0:00

Okay, Dr. Schupeck,

0:01

let's take on this 62-year-old man.

0:03

He's got a history of prostate cancer since 2005,

0:07

so for at least eight or nine years.

0:10

And he's got low back pain extending down to both knees.

0:14

And I would call this kind of a kinky case, right?

0:16

Because there's a kink right here.

0:18

And we come down, we see the conus,

0:21

and then all of a sudden, it makes an anterior turn.

0:24

And then we have these stringy structures

0:26

that seem to be aggregated together.

0:28

And then we get to this thing right here at L4-5,

0:31

which is weird.

0:33

Another example of low field doing a great job,

0:36

by the way. The patient wouldn't get in a high-field scanner.

0:39

Look at the degree of generous adiposity in this patient.

0:44

No wonder they can't get in the high-field scanner.

0:46

And the low-field scanner does just fine.

0:49

So for you, low-field naysayers, get over it.

0:52

Here's a sagittal T1, fat-weighted.

0:55

Here's a sagittal T2, no fat suppression to speak of,

0:59

maybe a little bit,

1:00

and an axial T2 with very gentle fat suppression.

1:03

So we follow the CONUS down,

1:05

and then let's follow it from the CONUS.

1:08

There's the CONUS down to the tip of the CONUS.

1:11

And then all of a sudden, we run into another cord.

1:15

Here's a cord up higher, and here's another cord.

1:18

Now, you have to ask yourself, is that still the cord?

1:22

And do we have a tethered cord down here,

1:25

or is that a pseudochord from clumping?

1:28

And the answer is, by looking at the sagittal T2,

1:32

when you really drill into it and you pointed out this

1:35

before, you can see little strands of CSF in between.

1:39

You'd never have that in a cord unless you had multiple

1:42

little syrinxes. So this is a pseudochord down low.

1:46

This is actually nerve roots.

1:48

These are nerve roots that are stuck together,

1:51

creating the impression of a chord.

1:53

I mean, look at that.

1:54

You might call that if I just showed you that image,

1:56

you'd call it a cord almost every time.

1:58

And then it gets a little crazy looking when we get to

2:01

this object back here, which is either intradural,

2:05

extradural, or intramedullary. Well,

2:08

it can't be intramedullary because the cord is up here.

2:10

So it's either intradural or extradural.

2:12

And it's extradural. And it's lined up with a facet,

2:16

which is distended. So it's a facet cyst.

2:19

So we have a lot going on here.

2:21

We've got arachnoiditis with a pseudochord

2:24

sign for a very, very long distance,

2:27

a kink right there at the filum terminale,

2:30

and a big arachnoid cyst and some bad facet arthropathy

2:34

with a distended hyperintense facet sign with facet

2:39

distension suggesting microinstability.

2:42

So my question to you is this is mostly a radiologic case.

2:45

I'll put up the Sagittal contrast image,

2:48

and I'll blow that up.

2:49

I don't think it adds a tremendous amount.

2:51

But is there anything within the realm of surgical

2:55

possibility to do for this patient?

2:57

I think the thing to do is to go back.

2:59

To the patient, find out what are we trying to solve here?

3:02

Like what are the symptoms?

3:04

Because really,

3:04

the only at least directly

3:08

surgical lesion is going to be this synovial cyst.

3:11

Meaning if a large portion of the symptoms may be could

3:15

correlate with that lesion or with the facet

3:19

distension that's associated with it.

3:22

Okay,

3:23

but so meaning left leg pain,

3:26

maybe some mechanical back pain at that level you may be

3:30

could do something. As far as all these loculations,

3:34

meaning you're talking about a big open dura case.

3:37

Lysing adhesions. There are articles about it.

3:39

Some of them are positive.

3:41

Would you do it? I have never done it.

3:43

Would you do it? I have never done it.

3:44

Never want to do it.

3:46

I don't think I know anybody else who's done it

3:49

because it would be very hard to solve a problem like

3:53

back pain with any back surgery.

3:55

I mean,

3:55

you have to be addressing a very discrete anatomic problem

3:59

with a correlation between the neurologic symptoms

4:02

exam and the lesion. Well, I respect you a lot,

4:05

but I'd never let you do that one on me.

4:08

One other caveat here.

4:10

You were asking me about what happened here.

4:12

What caused this arachnoiditis? There's no surgery.

4:15

We were talking about it before we went on camera and

4:19

I don't have an answer.

4:21

I think we both agreed that probably trauma is most

4:24

likely. Maybe he had an old pantopaque myelogram.

4:27

That would be another possibility.

4:28

But one thing we can exclude is that is radiation.

4:32

He's got prostate cancer,

4:34

but he doesn't have the yellow marrow power that you

4:39

would expect with radiation or a radiation port.

4:41

So we can exclude a very important potential cause of

4:45

arachnoiditis that we haven't discussed until now and then.

4:48

As far as paraneoplastic neoplasia,

4:51

you do get myelitis and Guillain-Barré and

4:54

all kinds of paraneoplastic syndromes.

4:56

I've never seen paraneoplastic arachnoiditis.

4:59

So I think we both agree that this is probably traumatic.

5:03

There's no other explanation that we can come up with.

5:06

This is a weird case of arachnoiditis

5:08

with a synovial cyst.

5:09

And unless there is focal left leg pain attributable

5:13

to the descending left L5 root,

5:15

it's pretty hard to justify an operation.

5:17

Let me ask you one thing though.

5:19

It's not relevant to this case particularly,

5:21

but I think I have seen something

5:22

like this with appendoma.

5:24

That is when you are operating on appendoma mixopapillary

5:28

appendoma hanging right off the CONUS.

5:31

The whole key to that surgery is not to

5:34

transgress the capsule of the lesion.

5:37

And the reason is you spread it all over the place.

5:39

And I have seen someone who had a matted

5:43

cauda equina like this with an appendy

5:47

moment with widespread.

5:48

So that would be one thing in an appropriate

5:51

setting that could be in your differential.

5:53

Not in this case,

5:54

because we know that we can see there's arachnoiditis

5:56

and there's a C plus MRI here.

5:59

Nothing.

5:59

Nothing enhancing.

6:01

But that is one other thing I've seen give you that

6:04

kind of Matting Leptomeningeal it's been reported.

6:09

You commented on that. Yeah.

6:11

Last caveat here,

6:13

and that is the enhancement pattern of the synovial cyst.

6:18

They typically enhance a little bit like an abscess,

6:21

a little thinner, obviously not as much inflammation.

6:24

But when you look at it,

6:25

you can see a little thin rim of enhancement around here.

6:28

And it has this sort of sessile base right up against

6:32

where you have your distended facet.

6:34

So that is very typical of a synovial cyst.

6:39

Now,

6:39

sometimes one other thing to point out is they're

6:42

not bright. Like, look at this one.

6:44

Parts of it are bright right there,

6:46

and parts of it are a little darker.

6:48

These things are very gooey.

6:50

They contain a lot of proteinaceous material.

6:52

And I have seen synovial cysts that are completely gray.

6:56

So while the thinking would be, okay, it's a cyst,

7:00

it should be really bright,

7:01

that is not the case all the time.

7:03

In fact, in my experience,

7:04

ten to 20% of them are not either white or uniformly white

7:09

just on the cyst. You'd look at that and say, well,

7:12

why can't you just take a needle and put a hole it's not

7:16

going to work. Okay? It's been tried a thousand times.

7:19

Because if you see what this looks like at surgery here,

7:23

we see the cyst.

7:24

But what you're going to see at surgery is on these I used

7:26

to make a much bigger exposure because what you'll see is

7:30

this gelatinous thing all over the sac of which this cyst

7:34

is apart. So it's actually only a part of the pathology.

7:38

So you have to make a big exposure,

7:39

find normal dura both sides and work your way in.

7:43

Yeah. Bilaminectomy well, it depends on what you need,

7:46

but basically you got to get to normal dura,

7:49

find a plane and peel that off.

7:51

So you'd have to go around here and around here.

7:54

You have to find normal dura somewhere and get

7:56

a start on it because it's really stuck.

7:59

CSF leak,

8:00

very high risk in this kind of problem because

8:02

of how adherent that thing is.

8:04

So really the pathology is much bigger than

8:07

what you're seeing as a cyst.

8:08

And as Dr.

8:09

Primarance just mentioned, yeah, it's not like fluid.

8:11

It's just going to come out through a needle.

8:13

It's a very gloppy proteinaceous kind of thing.

8:16

But really you'll be surprised at what it looks like.

8:19

There'll be this Matted Gelatinous thing all over the sac,

8:21

of which that's crossing the midline.

8:23

Right? Right. Yeah. So can you do it minimally invasively?

8:27

I used to do these open,

8:29

even though I did a lot of minimally invasive.

8:30

I think you can do it minimally invasively,

8:32

but you got to make sure you got enough exposure.

8:35

You have to take your tube and wands it so that you

8:37

can really get around and get in the right plane.

8:40

If you're in the wrong plane.

8:41

You're going to have a long day.

8:42

Great. All right, let's move on to another one, shall we?