Pictures of the Week

[Orin]

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Modic changes only in posterior endplate.

Looks like a bit of connective tissue buildup higher at C1/C2 like you might see in RA's inflammatory pannus. The posterior bodies show some degenerative changes from C1-C5. What do the T2 and FS imaging look like?

 

[clubdeac]

View attachment 424318

Modic changes only in posterior endplate.
As read by Radiologist.
I have not seen this before, and wondering if anyone else has anything to add.
Non suspicious neck pain without significant history.

What’s T2 look like

 

[lobelsteve]

What’s T2 look like

Stir and T2 look same, but more degraded from motion artifacts.
Why limited change to posterior corners only?

 

[BobBarker]

I don’t think so. It is the PLL.

 

[BobBarker]

I see you mean the sclerotic posterior end plate now. I wouldn’t call that modic changes.

 

[Orin]

I think these could probably be described as vertebral corner lesions/signs. Without a T2 FS/STIR, though, it’s hard to tell whether the T1-dark signal represents active inflammation/edema or old sclerotic change. Active “Romanus-type” lesions should be T1 dark and STIR/T2-FS bright, whereas a chronically sclerotic corner can be dark on both.

Classically, I think of these as being reported more anteriorly and in association with AS/axSpA, although posterior corner inflammatory lesions are described as well. The problem is that corner marrow signal isn’t specific for inflammatory disease, and degenerative endplate changes can be quite focal or asymmetric depending on local disc/endplate mechanics.

I hadn’t really appreciated this particular posterior pattern before either, but focal/asymmetric cervical Modic changes are described. Interestingly, in a 20-year prospective MRI study of initially asymptomatic volunteers, pre-existing posterior disc protrusion was associated with subsequently developing cervical Modic changes (OR 3.31): https://pubmed.ncbi.nlm.nih.gov/30642726/

Given the otherwise nonsuspicious history and the degenerative changes at these levels, my suspicion would be focal posterior discovertebral/endplate stress or microdamage rather than SpA-type inflammatory corner lesions, assuming the T2/STIR appearance supports that.

I probably wouldn’t BVNA it.

 

[clubdeac]

I think these could probably be described as vertebral corner lesions/signs. Without a T2 FS/STIR, though, it’s hard to tell whether the T1-dark signal represents active inflammation/edema or old sclerotic change. Active “Romanus-type” lesions should be T1 dark and STIR/T2-FS bright, whereas a chronically sclerotic corner can be dark on both.

Classically, I think of these as being reported more anteriorly and in association with AS/axSpA, although posterior corner inflammatory lesions are described as well. The problem is that corner marrow signal isn’t specific for inflammatory disease, and degenerative endplate changes can be quite focal or asymmetric depending on local disc/endplate mechanics.

I hadn’t really appreciated this particular posterior pattern before either, but focal/asymmetric cervical Modic changes are described. Interestingly, in a 20-year prospective MRI study of initially asymptomatic volunteers, pre-existing posterior disc protrusion was associated with subsequently developing cervical Modic changes (OR 3.31): https://pubmed.ncbi.nlm.nih.gov/30642726/

Given the otherwise nonsuspicious history and the degenerative changes at these levels, my suspicion would be focal posterior discovertebral/endplate stress or microdamage rather than SpA-type inflammatory corner lesions, assuming the T2/STIR appearance supports that.

I probably wouldn’t BVNA it.

Don’t BVNA it. BMAC it!

 

[cowboydoc]

Presented my clinic a few weeks ago with bilateral extremity numbness and tingling, otherwise intact. Ordered cervical MRI, delayed secondary to radiology department’s unwillingness to deal with a MRI compatible pacemaker. Two weeks later, presented to ED with progressive upper extremity pain and gait difficulty where they obtained MRI and admitted. I was contacted to see if we could schedule the epidural I had discussed as a potential option during the last office visit. Nope.

Anyone doing MILD cephalad to approved levels?

 

[MitchLevi]

LOFL at, "Hey man, can you come in and give this lady a steroid epidural spinal pain shot? You mentioned it in your note."

 

[lobelsteve]

Presented my clinic a few weeks ago with bilateral extremity numbness and tingling, otherwise intact. Ordered cervical MRI, delayed secondary to radiology department’s unwillingness to deal with a MRI compatible pacemaker. Two weeks later, presented to ED with progressive upper extremity pain and gait difficulty where they obtained MRI and admitted. I was contacted to see if we could schedule the epidural I had discussed as a potential option during the last office visit. Nope.

Anyone doing MILD cephalad to approved levels?

View attachment 424397

Go to the dick of the week thread. Guy there can fix it with dead baby dust.
Surgery yesterday.

 

[Orin]

Go to the dick of the week thread

Why isn't that a sticky...