0:00

Dr. Schupeck, let's look at this 66-year-old man.

0:03

His back is a mess.

0:04

You know, you're a neurosurgeon, you're a neuroimager.

0:07

I mean, everything's going on here,

0:08

but his history is back pain, leg pain,

0:12

every which way, but loose.

0:14

I won't get into the history in too much detail,

0:16

but I think the audience will be struck by this weird

0:20

pattern of cord. Then the cord looks kind of funny,

0:24

looks maybe it has a little signal or slit inside it.

0:27

Then we sort of lose the cord.

0:28

I'll scroll a little bit right here.

0:30

Then the sac gets saccular.

0:33

Then we run into some more solid-looking,

0:36

neural-like tissue.

0:37

And then we're down here at the bottom,

0:39

where one of our colleagues,

0:40

very respected and smart neuroradiologists,

0:43

called this an arachnoid cyst,

0:45

a congenital arachnoid cyst, which it's not.

0:48

The patient has been instrumented.

0:50

They've been fused. So what's going on here?

0:54

And I think I'll have you weigh in on it,

0:58

although I will say this is not going

0:59

to be a congenital arachnoid cyst.

1:01

It's more likely going to be loculated CSF fluid.

1:04

So how do we explain this bizarre pattern?

1:07

Well, obviously,

1:10

there's an alteration in the cauda equina and this

1:15

area that you were talking about here sure is.

1:18

There's clumping of nerve roots,

1:19

and we're in a postoperative setting

1:24

here's.

1:24

Some serious clumping right here between these pedicle

1:26

screws right. Going through the goalposts here.

1:29

That's all clumping there on the axial.

1:31

You can also see there's peripheralization of the

1:34

nerve roots. If you go higher yes, you can.

1:36

I think it's actually lower right there.

1:40

So, arachnoiditis. Okay.

1:42

We sort of have loculated arachnoiditis in this case,

1:46

because not only are the roots stuck together,

1:49

but there's an alteration of CSF flow because of that.

1:53

And it looks to me like there's even a

1:54

little bit of tenting on the conus.

1:56

Everything's kind of they're absolutely straight up

1:59

higher. Yeah, it's kind of straight kind of weird.

2:01

And I wondered if there wasn't a little

2:04

cyst you had asked about this,

2:06

but I wondered if there wasn't a little

2:07

cyst brewing in the filum right here,

2:10

because the signal gets a little dark on the T1,

2:13

a little light over here.

2:15

So there may be a little microcyst in the

2:17

filum terminale along with all of this.

2:20

But clearly this CSF pathway and that CSF pathway

2:25

are not very nicely or intimately connected.

2:29

They may be sort of walled off from each other,

2:31

explaining why this one is dilated and ectatic.

2:35

That one's dilated and ectatic.

2:37

And in between,

2:38

we've got this giant syndicatrix of nerve roots that

2:41

is preventing communication between the two.

2:44

Do you have any other comments about this

2:46

case other than the ones we've made?

2:48

Well,

2:48

I just think that it's really important

2:50

to look at the history,

2:51

because you'll see something that's like this and say,

2:54

oh, that's obviously it's terrible,

2:56

but not everything can be explained by it.

2:58

Meaning.

2:59

You have a history that says pain, tingling,

3:03

numbness that I can buy for arachnoiditis.

3:06

On the other hand, if the history is different,

3:09

that is, progressive, lower extremity weakness,

3:12

gait disturbance. You haven't explained it here.

3:15

And in this case,

3:17

where you have a lesion that can be associated with

3:20

things up higher in the cord, for example,

3:22

a syringomyelia okay,

3:23

because due to the alteration of CSF flow,

3:25

you may be obligated to recommend looking further

3:28

to explain that. Okay, so we may have pain.

3:31

Can believe that. Maybe some numbness,

3:33

maybe some tingling.

3:34

But depending on what the history is,

3:36

you got to make sure you're explaining the history

3:38

that's actually given and what the patient has.

3:41

And this is a complex case,

3:43

so this problem can cause others.

3:44

So we got to kind of keep those in mind.

3:46

So you might look for a syrinx up higher and

3:48

for the audience, you heard it here first.

3:50

Here's a neurosurgeon recommending

3:52

another radiologic study.

3:54

So it does happen from folks other than radiologists

3:57

because we get hammered on this all the time.

4:00

And there was another point you made earlier that I

4:02

thought was really helpful and educational for me,

4:05

and that has to do with back pain and spinal stenosis.

4:09

People with spinal stenosis, including my own mother,

4:12

she's got back pain,

4:13

but she can walk around for 2 hours at graduation,

4:16

and she's pretty darn functional.

4:18

So you made the point that people with slowly

4:21

progressive spinal stenosis are pretty functional

4:24

neurologically. They primarily have back pain, right?

4:27

If your history you have is progressive weakness,

4:32

lower extremity weakness, and you see severe,

4:35

even very severe spinal stenosis,

4:37

you have not explained it.

4:39

Okay? Those people, even the most severe,

4:41

do not generally have a neurologic deficit.

4:44

You'll see it occasionally.

4:45

You'll see it when something else has happened on top

4:48

of it. But most of those people do not have a deficit.

4:51

So if somebody has that history,

4:52

do not attribute it to lumbar spinal stenosis because

4:55

it happens so slowly that they are able to compensate.

5:00

So you really need to provide another

5:02

explanation for that,

5:03

and then we can start ordering more

5:05

radiologic studies. Great.

5:07

Your decades of insight I'm going to compliment you.

5:11

Your decades of insight are invaluable

5:13

to this audience,

5:14

and they produce a whole different perspective

5:16

on how to look at a case.

5:18

Let's do another one, shall we?

5:19

Sure.