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Today we are honored to welcome Dr. Marcello day

0:54

Abreu.

0:55

for a lecture on spine degeneration and inflammation

0:59

Dr. Abreu is a member of international skeletal radiology

1:02

and staff at Davos idkd annual

1:05

course. He completed his msk fellowship

1:08

and neuroradiology fellowship at UC, San

1:11

Diego.

1:12

He has now head of radiology at Hospital May Day

1:15

do.

1:16

At the end of the lecture, please join Dr. Abreu in

1:19

a Q&A session where he will address questions you

1:22

may have on today's topic. Please remember to use

1:25

the Q&A feature to submit your questions so we can get

1:28

to as many as possible before time is up.

1:31

And with that we're ready to begin today's lecture Dr. Abreu.

1:34

Please take it from here.

1:36

Okay guys, so that's talk about

1:39

these generation and inflammation.

1:43

fine

1:46

So this is a very for me

1:49

very interesting topic.

1:51

We see this every day a lot

1:54

of cases.

1:56

Of spine generation and information. I'm

1:59

beginning the presentation. They're showing you.

2:02

example of two individuals

2:06

with no symptoms and

2:11

some definitive changes and I

2:14

will ask you to guess the age

2:17

of both.

2:24

So both individuals here. They have 75

2:27

year old, both are male.

2:31

and we see a lot of

2:34

a lot of difference between the definitive process

2:39

in the same in the individuals with same

2:42

age and that's because

2:45

it varies a lot the difference of

2:48

process.

2:49

and

2:52

it has to do with genetic component.

2:55

Yeah, and that's very specific for each individual.

2:58

The genetic component can be at the

3:01

molecular level talking about

3:04

collagen type.

3:07

Or an atomic level for example, if the

3:10

individual have a use it

3:13

segment for transitional fat.

3:17

And also the definitive process could be

3:20

caused by overuse for micro trauma.

3:24

So that's why we have

3:27

a lot of variation.

3:29

between individuals

3:34

about the anatomy mainly the weight

3:37

that

3:40

will reach the spine will

3:44

Reach the interval people disk 70%

3:47

of the weight.

3:50

So most of these native process

3:53

they begin in the spine at the

3:56

disk level in after that.

4:00

At the facet joints usually the facet trying

4:03

to process.

4:05

I

4:07

the secondary to a problem in the

4:12

Interior portion of the spine. Okay so

4:15

that we need to know that to understand all

4:18

the biomechanics and how

4:21

the things will develop in spine. Okay.

4:24

We have something called the degenerative Cascade.

4:28

And that begins with the

4:31

he died dehydration.

4:34

Of the disc and that's has to

4:37

do with the end played

4:40

that nourish the disc. It's a

4:43

collage. It's a cartilage layer

4:46

and near the court football

4:49

that we cannot usually see and that

4:52

will

4:53

give a nutrition for

4:56

the disk.

4:57

and a problem at that

5:00

include will

5:02

Begin, the definitive Cascade. Yeah that

5:05

usually begins.

5:07

yeah, the third deck of Life

5:10

MRI can show

5:14

that beginning with dehydration of

5:17

internal portion of the local posters here

5:20

that we can see

5:22

and then

5:24

after the dehydration will have

5:27

features.

5:29

And the structuring of this so called

5:32

alteration osteophyte in some

5:35

cases will have instability. So this will

5:38

start at the third decade of Life can start

5:41

before if the patient has like spondylolises

5:44

has a

5:47

trial or Reason young athlete

5:50

team athlete could

5:53

start in the in the second decade

5:56

of life. Okay?

6:00

I'll show you an example of that.

6:04

We can see here dehydration of

6:07

Calgary or 4 and 405.

6:12

This could be normal with 47 year old.

6:15

But the patient had a presented with

6:18

left Randy left radical property.

6:21

Okay, and then with this coronal sequence

6:24

that is the food sensitive sequence. We

6:27

can see animals fibrosis

6:30

feature here a high signal

6:33

intensity.

6:35

and

6:37

because of the the sensitivity to inflammation and

6:40

edema, we can see edema outside

6:44

that this year so

6:47

When you have a chronic.

6:50

And it was fibrosis there here in

6:53

the below level. But this one

6:56

in our Field Four is a cute we

6:59

can see that in a zoom image here because of

7:02

the information around that.

7:06

And using a diffusion sequence

7:09

that we are using right now a

7:12

lot with the sometimes in

7:15

routine Mr. But sometimes with the exam

7:18

the pair of calling neurography we can

7:21

actually see the nerve itself. Okay. So

7:24

for example, this is an axio.

7:28

Diffusion we put psif sequence

7:31

showing the inflamic nerve

7:34

the left LT root.

7:39

And just adjacent to the animals fiber

7:43

there. This is a movie.

7:46

showing

7:48

showing that

7:50

Okay, the relationship between information

7:53

and radicalopathy.

7:57

In the scenario of digital to

8:00

this Cascade, okay.

8:03

So it's important to look that when we

8:06

look at this active spines.

8:08

There are paper showing that.

8:13

this

8:16

when we inject contrast we can have that Vision

8:19

we can see the information process

8:22

in addition to this.

8:25

With acute analysts of

8:28

fiber pair. Okay, there are

8:31

usually three types of pairs the ones

8:34

that cause most inflammation are the consensic

8:37

tears.

8:39

The radial tear usually does not

8:42

cause inflammation the radio care.

8:45

Allows communication of the nuclear proposals with

8:48

the animals and is a kind of free herniated

8:51

disc.

8:53

and

8:55

okay.

8:57

so this is

9:00

a thing that when we are looking at that that exam.

9:05

We see a lot of tradition and we

9:08

should.

9:09

Try to find the point of information that

9:12

can come.

9:15

inside the disc subchondragon

9:18

Facet Joint into spinous process

9:21

joint so there are many points that

9:24

we can see the compensation of

9:27

additional tips spine. Okay, and

9:30

we need to set our protocols

9:33

to find that.

9:35

and that's why we are using lot the

9:39

the food sensitive sequence. We are using steer

9:42

or T2 headset in this.

9:45

sagittal plane and also in the coronal plane

9:49

To look to those hiding areas of

9:52

information.

9:54

This is an example here.

9:57

Yeah, patient seven years old enough pain.

10:00

We have a transitional vertebra. So

10:03

we have a patient with a

10:06

congenital defect the congenital level

10:09

defect so there is

10:12

one transitional value with

10:15

Articulation with the sacrum here

10:18

some kind of degenerative process and we

10:21

use the fluid sensitive sequence to see

10:24

that inflammation. Okay.

10:29

And we can get we can catch that see a lot

10:32

of Edema here showing that beside the

10:36

the OA there is a

10:39

lot of bone marrow edema here and probably

10:42

related to symptoms. Okay,

10:45

so it's very important to use those people.

10:49

Also in the same patient see we can

10:52

find.

10:54

the modic type 1 change at the right and a

10:59

Inflammatory process around the

11:02

discount trio4 on the

11:05

right. So we probably have here and

11:08

our analyst here with inflammation and

11:11

that could be related to a the

11:14

right equal opportunity. So

11:17

we pay attention on those sequences.

11:21

Okay.

11:24

Also, it's good to remind when we have that transition of

11:27

bad people. So we have an atomic

11:30

effect.

11:31

Will alter all the biomechanics okay

11:34

of the spine, so we have an increase

11:37

it.

11:39

Angulation between L4 and

11:42

L5 in this patient with fuse it transitional.

11:45

We have the bread on the right and that will

11:48

create dispose to

11:52

listis dictionary process can also

11:56

for I mean

11:58

of the canal, okay.

12:01

So it's important to understand.

12:04

The biomechanics when you look at this

12:07

time.

12:08

so the digital Cascade

12:11

and we can

12:13

have some micro instability. Okay,

12:16

and in the beginning

12:19

of the process when we have a black disc.

12:23

and just after the it dehydration

12:26

completes we this black

12:29

this

12:31

They are soft they are usually soft

12:34

and they develop some Michael disability that

12:37

usually we don't catch that with.

12:41

Conventional MRI we need to do a dynamic exam.

12:45

and here is an example of a dynamic MRI that

12:48

we

12:49

have a protocol use when with the open board

12:52

okay to do that.

12:55

and then we can see the

12:59

the instability on the on the right here

13:02

when we apply flexion to the exam. So

13:05

sometimes we have a boat in

13:08

this the black this and we have instability, but

13:11

we don't see it. And then with the

13:14

dining camera I can in this example showing that

13:17

them this is exist. We

13:21

are adding this new neurography protocol.

13:24

Okay for the

13:27

For the routine MRI, we

13:30

use a 3 minute sequence

13:33

a coronal steer space. Okay. It's a

13:36

fast sequence and it's a good gives you

13:40

a good clue.

13:42

About the nerve Roots. So you have

13:45

a definitive spine. You want to know the level of

13:48

the problem and then

13:50

You can have a group with this sequence here

13:53

see the roots.

13:56

and the ganglion the sciatic nerve

13:59

bilateral

14:01

and when we have on

14:04

your native use if you want to to look at

14:07

and

14:09

And do a complete protocol this is

14:12

the complete neurology protocol this sequence here,

14:15

and I'm sure is the psif but

14:18

the diffusion cpacy showing the relationship

14:21

between the native. Yes that we

14:24

can see on the right health for a fight and the

14:27

relationship with L4 and L5 group.

14:30

So you can tell what route

14:33

in this case the out the right L4 route.

14:37

is a speaker is brighter and

14:42

has ridiculopathy Okay, so

14:46

Is it's a very good sequence. This is another example

14:49

of the Easter coronal.

14:53

shown that

14:55

That is fine. And the the roots

14:58

are just compare between

15:01

the sides. This is an

15:04

example of a case a patient 45 year old

15:07

leftover property level on

15:10

the conventional. We don't see a

15:13

lot but when we apply those

15:17

and sequences fluent sensitive see

15:20

we can see there's something going on here on the

15:23

Corona. Okay. We have a lot of the edema.

15:26

We have a herniated

15:29

lateral disc.

15:31

It's common That You Don't See this herniated

15:34

lateral this.

15:37

On the conventional units, it's common. Okay,

15:40

especially in the acute phase when it's

15:43

the discard.

15:46

bright, okay and another

15:51

utility of that coronal sequencing steer

15:54

Corona applied to the conventional

15:58

routine exam is to you can

16:01

you can

16:03

make you screening about the secondary joints

16:06

and you will catch a lot of

16:09

sacrileitis. So

16:12

a lot of patient will come by send

16:16

by Orthopedic surge, you know

16:19

spine surgeon, they are thinking the patient and

16:22

having a different problem

16:25

or needed. Yes. And with

16:28

this sequence. You just tell their

16:31

probably the symptoms are

16:34

coming from the secretly eyes and then

16:37

perform is specific exam to

16:40

make that this is very common for us

16:43

here. Yeah. It's a interesting also

16:46

to understand

16:49

About the after the acute

16:52

phase of the ruptured analyst fibrosis or

16:55

heated this you have a dehydration of

16:59

the area itself. Okay. This is

17:02

an example of acute hernia with a

17:05

lot of high signal. So a lot of nucleus proposals

17:09

inside that area with

17:12

and radio pair of pianos

17:15

and one year after seeing what

17:18

happens a resort from

17:21

that.

17:23

Extruded that start happening usually after

17:27

one month.

17:29

Started happening there with charging up you're making

17:32

so looking at the signal of the anemia. You

17:35

can tell if it's secure

17:38

chronic. Okay, you usually

17:42

we are using the classification Fireball classification

17:45

about the the nomenclature

17:48

of the herniated this

17:51

and I recommend that

17:54

for a better study to to

17:57

use that okay to use this no

18:00

makeup tour the direction 2.0.

18:03

That's from

18:05

the year 2014. Okay, so

18:08

we'll not get into detail about tour in

18:11

this presentation. We're gonna

18:14

go more.

18:15

through the additional Chief process

18:18

and some advice so

18:21

Also, we can see that the

18:24

support for boom.

18:26

Will you suffer from the nationality

18:29

of changes? Okay, so we have in the

18:32

negative casting of the disc. We have

18:35

a stage here that we have

18:38

boom alterations.

18:40

And the bone alterations, I think probably all

18:43

of you know are the modic type 1 2 and

18:46

3, okay.

18:48

and so we have a demon in the beginning or acute

18:51

phase we have and

18:56

fan substitution and we have sclerosing on

18:59

the third on the third type of

19:02

model.

19:03

and that a lot of time is not

19:06

easy to tell if we have

19:09

a

19:12

alteration here on the ball

19:14

that is a definitive only

19:17

or if we have an infection or a

19:20

primary information. It's not easy to

19:23

tell.

19:24

sometimes we need to use another sequence

19:27

for example a diffusion sequence like

19:30

in this case here that we had a doubt because we had

19:33

this digits finally have

19:37

Can see erosions? Okay when you see erosions the

19:40

red people

19:43

plates you always.

19:45

Need to be concerned. Okay, but most of

19:48

the time you will have arrowsy of

19:52

type of

19:54

definitive businesses or you have

19:57

a micro instability. Okay. So for

20:00

example using the diffusion sequence when

20:03

you have about between this or an

20:06

infection, for example, there is a sign that

20:09

can help us to listen distinguish the movie

20:12

time change the core sign.

20:15

It is a sign and that we

20:18

have high signal now.

20:22

A simulating a core in the High symbol

20:25

is adjacent to the between

20:28

the the errors of normal bone in in the

20:31

vascularize it bone marrow. Okay. So this is one

20:34

tip that we can use to

20:37

display what we need to remember that. We always have renovation

20:40

tissue the soup

20:43

onto definitive bone and that can enhance

20:46

and also inside the disc. So

20:49

you have if you have this in handsman,

20:52

you can be dealing with

20:55

Physicians you process because the they have

20:58

this has a granulation tissue vascularize it

21:01

okay. So this can be

21:04

tricky. Okay. This is another example of

21:07

a six year old female with back pain left

21:10

you radiation.

21:11

We can see.

21:14

That the soft tissue edema around the

21:17

extruded disc here.

21:19

We can see the budget type 1 changes

21:22

here on the left. We can see it Fusion

21:25

on the t2 here at the

21:28

below level. Okay, that is

21:31

pretty disposed into that alteration. Okay

21:35

and using the neurography

21:38

using the neurography this

21:41

is the diffusion there are you can actually distinguish the

21:44

nerve what their?

21:48

And after Roots here, okay.

21:54

Signs of Mr. Beans. Okay.

21:57

What is instability? The stability is a

22:00

hypermeability.

22:02

Of a level. Okay, and how can you tell that with

22:05

Mr.

22:07

If you have a fluid inside the discuss in

22:10

this case, you have a lot of money signal.

22:13

This is one side of things Community.

22:16

If you have he we often

22:19

this finest process, if you have a lot of fluid inside

22:22

the facet joints or assign

22:25

August that sign of instability. Oh

22:28

see this is a diagonal showing

22:31

the this the hydrated

22:36

the secondary away of

22:41

passive and interest Finance, okay.

22:44

We can we usually use grading system

22:47

for that one two,

22:50

and three depend on the severity.

22:54

Between and how to define instability.

22:57

What is the best modality to

23:01

Define instability in the it's important to

23:04

Define it because most of the time if you

23:07

have it's a bit it's a surgical procedure.

23:10

Okay. The best still is the

23:13

dynamic radiographs. Okay,

23:16

you do radiographs infection in extension.

23:20

and you will

23:23

Try to see how hypermobility is

23:27

the hypermodel is

23:30

the disc. Okay, so if you

23:33

have a translation on the sides the pain larger than

23:36

40 millimeter, then you have instability or

23:39

if you have

23:42

Increase in angle and

23:45

between the fraction and extension 15 degrees

23:48

that will be also a

23:51

sign of Instagram. So this is important. Okay. This

23:54

is a the way we measure

23:57

canal stenosis. Okay, we measure the

24:00

area of the durocycle

24:03

on the Lumber's fine. It's important

24:06

when you are dealing with instability to see

24:09

if you have also a spinal canal stenosis

24:12

or you don't have okay. So

24:15

it's important to to use those measurements.

24:18

So stenosis and below

24:21

10 millimeters and advances can

24:24

always below 70. It's good

24:27

to know that a lot of old patients.

24:32

With both criteria can be

24:35

asymptomatics. Okay, so it's good to

24:38

know that.

24:40

Okay.

24:41

Sometimes you will be in doubt. Okay,

24:44

for example, in this case. We have

24:47

a 50 year old female back pain.

24:50

And we can see there is no there

24:53

is a guy that hydration here else Bible S1.

24:57

Okay, if some enhancement, yeah

25:00

both Gathering here. So a

25:03

little

25:05

Small HIV okay, but what

25:08

can we see here? Also, we can see

25:11

some high signal intensity here.

25:14

And here and Superior parts

25:17

of the vertebra board this fine density

25:20

area T2. They are also I

25:23

intensity on T1 and there

25:26

is no Gathering enhancement. So what are

25:29

we dealing with here? Is it the

25:32

kind of money type changes?

25:35

This is the kind of

25:39

lesion that has to do with the insertion of

25:42

the anteriorated to the low line. Okay, if

25:45

we look more here we can

25:48

see posteriorly. We have another

25:51

similar area near description

25:54

of the posterior to know. Okay. We

25:57

are dealing with finding from

26:00

a spawning our property. Okay. It's

26:03

a primary information of

26:06

spine. So the antibodies they will.

26:13

We will.

26:15

Travel in deposit in at the

26:18

entities. Okay, and this is

26:21

of the anteriorological limits the animals fibrosis

26:24

insertion and they

26:27

will produce information and that's how it will

26:30

appear to us. Okay, so we are dealing

26:33

with

26:34

early activities for your property when

26:37

we have edema, okay.

26:40

You know why I'm showing here

26:43

is a main patient with Fidelity process.

26:48

can

26:49

also have together.

26:52

The information from this phone

26:55

to our property. Okay, the we can

26:58

have in acute phase. We'll call them Romanus

27:01

lesions, okay.

27:05

When the lesion the edema is

27:08

broader will call it understand. Okay

27:11

will be like a multic. It's

27:14

very similar to the modified one changes

27:17

and another understanding.

27:20

Inferior here and when the

27:23

process heals them

27:26

from a party process heals, we will see

27:29

high signal T1. So we

27:32

will

27:34

T and all romance like in this

27:37

example here

27:38

we were dealing with old romance

27:41

here because we have fat

27:44

deposit on T1.

27:47

Still writing on T2 because it's too too

27:50

without that sad and posteriorly here.

27:53

We have a good romance. Okay, low

27:56

on T1 high in T2

27:59

enhancement with conscious. Okay. So those

28:02

are signs of responding to

28:05

our property. Okay?

28:08

So in some cases we will

28:11

have about for example on this

28:14

one here. What is this? We have irregularities of

28:18

the vertebral and things we

28:21

have.

28:23

Mary of the space. Okay, we have

28:26

detective this diseases, but we

28:29

have a lot of for more deep type changes in some

28:32

parts. We have type 1 in order

28:35

to have type 2.

28:37

This for example with fatsat. We

28:40

have type 2 because it a lot

28:43

of fat but with the enhanced and

28:46

we can see we have panels fibrosis enhancement.

28:49

Which diffusely

28:51

animals fibro system

28:53

another one here this lq and

28:56

enhancement of material

28:59

to low limit. So this is typically off.

29:04

inflammatory lesions from

29:07

sportular property so we have

29:10

a cute. Okay. We have

29:13

a cute Romano station. Yeah.

29:17

we have

29:18

healed lesion

29:20

with high signal on T1 and we have

29:24

a strong little decided but it's not.

29:27

It's not responded with the status with the infection.

29:32

It's more like this form

29:35

the lights. Okay. It's without germs from

29:38

this formula property process. Okay, so we

29:41

can take a look at some cases

29:44

and try to figure out the differential bag,

29:47

you know also see between achieve this

29:50

process and

29:53

Inflammatory primary summer toy or

29:56

infectious, okay.

29:58

So this case for example 45 year old

30:01

male drug abuser, okay.

30:05

We have doors open.

30:07

And we can see we have on T2 alarm

30:10

this disease here. We have

30:13

some

30:15

alterations here. So comparable

30:18

support for bone.

30:23

And this with Gathering we had some enhancing

30:26

but what goes our

30:29

attention a lot of digital teeth irregularities erosions,

30:33

okay.

30:36

And this turn out to be actual exponent

30:39

about this. So in this case, it was

30:42

tricky. It was not easy to tell the difference.

30:45

Okay, but you need at least

30:48

when you have a definitive process,

30:51

that is too much.

30:53

You may call the attention on the report. You

30:56

may tell this looks like the healthy process but

30:59

We have a prominent modified one

31:02

changes we have erosions.

31:05

So I would suggest you clinically to

31:08

exclude a rheumatologic process. Okay, another patient

31:12

that we have 55 male.

31:16

Paying for six months with lab some

31:19

information.

31:22

Lamp what? Can we see here? Okay, we see.

31:26

T2

31:32

get lenient

31:35

a lot of enhancement around

31:38

around this so this

31:42

We have addition to process but we have

31:45

something.

31:46

more okay when you have soft tissue

31:49

outside

31:51

The the DS outside the

31:54

vertebral Bowl. It's probably

31:57

not only the

32:00

efficiency process. Okay. So this will call

32:03

our attention. Usually the more deep type 1

32:06

changes. They don't compromise all

32:10

the different body as in this

32:13

so we asked for a CT on this

32:16

case and we could see that we had

32:19

bone proliferation.

32:22

square roots and also some erosions

32:27

Like we assuming of the Osteo fight. So

32:30

this is very typical of EXO responding

32:34

or property. So this patient

32:37

had soretic arthritis and it

32:40

had a active inflammatory

32:45

process. So this was the

32:48

regulus in this field here.

32:51

Another case showing also

32:54

the differential between

32:57

the different types of process and the primary commentary

33:01

process.

33:03

patient with

33:07

erosions a demon

33:10

but they they are oceans on this page were so

33:13

large.

33:15

And that this is very typical of

33:18

responding science. Okay.

33:22

So this was the diagnosis it's important

33:25

when you have responded with

33:28

the site down.

33:30

between that and eventually process

33:34

we can use the diffusion to see the cosine.

33:37

Okay, the class sign will

33:40

exclude the the style

33:44

is option or we can have this

33:47

a CT. Yeah, if we perform a CT

33:50

and we find the air.

33:53

in the inside of this it

33:58

almost exclude the possibility of infection. Okay,

34:01

when you have infection, usually

34:04

you don't have air inside this.

34:07

Okay. So this is another tip, okay.

34:11

Another differential diagnosis of the super control

34:14

bone support for bone. We can

34:17

see in this case again patient with back

34:20

pain, but this station had a

34:23

trauma. Okay a small trauma.

34:26

And then this is another one that

34:29

gets into the differential you have a focal and

34:33

a focal depression of

34:36

the

34:37

Vertebral plate. Okay

34:40

and with Atmos surrounded surrounding

34:43

with enhancement awesome. Okay. So

34:46

this is very typical of a small snow

34:49

Cube small.

34:51

And this happens a lot when you

34:54

have a bone fragility when you have for example,

34:58

osteomalacia or osteoporosis or

35:01

osteopenia?

35:03

You will have those acute Smalls know

35:06

and then you have about you.

35:09

Sometimes think it could be

35:12

infection could be yeah under

35:16

solution but most

35:19

of the time it's a good

35:22

Milestone. Okay, another example,

35:25

that could be tricky. Okay,

35:28

this could be three. Yes, you

35:31

find that for instance this patient 56, you

35:34

know female back pain.

35:38

It's of course. We have a definitive

35:41

process here. Now. It's for three three four

35:44

and four five, okay.

35:46

We have some animals fibers pairs.

35:50

When we see many tears.

35:55

Probably they are chronic. Okay, because

35:58

you have multiple Pairs and

36:01

when they heal.

36:03

They still have the granulation tissue.

36:06

These two still will have a high seasonality

36:09

on T2. They will still enhance. Okay,

36:12

but what you cannot see is outside, okay, but

36:16

what's happening here that make this

36:20

thing? Okay, we can see

36:23

that we have bone marry

36:26

you at the corners.

36:29

So we have a typical density of this disease. We

36:32

have some high intensity zones.

36:35

but

36:36

do we have here together? He's founded

36:39

what property beginning because we have

36:42

the Romano sign, okay.

36:46

and

36:48

maybe we can we can get a

36:51

CT to look bad and we find

36:54

a lot of fosterophiles you see and

36:57

actually at the levels that we found Vietnam so

37:02

we are doing for maybe five years a lot

37:05

of over diagnosis of

37:08

early.

37:11

And SpongeBob property. Okay early Romano sign

37:15

we are doing a lot of them.

37:17

and

37:19

maybe too much probably too much and

37:23

we realize now all the scientists

37:26

realized that when the Hostile fights are for me. Okay

37:29

when they are

37:32

with the traction when they are with permit metabolism,

37:35

we we can have a demon

37:38

so

37:40

Be careful. When you see edema on

37:43

the corners of the field Super Body main times

37:46

would be only the formation

37:49

of osteophytes. So it's good

37:52

take a look at the X-ray or with City.

37:55

Okay.

37:57

So we have another case here treaty case

38:00

we have.

38:03

45 minutes or something. Okay, we

38:06

could see.

38:08

Muscle edema, okay.

38:14

This is a super spinal cedema. We

38:17

could see also with the nerve sequence

38:20

High I see you know

38:23

of radio packs of Bio Arrow.

38:27

And turn out the patient had the covid.

38:30

Okay and also have

38:35

Also edema on the hip and

38:38

root of us with demo so many patients

38:41

with oriented they did have them

38:44

mile size. Okay, and then the

38:47

king with for

38:50

lumber sacred exam

38:53

or Servco spine exam and most

38:56

of the time they were with the myosites.

38:59

So we need to or neurologist, okay?

39:04

This is an example of a focal

39:07

myositis of a patient.

39:10

see patient team with left

39:14

over pain

39:16

on diffusion we saw High signal focal High

39:19

signal here. And then on T1.

39:23

We saw a lot of fat surrounding. It

39:26

probably was a demeration here

39:29

and we've CT we found the

39:32

classic.

39:33

Myocyte is specifically so this will also

39:36

be seen with sample

39:39

with patients. Okay, after two

39:42

three four months from the from the infection.

39:48

Realize that those patients will have a private

39:52

people myocyte this

39:55

can sometimes we can see that with Mr. And

39:58

make the differential. I know this. Okay. This

40:01

is another example okay of

40:05

spending clamatory

40:08

process that this is a very interesting case the

40:11

patient came for a PET CT.

40:14

in 2020 and from

40:18

SUV at L4

40:22

Level the previews exam from

40:25

2016. We didn't

40:28

find anything here. Okay, so we

40:31

thought the patient was a follower of

40:34

lung cancer. We thought that this would

40:37

be a

40:40

Fast okay, and then

40:43

we call the patient for an MRI and then

40:46

we saw a typical image

40:49

Omar and L5.

40:51

we saw

40:53

low, signal diffusion vertebral body

40:56

low signal on T2

41:00

a low signal in

41:03

simply aside with this here. I intensity zones,

41:06

so

41:07

animals fiber pair

41:10

a small migration of the locals here

41:13

and we

41:16

and came we call the

41:19

patient for a CT and that's what we

41:22

found found calcification inside

41:25

this in my rating

41:28

to the receiver body

41:31

through a small snow. So the

41:34

diagnosis, you know, we thought we saw.

41:38

We remember that the Pet City the preview had

41:41

a CT also, so we look

41:44

at that and we found a concealed calcification

41:48

and very cheap people of hydroxyapatide

41:51

Crystal deposition disease.

41:55

So this is showing the migration process of

41:58

calcification. It's

42:04

It's a crystal deposition disease that

42:07

can cause a lot of symptoms and

42:10

it's in the differential diagnosis of

42:13

inflammation of the vertebral spine. It's

42:16

normal to have calcium pyrophosphere.

42:19

They deposit.

42:22

As we can see here. We have

42:25

a lot of that.

42:27

More than 30% of autopsis demonstrate

42:30

that if you look at the Microsoft is

42:33

almost 100% Yes and

42:36

ligaments and capture. This is very this

42:39

is normal after some

42:42

age but hydroxia, but that is

42:45

different. Okay. It's an on the type of person. It's

42:48

the same priest that we find.

42:51

Superspinators good you

42:54

stand them calcific tendonitis is

42:57

the same crystal. So that is

43:01

a process of the

43:03

sky, so

43:05

I think we can.

43:08

We can stop and maybe have

43:11

some discussion about I just

43:14

would like you to to understand

43:17

the the point here

43:20

in this talk within this generation

43:23

and information of the spine is that it's

43:26

inevitable to have a definitive

43:29

process of this fine and begins early, okay.

43:33

So when we look at the exams, we need to look for

43:36

red flags red flags inflammatory

43:39

red things that will

43:42

tell us what is the level that is

43:45

responsible for symptoms. Okay, if we

43:48

find that

43:50

it to get easier to treat especially if

43:53

minimal Interventional procedures. Okay,

43:56

so we will look at the HIV the

43:59

premature in of the

44:03

In the acute phase of the analyst I was there we'll

44:06

look at radicalopathy with neurography or

44:09

with the addition of a

44:12

conventional chronosphere in all of

44:15

your routine spines.

44:18

We'll look at bone marrow edema around

44:21

the fastest joints in

44:24

this Finance process. This hotel is that

44:27

we have more than always we

44:30

have always with information.

44:33

and we'll look also for instability and

44:36

we always need to be

44:39

to be cautions

44:42

with the differential diagnosis. Okay,

44:45

we can have a spawned about

44:48

property together with the definitive.

44:53

Process we can have this to the position

44:56

disease for example the hydroxia that

44:59

we can have.

45:00

Something that is very prevalent nowadays.

45:03

That is long covid or causing. My

45:08

outside is for plexopathy neuropathy.

45:13

So we need to be aware of that. Okay, so

45:16

I think

45:18

it was fast to talk

45:21

was 45 minutes and

45:24

we have some questions here that we see

45:27

the passions, okay.

45:33

Okay Alex first.

45:38

Classes from Alex. How common is

45:41

dynamic? Do you see the Q&A here

45:45

or no? Or only only

45:48

you can see I'm yeah, I don't

45:51

read the question and then yeah answer.

45:54

Okay.

45:56

Can you read for me here?

45:58

No, I can I can really not sure. How common is dynamic diet

46:01

to see and can it be done in standard?

46:04

Seven sent me. There's more MRI. Yes. Yes.

46:08

We can do the dynamic MRI. Okay

46:11

in the 70 centimeters or like

46:15

if you have this free if you have out here, if

46:18

you have a free MAX, the free MAX with

46:21

eight centimeter board is very good

46:24

to do it. Okay, so I'm performing with that is

46:27

this and your new zero point

46:30

55 years of from Siemens? Okay. It's an

46:33

open War within okay.

46:37

Some tip. Okay when you are doing Dynamic, what

46:40

can you do? You are only interesting.

46:44

You see if there instability or not?

46:47

And how the anatomy of

46:50

the of the spinal canal gets with

46:53

the motion and and for a

46:56

minute? Okay. So the tip is you can do

46:59

a very fast sequence T2 sequence. Okay.

47:02

You can do a sequence very thick.

47:06

slices like for example eight millimeters with

47:09

50% Gap

47:13

and use a fast recovery. Okay, so

47:16

we can do like a six slice.

47:19

T2 weighted fast recovery. Okay.

47:22

So then you with fast recovery. You can

47:25

use a very low TR so

47:29

you can use 1,100 here.

47:33

Okay, and this

47:36

is gonna be like 40 seconds.

47:39

So you do 40 seconds flexion 40

47:42

seconds extension you can

47:45

and if you would like also do at your

47:49

Also now with thick slices and a

47:52

lot of Gap.

48:01

Okay, let me see another question.

48:08

Okay some Mary.

48:12

Tells us.

48:14

asking about this sequestration if

48:17

it's important to administrate contrast for

48:20

diagnosing it okay, or

48:24

you if we don't need most of the time you don't

48:27

need to administrate contrast for the

48:30

disk sequestration. Okay, most of the time you

48:33

don't let me see if I have some musician here

48:37

listening.

48:45

So alright.

48:46

I don't have let me come back to the green heat,

48:49

okay?

48:51

but most of the time you don't need but sometimes for

48:54

example, I think

48:58

One case in 50 case of this sequestration I

49:01

would have doubt.

49:04

Is it a neurofibroma? Is

49:07

it a sign of your

49:10

facet cyst? Okay, then you

49:13

should call the patient

49:16

and atmosphate concept because if you have what this

49:19

equation the enhancement will be very typical will be

49:22

very very peripheral. Okay?

49:26

Okay.

49:29

Let me see another question here.

49:36

A question can infection

49:39

we have some air inside this like

49:42

in soft tissue?

49:45

The most of the time no, okay.

49:50

Most of the time when we have infection when

49:53

we have this Guidance the the information

49:56

produce it will cover

49:59

you that vacant phenomena.

50:02

Okay. This is a

50:05

very emphasized about Dr. Reynick in

50:08

his talks. Okay, but if you

50:11

have in the beginning of the informatory process

50:16

if you have a lot of frequent phenomena

50:19

you could have

50:21

Some days or first weeks that

50:24

you still have the vehicle Canon

50:27

but most of the time if you have air

50:30

in this space.

50:34

It excludes infection, okay.

50:40

Okay, another question.

50:46

Oh someone

50:50

asking for the protocol the

50:53

the protocol. Let me

50:56

let me show you the protocol. Okay, so I don't have a specific

50:59

protocol for digital.

51:04

Only I have a specific protocol for

51:07

MRI of the lumber is fine. The protocol

51:10

is here. Can you see it? Yes, you see it.

51:15

Okay. Yes. Okay. So I have we are

51:18

we are doing three sets those.

51:21

Okay T1.

51:23

T2

51:25

and T2 fat set. Okay, so

51:28

three said

51:31

We are doing two axles T1

51:34

and T2 and we are doing one coronal.

51:38

Here 42 fat this Corona is

51:41

very important. Okay, this will

51:44

catch a lot of lateral.

51:47

They need to disc.

51:50

Okay with the information.

51:52

We have some neurographic effect with

51:55

this coronal here.

51:58

So you will see in many insta see

52:01

the information of the nerve root.

52:04

and we

52:05

will also get a lot of diagnosis of

52:08

secretlyitis. Okay, and then

52:11

we'll

52:12

we'll put on the report and I can

52:15

say that patient between

52:18

four years old and 55 years

52:21

old maybe.

52:24

Maybe 10% of those patients that comes

52:27

to us. They have spondylar properties,

52:30

so they have a separate.

52:33

So you will catch a lot of diagnosis diagnosis of

52:36

that using the Quran so

52:39

don't.

52:40

Forget to put that you can do

52:43

a thick slice or oh no,

52:46

for example, you can do it with set seven

52:49

millimeters with the gap of two. Okay,

52:52

so many meters. Yeah.

52:56

you can do eight slice sequence or 10

52:59

slide sequence and that will take one minute one

53:02

minute and a half Okay, so

53:05

I really recommend that one.

53:15

Okay, this is a

53:18

another one another one from Alaya Ahmed

53:21

when we can label the

53:24

mirror with demon.

53:29

Due to stress injury edema. Okay, and

53:32

the Meridian is from fasting Okay,

53:35

so

53:39

What is the most common?

53:42

Bone marrow edema related to

53:45

stress in the spine. The most common is the

53:48

when we have the stress

53:51

factor pose formulasis and that

53:54

usually 90% of yours

53:57

in teenagers, okay.

54:00

And it's a very good diagnosis because when

54:03

we detect the bone marry edema.

54:06

The use of the teenager is doing

54:09

sports and in heintensity. Okay,

54:12

so it's better to

54:15

detect the stress injury before it breaks before

54:18

it forms a fracture. Okay.

54:21

So this is very important to

54:24

to use and the best

54:27

sickness to do to see that is the sagitta

54:30

the sage though to Fat

54:33

cell.

54:35

We can call stress injury edema.

54:38

Also when we have a facet

54:41

syndrome. Okay, when we have always okay of

54:44

the the interfacet carry

54:47

joint with a lot of Edema that's

54:50

a sign that that always seem

54:53

to manage. So it's probably faceted. We can

54:56

call that osteitis. We can

54:59

call stress injuries injury also, okay,

55:02

we can also call

55:05

stress into when we have which transitional

55:08

value. Okay, we're from

55:11

Mega processes that articulates with

55:14

the same in many cases. You have a

55:17

demon of that articulation and it's

55:20

a stress related injury.

55:23

Okay that edema because you don't have a true joints

55:26

there. You don't have a signal joint.

55:29

You have like a supertrotting point.

55:32

It's a false joint. So when we

55:35

have

55:35

And that hurts the portal art is

55:38

syndrome that hurt. So that's another type and the

55:43

great discussion is about can we

55:46

call a Modi type 1 change a stress

55:49

related change?

55:51

if you remember one two cases, we

55:54

have the scoliosis the

55:57

Modi type 1 change was in the

56:02

The the internal parts

56:05

of this choliotic curve. Okay, so that

56:08

tells us that the motif type

56:11

1 is is translated. Okay, so

56:14

it would be

56:17

like for example when you have song is

56:20

spontaneous Austrian acrosis of

56:23

the knee actually is stress injury. Okay insufficiently injury.

56:27

So this is a very broad discussion. Okay.

56:30

Let me see another question.

56:36

Okay.

56:38

The ERS or the CRP can differentiate

56:41

between EXO respond or property and

56:44

logic one?

56:45

Yes, it helps it helps a lot.

56:48

Especially if they are very high if the

56:51

infemetery lab is high.

56:54

It helps but there are other.

56:59

Clinical that can

57:02

clinical symptoms that can help differentiate.

57:06

If you have two differentiate as

57:09

a Radiologists.

57:11

I I would recommend you.

57:14

to use also x-rays

57:18

CT maybe Gathering

57:21

to try to make that differential diagnosis

57:24

and in some cases you won't

57:27

be possible in some cases. If you

57:30

will be you have to be satisfied

57:33

not making the diagnosis and telling that

57:36

on the report you can be.

57:38

You can tell that on the report that you

57:41

are in doubt that you're not sure but could be derivative

57:44

or exclude the rheumatologic process.

57:47

That's it.

57:53

We got one more question that's just came in

57:56

if you want to.

57:57

Check that one out.

58:01

Well, that one is it that transitional vertebra

58:04

the last one? Yeah.

58:08

Okay.

58:11

Transitional value not okay and a good

58:14

domain picture to describe the lumbo sacred translational veritable,

58:17

okay.

58:20

It's a chapter. Okay this and this answer

58:23

is a book chapter the transition of

58:26

the algebra. There are many types. Okay,

58:29

and it's not very easy to differentiate

58:32

the those but you need

58:35

to what you need to to you. Can

58:38

you there are more than one classification? Okay

58:41

what I usually do. Yeah, I don't

58:44

use a specific passage what they usually do is describe

58:47

and if there is a

58:50

transitional where not

58:52

if the transition of the altebra has a

58:55

megaforpsis.

58:58

If it has is what only natural or bilateral

59:01

does it articulate with the same

59:04

or not. Okay, if there is an articulation of

59:07

the megapoxes does it

59:10

have signs of stress related injury or away or

59:15

not? Okay in another very important is

59:19

When you have the transitional variable most of

59:22

the time.

59:24

Around 100% It's fixing segment

59:28

with the Satan. There is

59:31

no movement of that Phantom. But so most of

59:34

the time when you have a transition of the problem is

59:37

at the

59:39

Above it at the l4l5 for

59:42

so the first level above the

59:45

traditional character. You have a more

59:48

stress into the disc and

59:51

the facet joint and there you

59:54

have instead it there still noises of

59:57

the Forum, you know, a lot of they have

60:00

this disease so it would yeah

60:03

as a

60:07

it would act as a actual disease.

60:10

Okay, the transition we're going to put act as

60:13

actually so that's how

60:16

I describe it.

60:20

Dr. Dre, thank you so much for your lecture today. Thanks for

60:23

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60:26

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60:52

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director of the Breast Care Center at

60:58

Liberty Hospital and assistant professor of radiology UMKC

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School of Medicine. You can register for this

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lecture at MRI online.com and follow us on

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social media for updates for future new conferences. Thanks again,

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and have a great day.