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We're talking postoperative spine, Dr. Schupeck.

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In this case, it's an enigma,

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maybe wrapped in a pig in a blanket,

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because I don't know that we have an answer,

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but there are some good teaching points here.

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It's a 48-year-old woman, and after surgery,

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she reports immediately afterward that she's got pain in her

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back, she has trouble lying down, and she's got groin pain,

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which is kind of a very weird history.

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She had surgery at L5-S1,

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and we've got a sagittal T1, standard T1,

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non-contrast T2 fast spin echo in the middle,

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and a contrast-enhanced T1 on the far right.

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So nothing really stands out initially.

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And I'm going to pull down an axial, a non-contrast axial.

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I'm going to blow it up a little bit and get to the level

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of the actual surgery, which was L5-S1.

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And maybe you can tell us a little bit about the type of surgery

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that was done. It looks like they did a laminectomy, right?

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And so here's your interbody implant.

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So you got your screws.

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Okay. So it's the posterior approach.

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So, remember, I think we saw in an earlier one,

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and we'll look at it again,

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but those ones that are put in from the extreme lateral approach

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are big, rectangular ones. So this is one put in from the back,

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and there's a laminectomy here.

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So this is going to qualify probably as a PLIF

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posterior lumbar interbody fusion. Now,

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there's something that looks very similar that's called a TLIF.

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The difference being less laminectomy, more facetectomy,

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and the angle it's sort of put in transforminally.

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So it would look a little bit more like this as opposed to this,

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right? And you wouldn't have this bone removal as extensively,

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perhaps, because your bone removal would be out farther lateral,

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actually,

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in the facet to get you more of an angle to keep the cage out

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of the canal so you don't have to dissect the canal,

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but get your cage in there from a lateral.

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You have less bone removal with a TLIF and less medial bone,

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less lamina bone, more facet bone.

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Okay, so more facet comes out with a TLIF,

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more lamina bone comes out with a PLIF.

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Correct? Okay.

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And then the angle of the implant is different for a TLIF,

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more oblique for a TLIF,

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a little more vertical for a PLIF or a PLIF.

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So that's helpful to our imaging colleagues out there.

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And then there is this area of soft tissue or intermediate

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signal in the right recess at L5-S1.

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And so we might say, well, what does this mean?

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And that's where contrast-enhanced MRI may sometimes

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be warranted and may sometimes be helpful.

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In my experience, most of the time,

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contrast doesn't add a lot to the diagnosis of the

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postoperative spine. I use it when I need to.

2:48

I'm going to make these about equally big.

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And you can see this root is a little bit swollen.

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This exiting L5 root,

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it's got some enhancement around the periphery of it.

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Pre-contrast post-contrast.

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But the problem we have is the patient's

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symptoms are all left-sided.

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So in no way does that thing explain the patient's clinical

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symptoms. Classically, according to the radiologic literature,

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nerve roots should really stop enhancing at about 16 weeks.

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That hasn't been my personal experience.

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There's a tremendous amount of variability,

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and you're much better off correlating with the patient's

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clinical syndrome and the timing and the level, etc.

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That being said,

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we had a very difficult time, you and I, discussing this case,

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figuring out why this patient cannot lie down and why

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this patient hears an axial T2 spin echo,

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why this patient has pain radiating into the groin.

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Now look at how much signal change and actual damage is done to

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the muscular tissues posteriorly in these back operations.

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And that's why people are going more and more to

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minimally just to make one point you can see.

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So this is a midline incision.

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Now, you're going to be hearing a lot about minimally invasive.

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Okay? So how do you say, well, was this minimally invasive?

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Okay, so midline incision, not minimally invasive.

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Usually minimally invasive uses two incisions, one out here,

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one out here,

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and they put a tube and dock it on the

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facet. That's how that procedure is done.

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So you can tell you should be kind of reconstructing

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the procedure in your mind of how it's done.

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But this is sort of a marker.

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So this is a midline laminectomy,

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not through your so-called MIS or minimally invasive approach.

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So as a radiologist, if I see them going right up the center,

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I know it's not minimally invasive.

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Open? Yes, I would say it's an open.

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So then the other thing you pointed out earlier,

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and astutely with her clinical syndrome of groin pain and this

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sort of amorphous history that happened immediately after

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surgery, there's not a lot of options immediately after surgery.

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Maybe they damaged a nerve root.

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Well, all the nerve roots look fine.

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Maybe the screws are in the wrong place.

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Well, the screws look fine.

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Maybe she's got a big dural leak or a giant pseudomeningocele.

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Well, that wasn't the case.

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These are all kind of acute things that you have to think of.

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Maybe they fractured something during the surgery.

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Well, that wasn't it. And so together,

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we really couldn't come up with an answer as to why she's got

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this clinical syndrome. But we did have a pretty good idea,

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and I've experienced this as a clinician myself,

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which is sometimes with a really long operation,

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the patient is put in a funny position or somebody

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leans on the patient for a long period of time,

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and that could produce this very weird clinical

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syndrome that she had after surgery.

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Right.

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I mean, positioning is very complicated.

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If you watch the positioning,

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positioning can take as long as the case.

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And there are all kinds of protocols to protect every surface,

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the ulnar nerve, this, that.

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But no matter how much trouble you take, that can happen

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once again. That history is really important.

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Meaning particularly in disc surgery.

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The history of onset was better for like

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six days,

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and then all of a sudden back is a lot different history

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than the one that, hey, I woke up with this.

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Okay. Because one is recurrent extrusion.

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That history would be consistent with recurrent extrusion versus

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something that may have happened at the time of surgery,

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which could be positioning or could be something that occurred.

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The screws can be taken out, put back in.

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There's a lot of things that can potentially happen.

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So but just thinking about it in your mind, one,

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what's the distribution? So this is L5 and S1.

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Well, those don't go to the groin.

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Right. The back of the leg outside of the foot,

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or L5 to the shin and the big toe.

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Okay. So already you're kind of thinking,

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I don't know if this fits with the surgical site.

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It puts you onto another page.

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It doesn't fit another track.

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Right. All right.

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Your other idea was that maybe there was a disc abnormality up

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higher, and we checked for that too, and that wasn't the case.

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So we really were left with nothing.

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But we were also left with something,

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which is the surgeon didn't do anything wrong,

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and it's quite possible that this was a positioning issue.

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Right. And also, though, I mean, that thought process,

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that is your report, meaning how I would report this,

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all the things that we talked about are a pertinent

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negative because that's what the surgeons want.

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Oh, is my screw in the wrong place?

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No,

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malplacement of instrumentation check.

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So that's what your conclusion is going to be?

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All these things that we just discussed?

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No, it's not that. That's not broken.

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Okay. There's no recurrent extrusion.

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There's no this.

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All the things that he's worried about in his mind,

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you should have in your mind and put them down there.

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So they said, wow, this guy really thought through this case,

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and he didn't find anything.

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And that is actually a relief to me, as opposed to saying,

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I wonder if he looked for this or that.

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Leave no doubt about that.

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That's super helpful. All right, let's move on, shall we?