Tandem Myelopathy: Localize the Lesion

All right, so this is another kind of tandem lesion case. This person came in with ambulatory dysfunction, urinary urgency, essentially basically having trouble walking, balance issues. and he was seen by a neurologist who found him to be hyperreflexic with Hoffman signs and clonus. Okay. And Jason, what does the Hoffman sign and clonus tell you?

It's a sign within the legs to indicate claudication. well clonus is in the legs right that's when we when we take the the foot and we pop it up to you know very quickly dorsiflex it right and then there are beats the the foot beats down right and a hoffman sign where's that that's in your finger right where you do the index finger

You flick the finger flick it with a little uh basically like you know kind of that but to put somebody's finger in there. There are a number of different ways of doing it. You can also come under the fingers like that. And what happens is that the person reacts with this involuntary kind of jerk, or if you flick the finger, the whole hand will jerk in. So, well, so the significance, let's say I said he doesn't have a Hoffman sign, but he has clonus. What would that, what would that tell you? That the symptoms or the problem in his spinal cord is just below the neck. Exactly.

So if I said he has Hoffman's sign and clonus, where would you say the lesion is? In the cervical spine. More likely in the cervical spine, right? Good. Because it wouldn't affect his hands unless he had compression there. So again, that's a way of localizing where things go. So he has both. His complaints are ambulatory dysfunction. When you ask him, he says, my hands are working fine. I don't have any issues with my hands. This is primarily a leg problem, particularly with walking. So here's his scan, Jason. Tell me what you think. Give us a reading. So, C3 to C4, C4 to C5, C5 to C6, looks like there's a spinal stenosis compression of the spinal cord. Good. Where's the most severe compression? From C3 to C4.

And do you see anything else within the substance of the spinal cord? It looks like the dura is compressed, like the cushioning around the spinal cord is missing in those areas. good also if you look here's the spinal cord it's a gray gray structure and you can kind of imagine this but there's a little bit of whiteness within the spinal cord itself does everybody see that that's um that that's evidence that the the compression is severe enough that the substance the parenchyma of the spinal cord is demonstrating irritation so we call that there's some evidence of we call it T2 signal change within the spinal cord. So you would say there's severe stenosis at C34 with T2 signal change within the spinal cord, which could represent inflammation or myelomalacia.

So myelomalacia is permanent changes within the spinal cord. If this was a longstanding problem, this could be myelomalacia. Now, we don't know what it is because we're not going to take a biopsy of the spinal cord and look at it. but this is another piece of evidence that says this is very tight. This is a problem, okay? And the spinal cord clearly doesn't like it. These other levels, yeah, there's some stenosis there. There's some stenosis there. There's some stenosis even at C6-7. There's stenosis. C6-7, C5-6, C4-5, C3-4. But C3-4 is really the most severe. Okay, good reading. So let's go to the axial images now. Let's start at the top here. All right, so how do we know this is the top level, Jason? These are some advanced questions, but I'm pushing you because you were my scribe for a while. Well, you can see the skull, so that indicates that you're towards the head. Good. You can see the skull, a little bit of the skull. How about on the spinal anatomy? How can you say that this looks like it's an upper cervical area? Is it the shape of the processes, the transverse and the spinous processes? Well, you can see the odontoid process right here, and then this is the partial ring of C1, right? And you can see the vertebral arteries are coming in right here, right? These two big honking flow voids. So these are vertebral arteries, and you can see here, odontoid process. '

So we know we're high up in the cervical spine here. And of course, this is our spinal cord, right? And look at this spinal canal here. There's a good word for this. Have you ever seen it on radiology reports? Anybody? Patent. Patent. I would say capacious. It's capacious. It's generous. You could drive a truck through that thing, right? And commonly, when you think about the spinal canal at the level of C1, C2, you could fit, in a healthy, normal person, you could fit two spinal cords in this area, right? So this is a totally normal C1, C2 area. Now let's go down a little bit. Now we're coming into the body of the C2. And again, you can see this is quite open. You can even see the little nerve roots here. These are the C2 nerve roots right there and there. And there and there. They're coming out. They're going to go right out here and go to the back of the head.

Okay, now we're in the body of C2. Nice open spinal canal. CSF around the spinal cord. Looks good. Coming down. Next level. Coming into C3-4 now. See how the spinal cord is compressed. chest, you can see a large disc herniation slash bone spur, we don't know exactly know what that is but it's compressing that entire canal, it's compressing the lateral recess where the spinal nerves come out. And then we go below it and you can see a little bit of spinal fluid there, the spinal cord is a little less flattened. Then we go to the next level, you can see broad base disc bulge, spinal cord is, it's tight there. It's not pinched as bad as the last level, but it's tight. Then we go below that, the spinal cord's open again, no real cushion there, but it's not being pinched. And then we go down to the next level, and again, there's really no extra room there. The spinal cord usually looks like an oval like that, so it's not particularly pinched. And then it opens up below again.

All right, so let's go back to this level. okay so jason you got this guy he's got clonus he's got a hoffman sign he's got trouble walking um what do you think you is he had a full workup is he had enough of a workup to take him to the or um i would say so but perhaps maybe you would want flexion extension x-rays I have a quick question you mentioned he doesn't have many ridiculous symptoms in his arms correct he has no symptoms in his hands his main problem is walking so I would maybe think to do more of a work up of the spine like a further down Okay. So Jason, you want to get flexion extension films. We get those in there. They're normal. They don't have any pathological movement.

What other studies would you want to get? Well, I agree with Maggie. If the syptoms are worse in his legs, I'd like to see the lumbar spine as well. Okay. You got it. Lumbar spine. Here's his lumbar spine. Aha, the plot thickens. Is that a schmurls node? Right here? There's a little bit of a schmurls node, which is a herniation of the disc into the vertebral body. so what do you think of this one so there is severe compression of the spinal canal L5-S1, L4-L5, less so L2-L3. Good. He's got severe compression L4-L5. He's got some narrowing here at L2-L5-4-3-2-3. He's got a disc herniation at L5-S1, narrowing the spinal canal. So we got a multi-level lumbar stenosis, right? Alright, so what are this guy's symptoms? Go back to his symptoms. Colonus and Hoffman's sign. Right. And his complaints? Those are his findings. What are his complaints? The difficulty walking. Okay. And is that due to back pain or leg pain? It's not due to pain. He says his legs just don't work. His brain is trying to tell his legs to do stuff and they don't work.

You said there were urinary symptoms as well for this. That's right. He has urinary symptoms. Could that be coming from his cervical spine? Is that due to back pain and leg pain? It's possible, but it's more likely It's not due to pain. He says his legs just don't work. His brain could be either. He could be either. You said there were urinary. Now we got a guy with cervical That's right. He has urinary sclerosis. You've got a guy with lumbar stenosis. Could that be coming from his cervical spine? Now what do we do? Would you operate at this point or you would get another test? I'm asking you. What would you operate on? I would think to operate on the lumbar region first because that's where the majority of his symptoms are. okay you want any more information yes but i don't know how to test for the origin of the problems all right so he's got most of the symptoms are in his legs right Mm-hmm. He doesn't complain of hand symptoms. And we know he's got upper motor neuron findings. He's got clonus, right? Would you get clonus from the lumbar spine? No. No. Can you get clonus from the cervical spine? Yeah. Where else can you get clonus? Can you get it from the thoracic spine as well? Yep, because there's spinal cord there. It's all upper motor neuron in the thoracic spine, right? Yeah.

All right, so you want to get another study? Sure. What should we get? Thoracic spine MRI. There you go. All right. That's the money cut. What do you see there? I see severe compression at two levels, but I'm not sure which levels they are. Hard to tell the levels without getting a scout film or whatever. Suffice to say, I think it's T1011. It's the bottom one, and the higher one's, I think, T5, T56. I'm not sure. All right, so now let's get a little more precise here. Look at the top lesion again. We're going to go, oh, I don't know why that went like that. play. No, that's lumbar. So we're worried about this right here. There's a disc herniation right there. And then there's a stenosis right there. And what do you see within the spinal cord?

 

Are there T2 signal changes? Absolutely. Look at all that white stuff in there. in fact it kind of goes up and down this is more normal here that's there's a lot there okay now if we we let's let's look at this disc herniation up higher looks like there's spinal cord compression there it might be better further um at the end of the video okay well you can see here now at this level looks really narrowed here still but look see on the side here it doesn't look so bad up high okay so that one's off to the side a little bit i don't know do we have an axial this i can't remember if we got an axial i didn't put the axial in just because i wasn't sure which one you they have so yeah no problem no problem so this looks kind of bad but it's not as bad as this this is stenotic at all slices. This one's just stenotic at that one slice. If we go back, again, you can see the spinal cord kind of moves away from that disc a little bit, but it can't move away from this. At this level, there's narrowing at every spot there. In fact, I want to review this film with my partners today. I've got to make a note of that. Hang on one second. I've got to write that down. And he didn't have any like rib pain or, you know, like armpit pain, nothing wrapping around his thoracic? No, that's a good question. He didn't have any real thoracic radicular symptoms. Some unusual symptoms that thoracic patients complain of, they sometimes will complain that they can't lay on their back. Because when they lay on their back, that kind of extends them a little bit. because most people have a general, a slight kyphosis on their thoracic spine. So when they lay on their back, it kind of extends them a little bit and that pinches the narrowing that's already there.

So that's one unusual symptom. You mentioned another one. They can have like a band-like sensation or a belt-like sensation around their rib cage. That can be, or numbness or pain around their ribs. So those are two symptoms. He doesn't have those, but in my opinion, this is the worst level and it fits best with his complaints. He's got cervical stenosis, he's got thoracic stenosis, and he's got lumbar stenosis. So I told him, I said, listen, I think you may need more than one surgery, but let's tackle the thoracic stenosis first and let's see how you do because I think that's the number one problem, this one right here. and so we're going to operate on him on Thursday and see how he does. And the other hard part about this is it's hard to locate this lesion sometimes. It's hard to locate these levels because every bone looks exactly the same, and sometimes the x-rays, you can count up, you can count down. They still can sometimes be confusing, and so it's very easy to go up one level and think you're at the right level And so if you don't see what you think you're going to see, then sometimes you've got to go down a level or up a level. I almost always get a CAT scan after these operations to make sure I was at the right level. I tell patients, listen, it's possible you could operate on the wrong level. And me or the surgeon doing this has done nothing wrong because the thoracic spine is tricky in localization. so the key is if you do the wrong level or like the surgery doesn't go exactly like you expect, get a CAT scan and verify you were exactly where you were there's no harm and if you notice that a post-operative CAT scan day one or day two or the first week you know, you haven't done the patient any harm and you can get back to doing the thing that you need to so this case is making me a little twitchy because they're always a little tough I have a question because he does have cervical stenosis pretty severe.

Isn't it, I don't know how to ask this appropriately, but like not general practice, but wouldn't you usually operate on the cervical spine before the lumbar spine or thoracic if the cervical spine was also unstable?

That's a great question. And there are some surgeons who absolutely say, yeah, I would operate on the cervical spine first because the person's going to need to be intubated. So we're going to hyperextend them. We could cause a worsening of that stenosis. And there's nothing wrong with that. But nowadays with kaleidoscopes and fiber optic intubations so smooth, what I would do is just counsel the anesthesiologist. Listen, this guy has cervical stenosis. Number one, I don't want you to extend him. Number two, don't let us drop his blood pressure. But his number one pathology is thoracic. So I think we should go after that first. But I'm going to show this case to my partners this week. And I wouldn't be surprised if one of them said, I would do the cervical first. And it's not wrong. But I just want to fix this guy's symptoms as quickly as possible. I definitely wouldn't do the lumbar first. I would definitely do the ones compressing the spinal cord first, whether it's a cervical thoracic is it's a toss up and I'm, I'm, I'm opting to go where the symptoms I think are most likely the problem. Okay. Go ahead, Alison. Sorry. Um, I get confused by like, cause the way he presents, it sounds like a myelopathy, but then like, uh, so if it was like a radiculopathy, it would be more like dermatome or sensory issues, right? Yeah. So let's talk about myelopathy and radiculopathy.

Myelopathy is generally painless or not particularly painful. Radiculopathy is always painful. Radiculopathy is more commonly unilateral, one-sided. Myelopathy is bilateral usually. If people have myelopathy in the neck, they might complain of some tingling and numbness and discomfort in the hands, but it's not like a lumbar stenosis symptom or a herniated disc that's going down, sciatic down the leg. So myelopathy is generally, spinal cord compression is generally less pain more symmetric not always more symmetric and it it's the complaint is usually dysfunction and radiculopathy or lumbar stenosis is pain more unilateral and the inability to function because of pain not because the legs aren't doing what they're supposed to thank you with myelopathy that's where sometimes you ask like do you ever feel twitching of your muscles exactly but you know you can get twitching with radiculopathy too okay fasciculations can occur with you know denervation of a single muscle group too but if you're getting them bilaterally yeah again that's a bilateral symptom that's more likely myelopathy or some other type of neurological illness like you know als or something like that Thank you.