Thanks for a great video! I have a few questions: How do you describe discs that are bulging with associated osteophytosis? (disc-osteophyte complex for both cervical and lumbar spine?) Do you still use the nomenclature of disc bulge (more diffuse, circumferential or greater than 50%) vs disc herniation (protrusion/extrusion) with the addition of associated osteophytosis? In these cases often the annulus fibrosis is difficult to visualize, and then when there is some of the disc extending a little past the margin of the osteophyte, would you describe maybe a disc osteophyte complex with a more focal protrusion? One last thing, often a disc bulge looks more prominent at the foraminal zones even though it is circumferential, perhaps related to the shape of the vertebral body, would you still call this disc bulge or a bulge with superimposed foraminal protrusions (seen on sagittal view)? Hope that was clear, thanks!
@@DrChristophAgten agreed! some radiologist and orthopedic surgeon use the term disc osteophyte complex to describe it. sometimes its difficult to describe in cervical spine. thank you for your answer
Using this terminology , but not the sequestration one , I call it free fragement( fragment libre ) . Finding cervical MRI more difficult though !!!! Thank you very much .
Strong work! May I make a request: can you create a talk on evaluation of ddx of spinal cord signal abnormality? another good topic is ddx of white matter changes in the brain: everyone says "likely chronic microvascular ischemic disease" but sometimes a differential is more appropriate whether because of young age or atypical pattern. Many thanks.
adam---vast, vast majority of wm dz is microvascular stuff. ddx that covers majority of other entities is demyelination, cns vasculits, chronic migraine (more frontal lobe), infection (lyme) and then you can start to talk about real zebras like ADEM etc. hope that helps.
Thanks Dr. Agten, do you give any importance on the antero-posterior diameter (for example > 3 mm) of a bulging disc in the report? Does it has any clinical relevance ?
i just eyeball it. it it doesnt affect the nerve, the measurement is irrelevant in my opinion. also 3mm cut off value is different in 150cm women or 200m men :)
Hi dr. Agten! I just watched your video and I am struggling with reading my own MRI. My MRI was read by 5 different doctors, 4 out of 5 told me that I have a small herniation and 1 told me that the bulge at the l5-s1 is bigger than 15 mm. So I started researching and I think that they did not read it well and the bulge is far lateral, extraforaminal actually, but I am not sure of what I see on an axial view. I am in so much pain every day. I have sciatica too. Is there any chance to send my MRI captures to you for an opinion? Thank you!
Dear Evelyn, sorry to hear about your problem. I do offer second opinion readings with video call presentation if requested. you can contact me with the email address listed in my channel details.
In general, read the MRI aganist symptomatology. Over diagnosis by over reliance on MRI is a big problem these days. All patients will have varying degrees of degenerative discs by middle age which largely remain asymptomatic.
@@Docorif i agree, that is especially true in the spine, but its also a bit dangerous, because you could potentially seek an explanation and call a finding that you would not call if the other side would be clinically affected
I think that often when an anulus fibrosus tears, we see hemorrhage. This hemorrhage is always called a disk extrusion (or sequestration) but should be called a hemorrhage if the signal in it does not follow the signal of the nucleus pulposus on all MRI sequences. People somehow seem to think that miraculously when the disk tears there is no hemorrhage whereas if any other body part tears there is hemorrhage. Or more likely, it just doesn't occur to people to think about it. I think this distinction between a disk extrusion and a hematoma is important because a hemorrhage will usually shrink over time, possibly allowing the patient to avoid surgery, whereas a disk extrusion should not shrink...why should it...does the body recognize the nucleus pulposus molecules as a foreign body and attack it when this material is in its normal position, confined to the disk? No. Then why would the body attack it if it is a disk extrusion? This hemorrhage can be epidural (in which case I call it "epidural hematoma") if it is in the central spinal canal but the hemorrhage can alternatively be outside the central canal such as in a neural foramen. By the way, expect pushback if you call it "epidural hematoma" since that term has a more sinister connotation for physicians since historically an epidural hematoma is much larger than the hematoma associated with a disk protrusion. This shrinkage may explain why you see disk "extrusions" shrink over time (i.e.,, they are really hematomas). If you look very closely at high resolution slices you can frequently actually see the anular tear contiguous with the hematoma. Forget "migration" of disk material if it is a hematoma. Call it "extension of hematoma". I also notice that you do oblique MRI images of the cervical spine. I find these very useful for determining 1) the degree of impingement on the nerve root and 2) the degree of stenosis of the foramen. As you know, the nerve root courses mostly in the INFERIOR part of the foramen. The disk bulge or protrusion when small is in the UPPER part of the foramen. So when interpreting axial images it is important to keep in mind that even if the upper part of the foramen is very stenotic, there can still be a "tunnel" for the nerve root in the inferior part of the foramen. I wonder what degree of neural foraminal stenosis is required to cause a significant compromise of the microvasculature of the nerve root and result in radiculopathy in the absence of impingement on the nerve root.
thanks for sharing. If you have original research publication that points into this direction hematoma vs disc, please send it to me. I think all mean the same thing, but use different words. i would not use hematoma and tear because that somehow implies trauma as origina. I'd rather use fissure and disc. That the disc can have different signal inside and outside can be a sign of degeneration/dehydration of the extruded material and certainly, if you look at migrated disc material over longer time intervals, it takes sometimes a long time for disc material to get resorbed , wheres with hematoma i would expect pretty fast resorption. here a case report, ok not the best source, for migrating disc heriation, they do surgerey in these cases and it is disc material, not hematoma: www.hindawi.com/journals/cris/2017/1762047/ but I am happy to read your source.
I did not start that classification. It's what is suggested my panels and research papers. Something your referring base has a different nomenclature and sometimes it doesn't translate well in different languages. in the end everybody has to find his/her on way
Great clear explanations! Exactly what I was looking for. More spine videos would be appreciated!
Thanks for a great video! I have a few questions: How do you describe discs that are bulging with associated osteophytosis? (disc-osteophyte complex for both cervical and lumbar spine?) Do you still use the nomenclature of disc bulge (more diffuse, circumferential or greater than 50%) vs disc herniation (protrusion/extrusion) with the addition of associated osteophytosis? In these cases often the annulus fibrosis is difficult to visualize, and then when there is some of the disc extending a little past the margin of the osteophyte, would you describe maybe a disc osteophyte complex with a more focal protrusion? One last thing, often a disc bulge looks more prominent at the foraminal zones even though it is circumferential, perhaps related to the shape of the vertebral body, would you still call this disc bulge or a bulge with superimposed foraminal protrusions (seen on sagittal view)? Hope that was clear, thanks!
Really helpful video, thank you!
HI!! love your channel! do you know/use a cervical disc classification? How do you evaluate disc disease in the cervical spine? thanks in advance
I don't use a specific classification. It just the same, protrusion, extrusion, small, moderate large +locatio
@@DrChristophAgten agreed! some radiologist and orthopedic surgeon use the term disc osteophyte complex to describe it. sometimes its difficult to describe in cervical spine. thank you for your answer
Using this terminology , but not the sequestration one , I call it free fragement( fragment libre ) . Finding cervical MRI more difficult though !!!!
Thank you very much .
Strong work! May I make a request: can you create a talk on evaluation of ddx of spinal cord signal abnormality? another good topic is ddx of white matter changes in the brain: everyone says "likely chronic microvascular ischemic disease" but sometimes a differential is more appropriate whether because of young age or atypical pattern. Many thanks.
Thanks and thank you for the suggestions. Not typical MSK topics. But I'm sure I would learn a lot myself doing such a video.
adam---vast, vast majority of wm dz is microvascular stuff. ddx that covers majority of other entities is demyelination, cns vasculits, chronic migraine (more frontal lobe), infection (lyme) and then you can start to talk about real zebras like ADEM etc. hope that helps.
Thanks Dr. Agten, do you give any importance on the antero-posterior diameter (for example > 3 mm) of a bulging disc in the report? Does it has any clinical relevance ?
i just eyeball it. it it doesnt affect the nerve, the measurement is irrelevant in my opinion. also 3mm cut off value is different in 150cm women or 200m men :)
Hi dr. Agten! I just watched your video and I am struggling with reading my own MRI. My MRI was read by 5 different doctors, 4 out of 5 told me that I have a small herniation and 1 told me that the bulge at the l5-s1 is bigger than 15 mm. So I started researching and I think that they did not read it well and the bulge is far lateral, extraforaminal actually, but I am not sure of what I see on an axial view. I am in so much pain every day. I have sciatica too. Is there any chance to send my MRI captures to you for an opinion? Thank you!
Dear Evelyn, sorry to hear about your problem. I do offer second opinion readings with video call presentation if requested. you can contact me with the email address listed in my channel details.
In general, read the MRI aganist symptomatology. Over diagnosis by over reliance on MRI is a big problem these days. All patients will have varying degrees of degenerative discs by middle age which largely remain asymptomatic.
@@Docorif i agree, that is especially true in the spine, but its also a bit dangerous, because you could potentially seek an explanation and call a finding that you would not call if the other side would be clinically affected
Please do one on lumbar stenosis grading :)
mild, moderate, severe :)
@@DrChristophAgten LOL , Frankly he is absolutely true !!!! a lot get confused when it comes de grading stenosis !!!!!!
I think that often when an anulus fibrosus tears, we see hemorrhage. This hemorrhage is always called a disk extrusion (or sequestration) but should be called a hemorrhage if the signal in it does not follow the signal of the nucleus pulposus on all MRI sequences. People somehow seem to think that miraculously when the disk tears there is no hemorrhage whereas if any other body part tears there is hemorrhage. Or more likely, it just doesn't occur to people to think about it.
I think this distinction between a disk extrusion and a hematoma is important because a hemorrhage will usually shrink over time, possibly allowing the patient to avoid surgery, whereas a disk extrusion should not shrink...why should it...does the body recognize the nucleus pulposus molecules as a foreign body and attack it when this material is in its normal position, confined to the disk? No. Then why would the body attack it if it is a disk extrusion?
This hemorrhage can be epidural (in which case I call it "epidural hematoma") if it is in the central spinal canal but the hemorrhage can alternatively be outside the central canal such as in a neural foramen. By the way, expect pushback if you call it "epidural hematoma" since that term has a more sinister connotation for physicians since historically an epidural hematoma is much larger than the hematoma associated with a disk protrusion. This shrinkage may explain why you see disk "extrusions" shrink over time (i.e.,, they are really hematomas).
If you look very closely at high resolution slices you can frequently actually see the anular tear contiguous with the hematoma.
Forget "migration" of disk material if it is a hematoma. Call it "extension of hematoma".
I also notice that you do oblique MRI images of the cervical spine. I find these very useful for determining 1) the degree of impingement on the nerve root and 2) the degree of stenosis of the foramen. As you know, the nerve root courses mostly in the INFERIOR part of the foramen. The disk bulge or protrusion when small is in the UPPER part of the foramen. So when interpreting axial images it is important to keep in mind that even if the upper part of the foramen is very stenotic, there can still be a "tunnel" for the nerve root in the inferior part of the foramen. I wonder what degree of neural foraminal stenosis is required to cause a significant compromise of the microvasculature of the nerve root and result in radiculopathy in the absence of impingement on the nerve root.
thanks for sharing. If you have original research publication that points into this direction hematoma vs disc, please send it to me.
I think all mean the same thing, but use different words. i would not use hematoma and tear because that somehow implies trauma as origina. I'd rather use fissure and disc. That the disc can have different signal inside and outside can be a sign of degeneration/dehydration of the extruded material and certainly, if you look at migrated disc material over longer time intervals, it takes sometimes a long time for disc material to get resorbed , wheres with hematoma i would expect pretty fast resorption.
here a case report, ok not the best source, for migrating disc heriation, they do surgerey in these cases and it is disc material, not hematoma:
www.hindawi.com/journals/cris/2017/1762047/
but I am happy to read your source.
How to grade neural foramen stenosis?
Mild moderate severe
I like to keep it simple
@ thank you for replying. What’s taken as mild n moderate?
Sir my L5 s1 disc bulge ...please suggest me sir please. In this case surgery is compulsory or not
No weakness no surgey. If leg pain is severe even after months of treatment, may consider surgery. Not an absolute indication if no weakness.
can't give you medical advice here dude, sorry :)
If you don't have surgery, how will the spine surgeon pay for his boat?
Why start a classification if you don't intend on using it in your own department.
I did not start that classification. It's what is suggested my panels and research papers. Something your referring base has a different nomenclature and sometimes it doesn't translate well in different languages. in the end everybody has to find his/her on way
How to grade neural foramen stenosis?