0:00

It's okay. This is a 31-year-old.

0:02

It's a man.

0:04

And he's had low back pain and had some

0:08

undefined lumbar surgery in 2017.

0:13

He's had prior MRIs, none of which we have access to.

0:17

And we've got before you a T2,

0:20

two fast spin echo on the left, a T2,

0:23

one spin echo in the middle,

0:25

and a fat suppressed proton density

0:29

image on the far right.

0:31

And this patient has some obvious findings that

0:35

include some high signal at the endplate junction at

0:40

multiple levels almost in the center of each

0:44

vertebral body. Endplate junction.

0:46

And it's repetitive at virtually every level.

0:49

The disc faces are decreased in overall height,

0:52

and the vertebrae have a kind of a strange shape.

0:55

It's almost like they have reverse platyspondyly

0:58

or reverse fish mouthing, you know?

1:00

You have fish mouthing, you have something like this.

1:03

Whereas in this case,

1:05

the top of this vertebral body is convex upward

1:08

and maybe even a little convex downward.

1:10

So that's a little bit of a clue to the diagnosis.

1:14

And people with classic platyspondyly,

1:16

I use another color here for a minute, like blue.

1:19

They usually are kind of just

1:21

flattened out all the way.

1:23

They may not have so much convexity downward but

1:25

they're at least very flat as the name implies.

1:29

Platyspondyly.

1:30

So in a young man with multiple abnormalities of both

1:35

the disc endplate complex alteration

1:38

and shape of the vertebra itself,

1:41

I don't think the diagnosis is

1:43

really that much of a secret.

1:45

Do you

1:48

at least have a pretty good idea?

1:49

Think I just like to take a look at the SI joints,

1:53

if we can.

1:54

That's a T2 without contrast and they're not fused.

1:59

If we looked at the SI joints on the very heavily

2:03

water-weighted, fat-suppressed image,

2:06

which shows the inflammation optimally,

2:09

you can see that there is a little bit of abnormal

2:12

high signal intensity in the right SIJ,

2:15

but they are not fused.

2:17

There are no syndesmophytes.

2:19

There are no large arcing osteophytes.

2:23

You might see that with this condition.

2:24

You might also see it with psoriatic

2:26

arthritis and some of the other seronegative

2:28

spondyloarthropathies. So the answer is no,

2:31

they're not fused. But yes,

2:33

the right SI joint is abnormal.

2:36

Right.

2:38

It sounds like you were barking up the tree

2:41

of a seronegative spondyloarthropathy,

2:43

like AS or ankylosing spondylitis.

2:45

Right.

2:46

And young male would not be too bad a demographic

2:50

for it. Yeah, it's a good demographic.

2:52

And it's really common to be walking around with back

2:56

pain for years and get operated on without.

2:59

I'm assuming without this kind of overall condition

3:03

being recognized. Okay. Really?

3:05

That's probably what happened,

3:06

because you don't want to operate on

3:08

ankylosing spondylitis patients.

3:09

So my guess is he had back pain and had

3:12

probably some unnecessary surgery,

3:15

and that is not an uncommon scenario.

3:17

Kind of the opposite of a case we discussed in a

3:19

separate vignette where a patient might have a dural

3:23

AVF. And they don't get the operation they need.

3:25

These patients get operations they don't need,

3:28

especially in the early phases of their disease.

3:31

Well, I can tell you in this group,

3:32

if they need an operation, you're in trouble,

3:36

because

3:38

I want to hear more about that.

3:39

Yeah.

3:40

Part of this pathology is in order to understand

3:44

what's going to happen here and

3:45

where to look on these cases,

3:46

you got to think a little bit like an orthopedist,

3:48

which I try always never to do.

3:51

But what is occurring here is right,

3:54

is that these spaces are losing their flexibility,

3:57

meaning as stress goes on.

4:00

The spine.

4:01

It's not being distributed over a number

4:03

of spaces because they're ankylosed.

4:05

So basically, you have long bone.

4:09

Okay.

4:09

The spine is not this flexible thing that

4:11

it should be. Kind of like a fibula.

4:13

Long bones? Yeah, like a fibula.

4:14

So you're going to get that kind of a fracture.

4:17

So these people get fractures that nobody else gets,

4:21

because what happens is you have one area,

4:24

they fracture right through the disc space.

4:26

Highly unstable injury,

4:29

but often unrecognized because they're X-rayed

4:32

in a position where it reduces itself,

4:34

particularly in the C spine.

4:35

I've seen it a lot of times,

4:36

and you see these people don't

4:38

know they have this disease,

4:39

so they may decide they want to take up water skiing

4:43

until they find out that they actually

4:45

have a very serious problem.

4:46

And the difference between this you'll be looking

4:49

at this, and you wouldn't call this one dish,

4:52

but sometimes you see flowing osteophytes,

4:55

but these people are osteopenic.

4:57

The DISH people are not.

4:58

They're hypertrophic.

5:00

Solid, right? And that's the problem here, okay?

5:04

And so operating on them is a disaster because it's a

5:08

long bone. Basically, you need these huge constructs,

5:11

anterior, posterior, to stabilize them, okay?

5:14

So any operation they have is going

5:16

to be a total disaster.

5:18

And so operating on somebody like this is something

5:21

you wouldn't do if you knew they had this disease

5:22

unless there's just something awful.

5:24

But usually what happens is they present after trauma.

5:28

But also, this is pretty obvious at this point,

5:32

but this poor young guy, right,

5:34

has been walking around complaining of back pain.

5:36

Everybody telling him he's crazy,

5:38

somebody operating on him.

5:39

But if you just looked and said, wait a second,

5:42

he's got a syndesmophyte that sometimes is your only

5:46

clue. And you can keep somebody off the surge track,

5:50

give him a diagnosis,

5:52

get him a medical workup and a medical treatment

5:55

just by being aware and alert.

5:58

And in this guy who's got a lot of living.

5:59

That he wants to do,

6:01

but he's already very far advanced and

6:05

already had an operation. Now,

6:06

you can get a large you can get some pretty large

6:08

eccentrics and osteophytes as

6:10

I mentioned in psoriasis.

6:12

And it can happen before you ever have

6:14

the skin manifestations of psoriasis.

6:17

I've had cases where a patient presents with a sausage

6:20

digit and then shows up this way and doesn't have the

6:23

psoriasis until after those two events occur.

6:27

You can get a related seronegative spondyloarthropathy

6:31

with inflammatory bowel disease,

6:33

with Reiter's syndrome and some other

6:35

related conditions. Now,

6:36

this patient manifests one of the very classic

6:39

findings of AS, which is the Anderson lesion.

6:42

The Anderson lesion is an area of

6:44

focal endplate inflammation.

6:46

And you can see the inflammation is in

6:48

the center of every endplate.

6:51

Now,

6:52

the other very common manifestation

6:54

of AS is the rimous lesion, and.

6:59

And the rimous lesion shows up at the corner,

7:04

and these lesions are edematous at every single level.

7:09

Now, here,

7:10

all you see is a little bit of depression here so

7:13

a little rimous lesion occurred right there.

7:15

And once they heal or they subside,

7:19

they turn into fat.

7:20

So it's not uncommon in patients with chronic AS to

7:23

see a little fatty area at every single anteroinferior

7:27

and anterosuperior corner as a manifestation

7:32

of ankylosing spondylitis. Now, as Dr.

7:35

Schuppeck said,

7:35

as you get down further into the disease, things fuse.

7:41

You get calcification right here.

7:43

It starts in the middle and then expands out both

7:46

ways. So you get bamboo spine, but again,

7:49

calcification usually seen in the center first because

7:52

that's where the inflammation

7:53

and the Anderson lesions are.

7:55

And then you have to be on the lookout for sacroiliac

7:58

joint disease. And then you have.

8:00

Exclude systematically the other

8:02

causes of spondyloarthropathy.

8:04

Got to make sure they don't have inflammatory

8:06

bowel disease, psoriasis, Reiter's, and so on.

8:10

So this is a good example of Anderson lesions in a

8:15

patient with active ankylosing spondylitis

8:19

with a very curious shape,

8:21

almost convex upward and convex downward

8:24

of the vertebral bodies.

8:25

I'd like you to compare that with some examples of

8:28

Platty spondyli and a few other disease processes and

8:32

other vignettes and we'll have them labeled for you.

8:34

So do tune into those.

8:36

Shall we move on to another one?