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We're going to end the PowerPoint

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presentation with a couple of entities

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that may cause back pain,

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but that are not associated with spinal

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stenosis or degenerative disc disease.

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One of these is arachnoiditis.

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Arachnoiditis is an entity that can lead

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to chronic low back pain in patients who

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have been previously instrumented or who

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have had either hemorrhage or infection

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in the subarachnoid space. Effectively,

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what one gets is chronic clumping of the

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nerve roots that may be irritated

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and inflamed on a chronic basis.

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The manifestation of this may be clumped

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nerve roots together that are adhesed together,

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you could have the nerve roots that are

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flattened against the periphery of the

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thecal sac, the so-called empty sac sign.

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Or at the same time, you may have these

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nerve roots that all come together

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in the center of the thecal sac,

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in which case it looks almost

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like a spinal cord,

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the so-called pseudocord appearance.

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And you may have nerve roots that show

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contrast enhancement because there is

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the loss of the blood nerve root barrier

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that leads to gadolinium enhancement.

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This is nicely demonstrated on the

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post myelogram CT. For example,

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in this patient. Here we have a patient

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in which when we look in the thecal sac,

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we really don't see any nerve roots.

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Well, you do see the nerve roots.

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They are actually clumped against

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the periphery of the thecal sac.

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So here we have peripheral nerve roots

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that are not in their normal location,

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centrally within the thecal sac,

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but are adhesed to the periphery

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of the thecal sac,

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demonstrated on this post-myelogram CT

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in a patient who's been

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previously operated.

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This is sort of the empty sac sign.

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So here we don't see any nerve roots.

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They are again likely adhesed to

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the periphery of the thecal sac,

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but we don't see them at all.

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The so called empty sac

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sign of arachnoiditis,

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and some people would call it

2:08

adhesive arachnoiditis.

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This is another example. Again,

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a patient who is post-op, post-myelogram,

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and again with an empty thecal sac sign

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in the lumbosacral junction.

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Another entity which is

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somewhat curious,

2:25

but which may lead to chronic back pain,

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is so-called Baastrup's disease.

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This is also known as kissing spine disease.

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What one has is narrowing and opposition

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of the spinous processes to each other.

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In this situation,

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you may see some inflammation in the

2:45

interspinous ligament region or actually

2:48

in the synovium that may be extending

2:52

from the facet joints or post early into

2:55

the spinous processes that leads

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to this chronic inflammation.

3:00

It's typified by the pain which is worse

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on extending the spine and relieved by

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flexion of the spine, which is generally

3:07

the opposite of what we see with

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anterior disc disease, for example.

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This occurs in the L4-L5 level,

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most commonly, and may be seen

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also in young gymnasts.

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So here you can see that in the

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interspinous ligament region, you have

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high signal intensity which is at the L3-L4 level,

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which may be secondary to these

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spinous processes rubbing up against

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each other and causing associated

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inflammation.

3:39

What I was curious about this particular

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case was that it was associated with

3:43

a midline inflammatory cyst.

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So here you see that inflamed irritation

3:50

that is occurring between the spinous

3:53

process of L3 and the spinous

3:55

process of L4, but in addition, you

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have this little cystic area which is

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present in the midline and is displacing

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the thecal sac anteriorly.

4:07

This cyst here is actually not

4:10

associated with the facet joint but is

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associated with a communication with the

4:15

interspinous ligament inflammation and

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this was a manifestation of Baastrup's disease.

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Again, an unusual etiology for patient

4:25

having recurrent back pain

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or chronic low back pain.

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The next entity, which is another B,

4:32

is Bertolotti syndrome.

4:34

Bertolotti syndrome has to do with the

4:39

atypical fusion of the L5 transfers

4:43

process to the sacrum.

4:44

This is usually on a congenital basis

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rather than in a traumatic basis, and it

4:49

may occur unilaterally or bilaterally. It is associated with a concurrence

4:56

of L4-L5 herniated disc and it can lead

4:59

to a back pain and/or scoliosis.

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So here you have at the L5-level

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on the left side, the fusion of the

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transverse process to the sacrum,

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probably best seen on that

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coronal reconstruction.

5:16

So although it's seen as this sclerotic

5:19

area on the left side on the axial scan,

5:22

I think that this abnormal communication

5:25

between the transverse process and the

5:28

sacrum here, this is a portion of the

5:30

sacrum as well, represents the Bertolotti

5:33

syndrome that is associated with

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chronic low back pain.

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So these are somewhat peculiar but

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well known etiologies of low back pain.

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So, I hope that I've demonstrated the

5:50

value of MR imaging in the evaluation of

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patients who have low back pain or

5:56

cervical spinal pain, and the

5:58

different etiologies that

6:01

may cause either a myelopathy in the

6:03

cervical spine or neck pain, or shoulder

6:07

pain, or radicular pain in the upper

6:09

extremity in the cervical spine, or

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radiculopathy in the lower extremity

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in the lumbar spine. Certainly,

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I would like to emphasize the importance

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of using correct terminology as

6:22

provided by the coalition

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that described the nomenclature of disc disease

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and separating disc into bulges versus

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herniations, and herniations into

6:32

protrusions and extrusions and of the

6:34

extrusions sequestrated discs

6:36

that are free fragments.

6:38

I also wanted to give you my take on the

6:41

terminology that I like to use for

6:44

degenerative disc disease or spinal

6:46

stenosis, that is describing whether or

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not there is non compressive disease,

6:51

disease abutting but not displacing

6:54

nerve roots or thecal sac, or those

6:57

diseases that are causing displacement

6:59

or compression of nerve root or thecal sac.

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Thank you for your attention.