A*******s
发帖数: 9638 | 1 A real case of mine.
A 21 years old male with severe mental retardation, was sent to ER for
mental status change and ataxia.
He was found to be dehydrated and had a UTI. After the dehydration and
sepsis being corrected, he still could not walk. Because he was not able to
cooperate for MRI, a CT of C-Spine and L-spine was ordered. Results were
not remarkable.
The patient was discharged back to nursing home.
At the followup, his family member finally showed up and told me that about
1 month ago, he was able to walk on himself. But physical therapy at NH
did not help him at all.
On exam: areflexia, negative babinski's, no signs of UMN lesions.
I still went ahead for MRI. He had to be sedated for MRI.
He did have severe cervical stenosis with AP only 3.5 mm. He had the
surgery and recovered very well.
No more CTs for spinal stenosis, period.
This case has changed my practice. |
f******w
发帖数: 10267 | 2 是因为学到了，不能因为难（病人不配合）就不做MRI吗？ |
A*******s
发帖数: 9638 | 3 Yes.
Do not waste money on CT if you suspect a cervical disc disease. It is just
misleading. Cervical myelopathy can cause permanent disability so every
practitioner should be extremly cautious.
【在 f******w 的大作中提到】
: 是因为学到了，不能因为难（病人不配合）就不做MRI吗？
|
s*******1
发帖数: 428 | 4 始终搞不明白，什么时候该用contrast，什么时候该用non-contrast？
是不是只要是想看软组织，MRI就比CT好？ |
A*******s
发帖数: 9638 | 5 If you consider a diagnosis or differential diagnosis of tumor, infection
and inflammation, use contrast.
" 是不是只要是想看软组织，MRI就比CT好？" Yes.
【在 s*******1 的大作中提到】
: 始终搞不明白，什么时候该用contrast，什么时候该用non-contrast？
: 是不是只要是想看软组织，MRI就比CT好？
|
I****a
发帖数: 407 | 6 Did you MRI the entire spine? |
A*******s
发帖数: 9638 | 7 Actually I did C-spine and L-spine.
【在 I****a 的大作中提到】
: Did you MRI the entire spine?
|
I****a
发帖数: 407 | 8 Nice catch but the case seems a little odd to me. If patient has lower
extremity weakness and the stenosis is at the cervical spine, wouldn't that
automatically imply that patient has cervical cord myelopathy therefore he
should have UMN signs. |
I****a
发帖数: 407 | 9 Nice catch but the case seems a little odd to me. If patient has lower
extremity weakness and the stenosis is at the cervical spine, wouldn't that
automatically imply that patient has cervical cord myelopathy therefore he
should have UMN signs. |
A*******s
发帖数: 9638 | 10 Good question。
I posted this in a physician forum initially and a neurosurgeon also asked
same question. My explaination is that the patient may also have severe
neuropathy which masked the UMN signs。
The surgeon who did the laminectomy asked me to write an article regarding
these odd findings. He was also surprised about the LMNs on this patient
and even admited he would miss the diagnosis.
Another interesting fact a NSG mentioned is that the down's syndrome, CP and
neurodegenerative disease patients commonly develop spinal stenosis.
This is not a Zebra.
that
【在 I****a 的大作中提到】
: Nice catch but the case seems a little odd to me. If patient has lower
: extremity weakness and the stenosis is at the cervical spine, wouldn't that
: automatically imply that patient has cervical cord myelopathy therefore he
: should have UMN signs.
|
|
|
I****a
发帖数: 407 | 11 Very interesting. The doctor prematurely discharged the patient at the first time, patient deserved an EMG at that time but I can understand sometimes triage decision is indeed dependent upon who the patient is. In this case, a challenging mental status and concurrent infection probably misled the diagnosis. Importantly you were able to talk to the parents therefore made the pivotal diagnostic work up eventually preserved this poor young man's function. Job well done, doc! |
A*******s
发帖数: 9638 | 12 Thanks.
MRI should always be considered for cervical disc disease. If any
contraindications for MRI, myelogram can be the alternative.
first time, patient deserved an EMG at that time but I can understand
sometimes triage decision is indeed dependent upon who the patient is. In
this case, a challenging mental status and concurrent infection probably
misled the diagnosis. Importantly you were able to talk to the parents
therefore made the pivotal diagnostic work up eventually preserved this poor
young man's function. Job well done, doc!
【在 I****a 的大作中提到】
: Very interesting. The doctor prematurely discharged the patient at the first time, patient deserved an EMG at that time but I can understand sometimes triage decision is indeed dependent upon who the patient is. In this case, a challenging mental status and concurrent infection probably misled the diagnosis. Importantly you were able to talk to the parents therefore made the pivotal diagnostic work up eventually preserved this poor young man's function. Job well done, doc!
|
l*****l
发帖数: 47 | 13 这个解释真是简单易懂。 谢谢。
【在 A*******s 的大作中提到】
: If you consider a diagnosis or differential diagnosis of tumor, infection
: and inflammation, use contrast.
: " 是不是只要是想看软组织，MRI就比CT好？" Yes.
|
A*******s
发帖数: 9638 | 14 有人提到了spinal cord compression。 我想跟大家再提醒一下，特别是PCP， 不要忘
了cervical stenosis。 这是最容易miss的， 产生的后果也最容易打官司。
这个病人我上周看到他， 手术后已经可以独立行走， 没有任何后遗症。 |
h*********t
发帖数: 116 | 15 why only c-spine and L spine, why no thoracic spine
thanks
【在 A*******s 的大作中提到】
: Actually I did C-spine and L-spine.
|
A*******s
发帖数: 9638 | 16 Because of low yield.
If you could not find the answer, do T-spine then in this case.
【在 h*********t 的大作中提到】
: why only c-spine and L spine, why no thoracic spine
: thanks
|
h*********t
发帖数: 116 | 17 because spinal cord dysfunction more common in cervical and lumbar spine?
why not just lumbar spine or just cervical spine?
【在 A*******s 的大作中提到】
: Because of low yield.
: If you could not find the answer, do T-spine then in this case.
|
A*******s
发帖数: 9638 | 18 Because of the disc disease.
Depending on your exam, you can do cervical spine for UMN lesions, and
Lumbar spine for LMN problems.
But there are always exceptions.
【在 h*********t 的大作中提到】
: because spinal cord dysfunction more common in cervical and lumbar spine?
: why not just lumbar spine or just cervical spine?
|
h*********t
发帖数: 116 | 19 我糊涂了。请问能解释一下为什么c spine就是for UMN lesions而L spine 就是for
LMN lesions呢？ Thanks
【在 A*******s 的大作中提到】
: Because of the disc disease.
: Depending on your exam, you can do cervical spine for UMN lesions, and
: Lumbar spine for LMN problems.
: But there are always exceptions.
|
A*******s
发帖数: 9638 | 20 May I ask you why?
【在 h*********t 的大作中提到】
: 我糊涂了。请问能解释一下为什么c spine就是for UMN lesions而L spine 就是for
: LMN lesions呢？ Thanks
|
|
|
h*********t
发帖数: 116 | 21 是你说的"Depending on your exam, you can do cervical spine for UMN lesions,
and
根本就理解错了，能解释一下么。
谢谢你的案例。学习了
我本人的神经内科太弱，可还是很有兴趣，所以在这儿学习呢 |
A*******s
发帖数: 9638 | 22 A question for you: what is the coverage of a C-spine and a L-spine,
respectively?
,
【在 h*********t 的大作中提到】
: 是你说的"Depending on your exam, you can do cervical spine for UMN lesions,
: and
: 根本就理解错了，能解释一下么。
: 谢谢你的案例。学习了
: 我本人的神经内科太弱，可还是很有兴趣，所以在这儿学习呢
|
A*******s
发帖数: 9638 | 23 You can localize a UMN or LMN lesion based on your exam. Once you decide,
you can easily order a corresponding test.
C-spine is for spinal cord.
L-spine is for Cauda equina
,
【在 h*********t 的大作中提到】
: 是你说的"Depending on your exam, you can do cervical spine for UMN lesions,
: and
: 根本就理解错了，能解释一下么。
: 谢谢你的案例。学习了
: 我本人的神经内科太弱，可还是很有兴趣，所以在这儿学习呢
|
h*********t
发帖数: 116 | 24 Thanks a lot!现在明白了
【在 A*******s 的大作中提到】
: You can localize a UMN or LMN lesion based on your exam. Once you decide,
: you can easily order a corresponding test.
: C-spine is for spinal cord.
: L-spine is for Cauda equina
:
: ,
|
