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Thread: What is it? Thoracic spine questions

  1. #1

    What is it? Thoracic spine questions

    Hi--

    To be brief, have conflicting "impressions" from neuroradiologists (well, not conflicting in all cases, but no one sees exactly the same thing). So, I'll just summarize what everyone's seeing.

    MRI, January, some T2 hyperintensities periventricular/subcortical, 3x5 and a couple 3mm. NR says, can't rule out MS. Normal CSF study (no o-bands).

    Have two t-spine herniations, T6-7 and T8-9. Also have an arachnoid cyst just opposite the T6-7 herniation. Neurosurgeon says yes, need surgery.

    Have "altered signal" in the cord above the T6-7 herniation. It's in the "upper thoracic spine." NR says "nonspecific."

    Sx include paresthesias, numbness, right-sided weakness, hyperreflexia with clonus on right, Hoffmans +, Rombergs +, family hx of MS (paternal grandmother, primary progressive). NCT/EMG studies show CMAPs and SNAPS are half on right hand/arm compared to left hand/arm.

    Have lost memory/mind, can't spell any more (I teach college biology and have always had an excellent memory and have been an excellent speller). I'm heat intolerant--extremely--but I think I've been like that for awhile.

    Anyway...I'm still getting 2nd opinion from another neurosurgeon (my first insisted on it because t-spine surgery is so awful) and have a 3rd-opinion appt lined up with another neuro.

    I'm not asking for a dx, but you all seem like a very experienced group of people. My clinical findings/imaging findings confuse me. For example, with cord compression from a herniation (like the ones in my T-spine, which have been described as mild-moderate), would a myelopathy develop above the compression--like to vertebral bodies above (T4)? And has anyone on here EVER heard of having both a t-spine herniation AND an arachnoid cyst at the same levels? My neurosurgeon is truly impressed with that.

    I'm 39, excellent health (well, except for all that up there), mother of three young children, great life.

    Thanks for any insights.

    Bio

  2. #2
    Quote Originally Posted by biowham
    Hi--

    To be brief, have conflicting "impressions" from neuroradiologists (well, not conflicting in all cases, but no one sees exactly the same thing). So, I'll just summarize what everyone's seeing.

    MRI, January, some T2 hyperintensities periventricular/subcortical, 3x5 and a couple 3mm. NR says, can't rule out MS. Normal CSF study (no o-bands).

    Have two t-spine herniations, T6-7 and T8-9. Also have an arachnoid cyst just opposite the T6-7 herniation. Neurosurgeon says yes, need surgery.

    Have "altered signal" in the cord above the T6-7 herniation. It's in the "upper thoracic spine." NR says "nonspecific."

    Sx include paresthesias, numbness, right-sided weakness, hyperreflexia with clonus on right, Hoffmans +, Rombergs +, family hx of MS (paternal grandmother, primary progressive). NCT/EMG studies show CMAPs and SNAPS are half on right hand/arm compared to left hand/arm.

    Have lost memory/mind, can't spell any more (I teach college biology and have always had an excellent memory and have been an excellent speller). I'm heat intolerant--extremely--but I think I've been like that for awhile.

    Anyway...I'm still getting 2nd opinion from another neurosurgeon (my first insisted on it because t-spine surgery is so awful) and have a 3rd-opinion appt lined up with another neuro.

    I'm not asking for a dx, but you all seem like a very experienced group of people. My clinical findings/imaging findings confuse me. For example, with cord compression from a herniation (like the ones in my T-spine, which have been described as mild-moderate), would a myelopathy develop above the compression--like to vertebral bodies above (T4)? And has anyone on here EVER heard of having both a t-spine herniation AND an arachnoid cyst at the same levels? My neurosurgeon is truly impressed with that.

    I'm 39, excellent health (well, except for all that up there), mother of three young children, great life.

    Thanks for any insights.

    Bio
    Bio, from your description, it sounds as if you have both MS and thoracic spinal disc herniations. Yes, myelopathies do develop above the compression site (remember that the compression may damage ascending sensory axons and the parts of the axons that are separated from their neuron cell bodies die). The fact that there is an arachnoid cyst is bothersome. It suggests that something else may have been going on besides just disc herniation.

    When two conditions coincide, I suggest the following approach. First, consider what should be done if only one of the conditions were present. If you had only MS, you would want to start MS treatments right away, i.e. ABC. If you had only the thoracic disc herniations, you would want to have the surgery. Second, does the treatment negatively affect the other condition? It is possible that MS therapies will negatively affect healing from surgery. I don't think that the surgery will aggravate the MS. So, you would probably want to do the surgery first and then start MS drugs after healing has occurred. Third, would it be appropriate to treat one condition and not the other. I don't think so. The thoracic herniation may restore substantial function while the MS drugs will prevent further deterioration. In particular, cord compression affects bowel and bladder compression whereas loss of these functions tend to be delayed in MS. Fourth, are there any treatments that will help both conditions? Perhaps. For example, 4-aminopyridine (Fampridine) may improve function for both MS and cord compression.

    Finally, look at the potential risks and outcomes, ranked from best to worst
    1. Decompression helps and you don't have MS.
    2. Decompression helps and ABC therapy prevents MS progression.
    3. Decompression doesn't help but ABC therapy prevents MS progression.
    4. Decompression doesn't help and ABC doesn't prevent MS progression.
    5. Decompression makes things worse and ABC doesn't prevent MS progression.

    The fifth possibility is unlikely. I hope that this helps.

    Wise.

  3. #3
    Wise Young--

    First, thanks for the detailed and knowledgeable response and for having a board like this. With the conflicting neurorad impressions (one says "lesions"; one says "totally normal brain" with no other comment; two note both Tspine herniations; one just didn't see the second one; I know I'm not alone in this), what you are doing here is a service to people who simply get entangled and confused in all of the information, useful and not.

    My neuro says "not MS." Actually, until the +Hoffmans and electrophys results, he wanted to call my upper sx "conversion disorder" and attribute my lower sx to the T7-herniation. I was not amused. Even if it MS, though, it's probably primary progressive (sx >6 mos, no remissions, that's what my grandmother has), so not too many meds effective for that, right?

    I'm feeling squirrelly about the surgery. But I am getting the 2nd opinion.

    I haven't read anything too dire about arachnoid cysts, and the neuroradios and neuros and the neurosurgeon all seem pretty casual about it. Could you elaborate on what you mean in your comments about that?

    Thank you again for your time. My PI from grad school earned his doctorate at Rutgers.

    Bio

  4. #4
    Grrr. This is so confusing. The first neuroradiologist wrote that there were "several" foci of T2 hyperintensities in the brain and then he described three specific ones, one that was 3x5 and two others that were 3 mm, visible in axial and sagittal views. Overall, there are about 12 foci. He said "MS could not be excluded."

    I had a f/u MRI at a different place last week (three months after the first), and this neuroradiologist, in addition to completely missing a second t-spine herniation that even I can see, describes the brain as "negative," says that the 3x5 "focus" is really just granular ependymitis, and doesn't mention any of the other "lesions." He described the upper t-spine herniation and then explicitly said that there were no other herniations--but there are actually two (T6-7 and T8-9).

    I think I'm starting to go crazy with all of the conflicting conclusions I've been getting from specialists. Based on what the first neuroradiologist said, I had an LP and have been on a pretty annoying roller coaster ride ever since. Should I get a tie-breaker neuroradiology reading or just run with what the latest opinion is? I've attached a pic of three FLAIR slices of my unimpressive "foci." One just shows a dot-dash pattern along the corpus callosum. I just turned 40, no hx of migraines/stroke/etc.

    Any help or advice or comments or similar experiences out there for me? What would you do in my situation? My insurance is going to start taking issue with me pretty soon, I think, with the various opinions I'm getting. But I've got to decide whether or not to have this t-spine surgery for the concurrent herniation/arachnoid cyst/myelopathy, and I'd like to shut down worry about MS if all these little spots in my brain are just ependymitis or whatever.

    Thanks,
    Bio
    Last edited by biowham; 04-20-2008 at 05:30 PM.

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