in the front.

45:42

You can see it, you often see it in the thoracic spine,

45:43

but you can see it cervical, you can see it really anywhere.

45:46

It does cause pain, stiffness, limited motion, um,

45:49

can cause dysphagia as it's impacting the um,

45:53

esophagus, the airway.

45:55

Interestingly, it's usually older men,

45:57

it's a specific population.

45:58

Older men with other comorbidities like diabetes,

46:00

obesity, metabolic syndrome.

46:01

So there's something somewhat inflammatory going on.

46:04

This also, like they said, just like OPLL, this grows

46:08

very interesting to me again, right?

46:09

Not you, but I think it is.

46:11

This actually starts in the anterior ventral, um,

46:14

vertebral body and grows up and down.

46:16

So this is called a non marginal osteophyte.

46:18

A marginal osteophyte at the margins of the disc.

46:20

That's like your degenerative osteophyte margins.

46:23

Non marginal, starts in the middle, goes up

46:25

and down, fuses ankylos spine causing abnormal biomechanics.

46:30

So when you fall, you're gonna hurt your cord.

46:31

You're gonna have weird fractures,

46:33

just like something like ankylosing spondylitis.

46:35

So disc spaces can be preserved.

46:37

Um, you can have no degeneration,

46:38

you can have some degeneration.

46:41

Why does it matter again if you just good fracture.

46:43

Some people do need surgery for this.

46:45

This one I think had dysphagia. This ous xray.

46:48

Huge bulky, non marginal osteophyte

46:52

and used grow.

46:53

Oh, we treated with, um, bisphosphonates.

46:56

I didn't know that either. Till recently this person had

46:58

both very unlucky.

46:59

Sometimes you see they have ossification everywhere

47:02

OPLL dish.

47:03

And they, because they have this ankylos spine all fused

47:07

abnormal biomechanics, they get the unusual fractures just

47:09

like ankylosing spondylitis.

47:11

This poor person had one here

47:12

and they um, anterior inferior endplate also right here

47:15

through the um, like right under the endplate

47:18

of this body, the weakest part.

47:20

'cause all this is fused. This is like a solid block

47:22

of bone, as is this.

47:23

So this part where there was just a little bit of, uh,

47:25

weakness in these, uh, the anterior posterior blocks,

47:29

basically this is the weakest part.

47:31

They're also usually osteoporotic

47:33

when we have this, by the way.

47:34

Um, so that was the weakest part. That's where it fractured.

47:36

And these are often very severe cases.

47:38

High morbidity and mortality.

47:42

Um, oh, I'm gonna show this case.

47:44

'cause this was super interesting to me.

47:46

Um, my, I went back to work where I did my fellowship

47:50

and one day of my attending called me over, said my,

47:52

I need your opinion on this case, which any of you out there

47:55

who like you trained and then somebody your first needs your

47:57

attending ask you for something.

47:59

It's like the best feeling in the world.

48:01

If you like, you've accomplished

48:02

something, I've learned something.

48:02

Anyway, so I was really excited.

48:04

So he said, what do you think about this?

48:06

I think this is dish, but look at the thoracic spine.

48:08

What's going on? Here. And then also look at the sacrum.

48:11

There's fusion of the sacroiliac joints.

48:13

So is this, you know, enclosing spondylitis? Is it dish?

48:17

What's going on? So this is to show you

48:21

that people can actually have both together.

48:23

This person had both dish

48:25

and enclosing spondylitis, so they were at double the risk.

48:29

And um, this is, oh, I'm going fast

48:33

'cause I wanna show you that this can all go together.

48:35

These are the bulky, non marginal osteophytes in the spine.

48:38

Enclosing spondylitis,

48:39

super demineralized were those thin gray cell, um,

48:43

vertically oriented, um, ossifications in

48:46

as in ILOs spondylitis.

48:48

And then typical marginal osteophytes when it's just

48:50

degenerative, normal degenerative change.

48:53

So you can have both. And one way to tell the difference,

48:55

if you have few sacroiliac joints, um, get an mr

48:58

because if it's ankylosing spondylitis, you'll have,

49:01

um, edema.

49:02

So be T one hypo intense, uh,

49:04

T two hyperintensity and enhancing.

49:05

And that can help you determine whether it's

49:08

just kind of chronic fusion.

49:09

Somebody who has a lot of, um, kind, you know,

49:12

those calcium phos ossification, people

49:14

who have calcifications everywhere in their ligaments

49:16

and in their spine versus this inflammatory process.

49:20

Also probably their age and their history.

49:23

So all enclosed spines increased risk of trauma

49:26

by altered biomechanics.

49:30

All right, few more minutes. This one.

49:33

All right, this is something we see more common

49:35

that causes canal stenosis.

49:36

This is supercon. You see this almost every day.

49:39

So here we have a saddle T two here at um, L 4 0 5,

49:43

we've got this round structure in the canal.

49:44

That's T two hyperintense in the middle,

49:46

T two hypo intense on the outside.

49:48

It's arising on this axial image from the degenerated right

49:51

medial bici.

49:53

Same thing here on this one,

49:55

except it's a rising from a degenerated left side bici joint

49:58

T two middle hypo intensity on the outside.

50:01

We all know this is a synovial cyst.

50:02

Herniation of that synovial

50:04

through the facet capsule can cause radiculopathy

50:07

and compression of the thecal sac.

50:09

And this is just to show you,

50:10

because I thought everybody knew this

50:11

because I've been doing this since, you know,

50:13

different fellowship, this huge part of my practice.

50:16

But not everybody knows this.

50:18

Um, but these can be treated by us first.

50:20

Our first, first approach

50:21

by us can actually save the patients a lot of time

50:24

and money and maybe a surgery.

50:26

So, um, great paper by our friends at UCSF showing that,

50:30

you know, CT guides, that's the way I do them too.

50:32

Fenestration poking holes in those synovial cysts

50:35

can actually, um, decompress the cyst enough

50:39

to relieve symptoms in, you know,

50:41

almost about half the patients.

50:42

They don't end up having had surgery.

50:44

I didn't realize it was so

50:45

controversial in the surgery community.

50:46

They actually asked me to come talk

50:47

to big neurosurgery meeting.

50:49

It was in a debate about which is

50:50

better surgery versus this.

50:52

And um, you can imagine surgery,

50:54

even minimally invasive lungs.

50:55

It's, you know, there is some recovery whereas we can get

50:57

this done as an outpatient procedure.

50:59

15 minutes, not really any sedation

51:01

and they can go home with maybe not ever after a surgery.

51:04

So if you see these, think about this.

51:06

If you treat them and even if you don't,

51:07

when you report them, talk about the cyst.

51:10

These ways we can treat them,

51:12

I mean it's a good one for us to try first.

51:14

If it has a very thin rim,

51:15

this T two hypo intense rim is very thin

51:17

and there's very a lot of fluid signal on inside.

51:19

'cause we can either, you know, some people try to aspirate,

51:22

I just poke holes in it, kind of releases it, um,

51:24

out, but it'll dissipate.

51:26

But if they have a cal spread rim, like in this case,

51:28

or very thick rim, it's t hypot intense, um, in the middle,

51:32

then that's obviously not thing

51:33

we can do with needles to this.

51:34

That has to go to surgery.

51:35

So put those things in your report.

51:37

Um, maybe it'll get the patients to us

51:39

and we'll save some time.

51:42

Kudos for the patients. All right,

51:44

very quickly in the last few minutes,

51:45

I wanna show you just some post-op things

51:47

'cause I kind of showed you surgery throughout.

51:49

Um, this case I just put,

51:51

'cause it was so had it up long ago, it was very dramatic.

51:54

Um, this isn't really anything

51:55

that learned except that it can happen.

51:56

I had no idea it could happen.

51:58

So 45-year-old came in, this was a stroke case,

52:01

obviously it came into the er,

52:03

I found out later they had had an anterior cervical

52:04

discectomy infusion the day before.

52:06

And were looking at their carotids

52:08

and you can see there is a loss

52:11

of the right carotid here

52:13

and that's what caused their stroke.

52:15

So, um, when they do anterior cervical discectomy infusion

52:19

with anterior plate screw fixation,

52:20

which you see all the time,

52:21

the most common spine surgery you're

52:23

gonna see in post-op findings.

52:24

This is the way they go in and it looks pretty gruesome,

52:27

but it's super simple for a spine surgeon.

52:28

They've been doing this forever, super safe.

52:30

Um, but they kind of split open the neck to get there,

52:33

you know, and they're pulling the, you know, the,

52:35

the carotid sheet that this, the, this space

52:39

to the right separate from the airway.

52:41

Um, and I thought, oh, did they hit it?

52:44

You know, I'm like, well how did this happen?

52:45

Did they hit it? I don't know what happened there,

52:46

but I found out researching this that actually if you have,

52:50

um, preexisting carotid stenosis from atherosclerosis,

52:54

they were traction of that for the period

52:57

of time when they're doing the spine surgery,

52:59

actually makes you more prone to stroke.

53:02

Um, so either from, oh, sorry, I went too far,

53:05

either from dislodged plaque

53:07

or just second ion of an den narrowed vessel.

53:09

So that's something I learned. So I'm sharing that with you.

53:11

So there's a lot of carotid disease already.

53:13

Maybe you can mention that when you're doing your,

53:15

the pre-op CT or something, I don't know.

53:17

But anyway, more pro stroke, it can happen.

53:19

So here are just some more

53:20

that you see every day when they're in the cervical spine

53:23

and they have their, um, lateral mass screws.

53:26

They don't wanna go into the foramen transfer cerium

53:29

where the, um, vertebral artery is

53:31

or the neural free, where the end dorsal root ganglia is.

53:34

Um, so here's some cases, you know,

53:36

where these screws are going kind of far forward a little,

53:38

making you a little nervous here, sweating a little bit.

53:41

'cause obviously I don't know if they,

53:43

they obviously their surgeons would not see a CTA when

53:45

they're doing the procedure, but this person was super

53:47

lucky, this patient 'cause their vert was coming in,

53:49

you know, a little bit in front there.

53:51

It wasn't quite in the, in this spot, um,

53:55

yet where the screw is.

53:56

They were super lucky. Um, the screws you sometimes see, um,

54:01

here in the sagal here on the axle, they can go a little bit

54:04

through the anterior cortex

54:05

but they shouldn't go too far like into the

54:06

uh, esophagus here.

54:09

I asked my, my spine surgeon friends,

54:10

I showed them both base cases and I'm like,

54:12

you know when you see these things

54:13

after, do you take it out?

54:14

What do you do? And they're like, no.

54:15

If it didn't cause symptom strength surgery,

54:17

we probably will just leave it go.

54:19

Wow, that's, that's bold.

54:21

Um, but anyway,

54:23

so these are the most common hardware

54:24

complications you see immediately.

54:26

Post-ops. You can have vascular injury very rarely.

54:28

Again, this is something that they,

54:31

they use all the time without injury,

54:32

but if you, you know, they can happen.

54:35

Vascular injury, nerve irritation if they're in the neural

54:37

foramen, prevertebral extension

54:39

of the screws hitting some vital structure in the

54:41

front or loading parts.

54:42

We saw this, we took us forever to figure what this was

54:44

and this was a cap that came off.

54:46

They're not gonna do anything about that,

54:47

but we wanted to know what it was.

54:48

You can have sometimes little parts that have dislodged

54:51

or I can also have pseudomonal, which we see on occasion.

54:55

You know, I told you about all the reasons you have dural

54:58

tears like the fat and the calcification and stuff.

55:01

Um, usually those are recognized during surgery.

55:03

But if a person comes in like the week

55:05

after surgery with CSF hypotension

55:07

or the static headache, then they might consider

55:09

that there is a new CSF.

55:10

Like they didn't see like in this case,

55:12

young patient dorsal leak decompression,

55:15

big fluid collection, not only subcu

55:17

but also intersection cavity.

55:18

And then, uh, kind of this I guess is the canal, it's kind

55:22

of compressing the thecal sac forward.

55:24

Um, same with this one.

55:26

So this big fluid collection is,

55:28

looks like it's really compressing the thecal sac.

55:29

This person that was not symptomatic, like from this,

55:32

from the compression of the nerve,

55:33

it was like CSF hypotension symptoms.

55:35

Um, this is susceptibility from the

55:37

crosslink from the hardware.

55:39

So that's another thing.

55:40

We have collections for compressing with equal sac.

55:42

We really don't know what to say about those

55:44

because they can be severe, um,

55:46

look severe to us and not our symptoms.

55:48

So we kind of just report them I think.

55:49

And we don't say too much because we don't really know

55:53

or we talk to the surgeons about it.

55:55

So sils, so, um, like I said,

55:58

most are detected during surgery.

56:00

It's, you know, maybe up to 16% of cases

56:02

and if they're longer surgeries, OPLL

56:05

or the calcification of the dural lymph fat et cetera,

56:07

or prior radiation or dilatation.

56:10

In some patients with collagen vascular

56:12

disease, that makes it more common.

56:15

And this, oh, I had to put this in

56:17

because it was not too long ago.

56:18

So now it used to be they said don't get imaging

56:20

after spine surgery for a month.

56:21

At least MRI now they're getting surgery like the day

56:25

after everybody is getting immediate post-op imaging.

56:28

And what do you do with this? So this is

56:30

ct, I don't know what to do with this.

56:32

This was a bad case. They had a lot going on,

56:34

but you see all this soft tissue and flu whatever

56:37

and I don't know what it's doing to the sac,

56:39

I don't know where the thecal sac is.

56:40

So I'm just showing you this

56:41

to say this is something that might happen.

56:43

I don't know what to tell you about it.

56:44

Maybe if there's anybody out there that knows what

56:46

to say about it, let me know.

56:47

'cause these are being done for patients

56:48

symptomatic, not symptomatic.

56:50

Get you a truck to surgeon

56:51

and say, what do you actually want me to say, um, about it?

56:55

So post-op infection, again, I'm going through quickly just

56:59

so I can get through a few more things here.

57:01

So this had been a person who got a mic, a, a discectomy,

57:05

uh, young patient, 45-year-old, um, that had back pain,

57:09

increasing back pain the weeks after surgery.

57:11

So getting worse instead of better, you know, expected

57:13

to hurt after surgery but it was getting worse and worse.

57:15

So she went in and this was, this was the imaging.

57:19

So, um, we got a loss of the black line,

57:22

which is the end plate here.

57:24

Usually we have this black magic marker line going around.

57:27

We can't see it here on this T one,

57:29

but they did rough up the edges, you know,

57:31

for the surgery there's some enhancement which can be seen.

57:35

Um, but you know, there, you know, it looks, it looked kind

57:39

of bad, but they sent her home or this was outpatient

57:42

and she came back and this was indeed a post-op infection

57:45

that continued to get worse.

57:46

So she ended up having an abscess in the dorsal,

57:49

um, soft tissue use.

57:51

So it's not very common, um,

57:53

that you get post-op spon discitis, but it's important

57:56

because everything you try to fix can get messed up.

57:59

So you can have implant migration.

58:01

So the implant they put to stabilize it

58:03

and um, it either won't heal or move around

58:06

and then they basically have to redo the surgery.

58:08

The surgery was for nothing. Um,

58:11

it's usually happening in the first month after surgery.

58:15

So, um, I think four is pretty early

58:18

and a lot of my body church

58:19

and friends, they don't call any infection four

58:21

days out when I agree with that.

58:22

But CRP is really the best way, not imaging

58:24

to, to evaluate this.

58:25

If you have your CRP rising, um, over this period of time,

58:28

if they keep measuring it then they know that's infected.

58:32

But you can have normally, you know, this kind

58:34

of T two hyperintense

58:35

or linear enhancement

58:36

where the surgery was even nerve root

58:38

enhancement for up to six months.

58:40

But, um, if you have like increasing enhancing

58:42

paravertebral, prevertebral, epidural soft tissues,

58:44

you know, that's not right And more

58:46

and more like demineralization of of the end plates.

58:51

All right, few more.

58:53

Um, 65-year-old with deformity

58:55

and pain dorsal decompression eight years ago.

58:57

So she remember the principles I told you about.

58:59

So like the rest of your body, your head is kind

59:02

of pulling your C spine forward post attention span,

59:05

holding it back so you can look up, look normally

59:07

and walk normally not looking at your feet.

59:09

When you have dorsal decompression you lose

59:11

that posterior tension band.

59:14

So for a while this surgical trends go back

59:16

and forth, which is better anterior approach to keep

59:19

that posterior tension band intact.

59:20

And this could be for anything for discs,

59:22

for opl, whatever I was talking about.

59:23

Or you could have a posterior approach.

59:26

Um, and hope that this hardware is good enough stabilization

59:30

to replace the posterior tension band.

59:32

And that's again the balance that the surgeons have to,

59:34

to um, to strike

59:36

and kind of fear which is best for that patient.

59:38

But super common is iatrogenic postoperative CE phos.

59:42

So with loss of that posterior tension band,

59:44

if they don't stabilize it, people you know,

59:46

gradually get more and more um, chin on chest.

59:49

So their head goes down, they're walking

59:50

around looking at their feet, their muscles cannot take the

59:53

place of that tension band, those tough bones

59:55

and ligaments that we're holding their neck back.

59:59

Um, they were holding them their head upright.

60:02

So you get more and more um, pain, muscle pain, um,

60:07

and then kind of nerve pain too.

60:09

And it actually disrupts the whole, um,

60:11

alignment of your spine.

60:13

And I wanna show this picture real fast.

60:15

It can also cause cord abnormalities.

60:17

So you're this picture from my friend.

60:19

Uh, this was such a great picture that a patient of his

60:22

and he published this, but the muscles atrophy so much

60:26

to kind of take the place of that posterior tension band

60:28

to stabilize the spine, but it's not enough

60:30

and it causes more and more pain.

60:32

You also pretend this is your cord right here.

60:34

You get more and more cord injury.

60:35

Is the cord like when your head is like that is stretched.

60:38

Um, it's like hitting the bone like we talked about the

60:41

other entities we talked about earlier.

60:42

And it's stretched and you get the same kind

60:44

of abnormalities as vascular abnormalities as

60:46

that anterior um, the spinal artery is compressed.

60:49

You get more and more ischemia.

60:50

So this is another thing, you know when we look at this,

60:53

these terrible cases of ssis, imagine

60:55

what this person looks like in real life.

60:56

Why around looking at their, their feet

60:59

and severe pain will try

61:00

to lift their head in this muscle hypertrophy.

61:02

Alright, um, let's see, let's see.

61:06

Oh, yvo, I don't wanna go over here.

61:10

It looks like I've done an hour so I'm gonna stop here.

61:13

The um, the rest of these are kind of more of the same.

61:16

I think I've shown them the best principles.

61:18

Maybe it's part two later

61:19

because there are a few things left.

61:20

But I've shown, like I said, the really the things

61:22

that I think are most important

61:23

that we talk about in our reports,

61:25

which is my main purpose of this lecture.

61:28

The rest are just, you know, show and tell cases.

61:31

But I'm gonna stop here. I'm gonna stop sharing my screen.

61:35

Think I stopped sharing my screen and gonna look at the qa?

61:39

Oh my gosh, there are a lot. Okay, let's see.

61:44

So let me start looking at some of these.

61:47

Does the aging process take part in the pathologic

61:51

pain in the elderly?

61:53

So every, so if I understand that, um,

61:58

does aging take part in oh like pain?

62:03

I'm not quite sure what that means.

62:04

So I'm gonna skip that one.

62:04

Sorry, you can send that to me on social media.

62:06

I'll try to figure that later. You can explain it.

62:09

Um, please let us know. Diagnosed kada aquina syndrome.

62:13

We showed as an emergency. They said it's not always urgent.

62:17

So, so kada is, um, clinical symptoms.

62:22

Um, so it'll be the bowel or bladder dysfunction weakness.

62:27

It's actually not well defined in the literature.

62:29

So, um, it's hard to study actually in the,

62:32

in the spine in any kind of emergency or spine literature

62:35

because everybody has a little bit different um,

62:37

definition of what it is.

62:39

But it always is supposed

62:40

to always involve bladder symptoms of some type.

62:43

So, um, how do we diagnose it?

62:46

So we're talking about what we see

62:48

that's causing those symptoms.

62:49

And so like I showed you lumbar disc herniation is maybe the

62:52

most common cause of CAU syndrome,

62:55

but it can be that's a whole another lecture I have.

62:57

It could be anything. It could be cancer,

62:59

it can be infection, um, things like that.

63:02

So anything that's causing those

63:04

that those compressive um, symptoms.

63:08

How long do you have IV contrast post MRI lumbar spine

63:11

for discectomy?

63:12

Um, so we don't do that. We don't give that.

63:17

Um, I think you're alluding to

63:19

whether we wanna see if it's recurrent disc versus fibrosis.

63:22

I would argue that we can tell that without contrast.

63:25

Um, so

63:27

but the, the principle that we used to learn was um,

63:31

that if you have um, if it's fibrosis it'll enhance.

63:35

Whereas if it's disc, it won't be more disc signal.

63:38

But if you wait too long, like over 10 minutes

63:41

then it'll enhance and you can't tell the difference.

63:43

So I think you can tell the difference without

63:46

why did you do a CT first?

63:48

MRI in the case of COTA of fine, well sometimes so

63:52

super young patient, 20-year-old, they did not expect

63:54

that she had anything wrong really.

63:56

She was saying she had severe symptoms.

63:58

But you know the in most real,

64:01

most places people don't go right to mri.

64:03

MRIs a little bit more scar resource.

64:05

So they're looking for things like fracture.

64:07

Um, like I showed you

64:08

that di you can see big discs on CT these days.

64:11

So you don't really need to go to MR MRI right away.

64:13

And I would've argued you didn't need to go

64:14

to MR MRI necessarily at all.

64:16

And if it's super severe they're gonna go straight

64:17

to surgery and maybe not get MRI.

64:20

Uh, how do you report disc counting in the case of

64:26

LATV mean this transitional anatomy, um,

64:29

especially in the case of surgical disc,

64:32

how do you narrate it in your report for the surgeon

64:36

and how do you protect yourself from

64:37

potential medical legal claims?

64:39

Wow, so that's another, okay, that's a great question.

64:44

So we always, oh gosh, there's so much to this

64:47

because I just learned more from a bunch

64:49

of the spine surgeons.

64:50

They asked us to be involved in this thing about

64:51

transitional anatomy and counting

64:53

because um,

64:54

it's a little bit different than what we've traditionally learned.

64:56

But because it's not established in literature, I tell you

64:58

what we've traditionally learned,

64:59

which is you can always count from the top

65:02

if you can't count from the bottom.

65:04

But always describe where you're counting from

65:07

and if you can count from both describe what the anatomy is.

65:10

Um, we have templates that always say whatever,

65:14

five lumbar whatever, I don't like that.

65:16

But at the same time if there is an abnormality

65:20

that you think is surgical,

65:21

always talk about the way you've counted.

65:23

And oftentimes this isn't everywhere

65:26

but like if it's thoracic spine

65:27

and the surgeons have trouble like localizing the level

65:30

without taking a million fluoro platforms,

65:31

they'll have us go in by CT and put in a gold bead

65:35

or something, a marker on that level

65:38

so they'll see it during surgery.

65:40

So that's another chance for us

65:41

to count share in any liability.

65:44

So I wanna count carefully. Okay.

65:46

Do you have any experience

65:47

with 0 0 0 T-E-M-R-I to get a pseudo ct?

65:52

I do not. I do not, but yes, I love that.

65:54

I think it's the coolest thing ever.

65:56

We will talk to our friend Johan Ham

65:58

in about this case.

66:01

He knows much more about um, about bone MRI

66:06

that looked like ct, which I think are the future.

66:08

But right now very few people are doing

66:10

and I think this audience probably it's a little not

66:13

something this audience would do at this time.

66:16

How do you different maybe differentiate

66:19

DD something OPLL from dish?

66:21

So OPLL posterior lung ligament is in the canal,

66:24

dish is anterior marginal osteophytes outside the canal.

66:29

How do we differentiate enhancing granulation tissue from

66:35

post-op infection, granulation tissue?

66:39

Um, I'm not sure

66:43

you mean the granulation tissue

66:45

but um, usually granulation doesn't form for a little while.

66:50

I would say that there have to be reasons for them

66:52

to think they're infected before you start looking.

66:55

Um, you're measuring the CRP Uh, gosh,

67:00

I don't know how to answer that exactly

67:01

'cause I don't think granulation tissue would

67:03

necessarily be a thing.

67:04

Again, show me a case on social media

67:06

and I'll, I'll if you can show me what you mean,

67:08

I'll be glad to tell you what I would think

67:10

and you can tell me what you think.

67:12

Do you always need contrast when you do surgical recurrence?

67:16

MRI on disc culture? No, I already answered that.

67:19

I don't think you do. Um, what sequence do you do in

67:24

hmm ls?

67:27

I don't know what that says. What sequence do you do in