0:00

I'm Dr. Stephen Pomeranz.

0:01

This is Dr. Malcolm Schupeck,

0:03

neurosurgeon, neuroimager, and neuroradiologist.

0:06

We're here to talk about the postoperative spine,

0:08

the cervical region.

0:09

And this particular case illustrates the importance

0:12

of differentiating neck pain from radiculopathy,

0:16

for they are different both from a clinical standpoint

0:20

and from a management standpoint.

0:22

What happens really matters.

0:23

So let's take a look at a sagittal T2,

0:26

a sagittal proton density, fat-suppressed,

0:29

water-weighted image, and an axial T2.

0:32

And I'm going to start out with some simple stuff here.

0:34

At the C5-6 level, we've lost some disc space height.

0:37

There's some desiccation. This is resident-level stuff,

0:40

introductory stuff. There's degenerative disc disease.

0:44

And as we look at the axial projection,

0:46

the left neural foramen is narrowed.

0:49

So the exiting nerve root at that level is getting

0:52

blasted or compressed by Luschka joint

0:55

hypertrophy and spondylosis.

0:57

And the exiting nerve root at that level would be what?

1:00

At C5-6 the C6 root.

1:03

C6 root goes down the arm, thumb, and index finger.

1:06

Okay, so if the complaint is arm pain and finger pain,

1:11

you're talking about 5667 above,

1:14

that C5 more in the deltoid,

1:17

maybe to the brachialis.

1:18

But if it's going to the hand,

1:19

you got to put it below C5.

1:21

So you got to know your levels.

1:23

So your report makes some sense,

1:25

and the only reason I know them is

1:26

because I get to work with you.

1:28

But now let's talk about neck pain.

1:31

You've told me many times that neck pain is a much

1:35

harder thing to overcome than, say, radiculopathy.

1:38

Radiculopathy is usually a more concrete reason

1:41

to operate, and neck pain is more amorphous.

1:43

Is that correct? Correct.

1:45

And this is the kind of study you're going to

1:48

see all the time. Nothing exotic about it,

1:51

but we're looking at it from the pre-surgical

1:53

standpoint this time. Okay?

1:55

And what every surgeon wants to know is the same thing.

1:58

Their question is the same.

1:59

Can I do an ACDF?

2:01

Okay, what's an ACDF?

2:02

Anterior cervical decompression and fusion.

2:05

Okay. Bone graft in between a plate these days.

2:08

The reason they want to know that is some people think

2:11

it's the only operation in neurosurgery that

2:13

really works. Okay. It's a great case.

2:15

People do better, severe symptoms, resolve.

2:18

They're happy in the recovery room.

2:20

It works. Okay, so your surgeon has that in mind.

2:24

Meaning someplace in your report you have to say ACDF,

2:26

yes or no and where?

2:28

Okay, question for you. If you do an ACDF,

2:31

and I've wondered this myself and asked you many times,

2:34

do you have to get bony bridging or fusion

2:36

at the level that you're fusing?

2:38

Well,

2:38

you certainly for it to be successful,

2:40

that is your goal.

2:41

And that is one reason that you want to really be

2:44

precise about the levels, because as you do more levels,

2:47

your chance of getting bony bridging are

2:49

going down with each level it's added.

2:51

So one of my goals is if there are multiple levels,

2:53

as there often are in spondylosis,

2:56

to get to the fewest levels that are going

2:58

to solve the problem. Because.

2:59

Best chance of getting a bony fusion.

3:02

Now there are instances where you will not have a

3:04

radiographic fusion and the patient will do fine.

3:07

Okay? So if I don't see bony bridging,

3:09

I don't hit the alarm bell on the report

3:12

because the patient may be doing well.

3:13

Patients are reading their reports maybe sometimes

3:16

even before the physician gets it.

3:17

So not always does it depend on bony fusion,

3:21

but that is the goal.

3:22

And one of the ways to do that is through

3:24

the fewest possible levels. Well,

3:26

that's really important from a radiologist standpoint

3:29

because we don't want to be sitting there saying

3:31

failed operation because it's unbridged.

3:34

So that's really important for us to know that there's

3:36

some latitude there. And as you said, in this case,

3:40

there's actually three levels of abnormality.

3:43

I'm going to use my color pointer since

3:45

my regular pointer isn't working.

3:47

But there's spondylosis with listhesis here.

3:50

There is spondylosis at C 56 we've already established.

3:53

And there's spondylosis at C 67.

3:56

So there's already three levels of abnormality.

3:58

You got to pick which one is the one.

4:00

So let's go on to the subject of neck pain for a minute

4:05

because we've already established a reason for the

4:07

patient to have arm pain, which you articulated.

4:10

So what about the neck pain?

4:11

I'm going to scroll in and out and for those

4:14

of you that are following along today,

4:16

the identification of neck pain is greatly assisted by

4:21

having a proton density fat suppression, spur, spare,

4:25

special or stir. In other words,

4:27

a really water-weighted sequence.

4:31

Because if you look at the T2-weighted image,

4:33

you don't really see all that much.

4:35

Yeah, there's a nerve root cyst here.

4:37

Okay. But you're basically looking for hotspots.

4:40

You're using what I call the dumbo approach,

4:44

like Dumbo the elephant.

4:45

You're looking for something big and bright,

4:48

very simple. And we found something big and bright.

4:51

There it is right there,

4:53

up high on the left side and also not as much,

4:57

but on the right side.

4:58

And those are the facets and lateral masses.

5:01

So especially on the left side,

5:03

we've got a good explanation.

5:05

Look where we are out here on the side,

5:07

we've got an excellent explanation for neck pain,

5:10

which is facet disease. So what's a mother to do?

5:13

What's a neurosurgeon to do with that?

5:15

Well, first of all, everybody loves ACDF,

5:18

but it is an operation for arm pain, radicular arm pain,

5:22

meaning you're not going to be

5:23

able to tell somebody that,

5:24

I am going to put bone grafts in these two

5:27

spondylotic disc five, six and six,

5:30

seven and get rid of your neck pain.

5:32

Neck pain does not respond very well.

5:34

So if you can identify another source of neck

5:37

pain that could be treated, perhaps,

5:38

let's say with injections or something like that,

5:42

or even stabilization, depending on the other situation.

5:47

But the patient expectations,

5:49

what you're trying to tell the patient you're trying to

5:51

accomplish, because they could wake up and say, hey,

5:53

my arm pain is gone, but boy,

5:55

my neck is still killing me.

5:56

What kind of operation did you do?

5:58

So all this has to be.

5:59

Find out what is responsible for what

6:02

is the goal of surgery.

6:04

Okay.

6:04

And the other point that you touched on is so you have

6:08

five, six and six seven these spondylotic levels,

6:11

and because they are so stiff,

6:13

you're getting instability at the level above, right?

6:15

There's a little listhesis, right?

6:17

Because it's right next to it's an adjacent level

6:20

problem. And everybody forgets to comment on that.

6:23

I mean, this is a static image,

6:24

so when they move forward, it could be even worse.

6:26

So you must comment on the listhesis,

6:29

even if it's just a little bit of listhesis.

6:31

Right? Because the guy's lying down,

6:33

he shouldn't be sliding forward.

6:35

Right?

6:35

Because if you fuse a level and you already

6:38

have his listhesis at the next level,

6:40

you're going to end up doing that one next year

6:42

or six months from now.

6:43

So double trouble.

6:44

So whatever you do to one level,

6:46

you have to figure out what's the main level?

6:48

Okay, so if you only had to do one,

6:51

which one would it be?

6:53

And then, okay, if I did that one,

6:55

what problems is that going to cause?

6:56

Looking at the adjacent levels to plan this surgery,

7:00

multilevel single level, as they say,

7:01

fewest levels possible.

7:03

But you don't want to create problems by stabilizing

7:06

next to an already unstable level

7:08

and then worsening that problem,

7:10

or at least discussing it with the patient, that, hey,

7:12

you could need another operation.

7:14

Sometimes you're surprised they don't.

7:15

But at least understanding the problem and being able to

7:18

lay out to the patient what the real goals of surgery

7:21

are and have your surgical plan

7:23

address the actual symptoms.

7:25

So we're going to break down cases as we go forward,

7:29

at least cases in the cervical region

7:31

into neck pain and arm pain,

7:33

and the same thing in the lumbar back pain and leg pain.

7:36

I think that's pretty darn important as to what

7:38

you're looking for, how you dictate the case,

7:41

how the patient is treated,

7:43

and then how you describe the abnormalities.

7:45

There are a couple of other caveats

7:47

in this case before we get off it.

7:49

We've already established the reason for

7:51

the radiculopathy of the left at C 56.

7:53

We've established separately and distinct the reason

7:56

for neck pain, which we at the facet level,

7:59

which we probably would start out

8:00

with a facet injection to treat.

8:03

But we've also got a couple of other incidentalomas.

8:05

You put this patient to sleep,

8:07

they've got a lot of gliosis in the pons.

8:10

Maybe they don't wake up so easily.

8:12

It's probably important to comment on the microvascular

8:15

disease from chronic hypertension,

8:17

so that shouldn't be overlooked.

8:19

We've got a little colloid cyst in the thyroid.

8:21

I think I found it right where'd it go?

8:23

Here it is, right there.

8:25

I mentioned to one of my colleagues,

8:26

anytime you have something that's round and really

8:29

bright, that means it's making colloid, it's mature,

8:32

it's well differentiated, it's not going to be cancer.

8:36

And then there are a couple of

8:37

other things to comment on.

8:38

Where do the vertebral arteries come in if you're doing

8:40

an operation? Usually they come in around C6,

8:44

but anomalies occur more frequently in males than in

8:48

females. So where that artery comes in is important.

8:51

What the foramen transversarium

8:53

looks like is important.

8:54

And I think that'll be a subject for another day.

8:57

So let's move on to another case, shall we?

8:59

Take care.