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Hello. Hello everybody. So, a warm welcome to the Fourth Be SSR Gland Grounds. And this is uh this time it's on back pain and it's very special because it's a collaborative session with BSN are that is the British Society of Neuroradiologist. It is my pleasure to introduce the panel members and we are very lucky to have four consultant ideologists independent. Today with uh fellow from Stoke Mandeville is Black. So our first speaker is Doctor Richard Hughes and I met Richard during my solution stand Mold. He's now a consultant in VESIcare radiologist at Stoke Manuel Hospital and part of the, which is part of the Buckingham share healthcare energies trust and also the home of the National Spinal Cord Injury Center. So his special interest is an image imaging of spinal injury, general, spinal and MSK imaging and also guided interventional techniques. Welcome Richard and then we have Dr mckeen radio research lead for Buckingham share. Um and he's also director of the Stoke Mandeville Musculoskeletal radiology fellowship. David completed his training in Oxford and he subspecializes in musculoskeletal radiology. Uh subsequently he did at the Nuffield orthopedic center and he's also at the Stockmen. Well, now. And the third colleague we have uh from the B S S R team is Doctor Joe Papa Nikita's and uh he's a consultant in Stoke Mandeville and he's talking to us about spinal infections today. And uh it's a pleasure to introduce uh BSN are member that is that Doctor Sugar Bra to Biswas, who is a consultant neuro radiologist at the Walton Center of Neuro Neurology and neurosurgery. Liverpool ships. Main interest is a epilepsy, imaging, cerebrovascular imaging and imaging of the spine and spine interventional procedures. He is a college shooter and he's also the lead for the BSN our grand run program. So welcome ship. And finally, we have Dr Abraham as um who's the M S K Radiology Fellow at Stoke Mandeville Hospital. So we will have all our speakers going through some cases and then about detailed discussions about those cases and an overall view as well. So I would first like to invite Richard to this stage. Thank you. Okay, thanks Pria. Hopefully you can see my screen. Uh Well, welcome everybody. Um So just in the next 10 minutes or so, we're just going to run through some brief thoughts um on imaging low back pain. Uh I've got a case of low back pain and a runner which is a contemporary case. So cases is a 42 year old and he's got a couple of weeks of low back pain on the left um struggling to run which is a problem because he's training for the marathon, um which you may have watched last Sunday first marathon that he first presented with about 14 days ago. And uh many of surprised those you on the call that have difficulty accessing opinions in the N H S. Um referral into NHS pathways and imaging was withheld pending a physiotherapy assessment. So why is it difficult at imaging? Well, we know low back pain is very common so common to be ubiquitous incidents and abscesses. Um worker increasing and imaging, an intervention for low back pain continues to to increase. Um This is from the literature from a few years ago, but I think the trends are still the same and the top graph have got lumber MRI utilization increasing and this is spinal fusions. There's a concern that imaging drives interventions and imaging low back pain produces costs, lots of incidental findings and induces treatment cascades. The picture on the rights of shows that we all know that uh degenerative spine disease is very, very common in people without pain. A lot of papers in the literature now that's showing that imaging isn't particularly associated with good outcomes in terms of population. Um There's a famous one for the Lancet from 2009. Sure that lumber amazing didn't improve patient outcomes. And there's a nice review from two or three years ago showing that imaging increased costs resulted in more interventions, increased absence from work. But um with no outcome benefits. This has driven things like the nice guidance which has just highlighted the headline, which is do not routinely offer imaging for people with low back pain with her at Sciatica. And this is what our primary care colleagues are confronted with if they've got a patient with back pain. Um This is an infographic from the BMJ following the nice guidance. Uh just highlighted what perturbed to us. So they've crossed off imaging. Um So you, you can't get your imaging is the headline. But interestingly, um I'm conflicted here because they're, they're asking these referrals to exclude specific causes of back pain such as cancer, infection, inflammatory disease. And to me, these are all imaging diagnosis. So there's a, there's an immediate conflict, don't image but exclude all these things that really our imaging diagnosis is. Um So there's lots of healthcare providers, commissioners are trying to decrease imaging. This is just an example of a patient poster explaining to patient's why they're back pain doesn't need an MRI. And despite all these interventions, there's an inexorable increase. So none of these interventions of work. People are still getting imaging. So if you work in departments and N H S or elsewhere, you've all got colleagues with low back pain. And if you're a doctor, you decide you've all got the cause is on the right. So we've probably all had scans or scandal colleagues because when your back hurts, these are the things that you think you might have, there's lots of aging pathways to try and draw these out. But I would contend that some of these are difficult nuanced clinical decisions. And this is where it gets difficult for us as images that we want to exclude these diagnosis. But where do you go this discourse in literature about some of these issues. There's a position statement on red flags from this journal a couple of years ago and this is one of their tables that shows that in primary care, people presenting with back pain and there's not an insignificant number of osteo product fractures. Up to 5% in older populations, malignancy can be up 2.7% the norm, mechanical pain and higher in in tertiary care. So withholding imaging from these, these patient's are difficult, you need very robust pathways. Um In Buckingham. Sure, we're, we're very fortunate to have the eye refers. A sure many of you have with the I refer latest guidelines that we use med current, which is an excellent product. But with our case from this week, I just went in as a test and put in to see what would happen. So if you put low back pain in it asked me what's the sort of low back pain the best fit seemed to be acute. So I picked that and then it asked me these red flag questions. So it has the patient got a fever lost weight and really hasn't So we've take no red flags. Next page we come to ask. So we're going to refer, well, not yet. And that's going to take some time. Do you think a fractional uh with no history of trauma? So no, so you take none of the above and on this I refer path where we're now into a page. It says imaging is not indicated. So it's a pretty hard break here um for imaging in, in patients presenting with, with back pain to the certainly the primary care refers now be very short talk if you had an image of this case that we have. So if you go on to image Mri's are gold standard, despite all the concerns about individual cost resource course and and the evidence um this is the scan, we're going to go for the majority of low back pain investigations in the UK is still with radiographs which I'm not going to dwell on. But we all know the sensitivities and specificities are pretty low for those red flag conditions we want to find out. And CT I would reserve as a, as a problem solver. If you're going to do an MRI, I would um say that we're gonna bother, we should really include a sagittal stare. You're going to pick up lots of stress lesion's power, stress features better for marrow. In our institute. We use actual T ones and T twos, but that's variable. And there's a little bit of chat and literally late about adding corona imaging a paper I used to refer to as from back almost 20 years ago now, which found a very low uptake of additional findings. Actually, more recent papers um contained, you might find up to 5% more and some centers now include corona aging, which have to we don't routinely, but you will find things like in the S I J S and in the pelvis. So back to our case, um so he had been struggling, was worried about his marathon and he couldn't get imaging. So he came to the private sector four days before the marathon. So, one of my orthopedic colleagues who referred him for an urgent MRI of his lumber spine and these are the images. So we're just going to run through the Sagittal T one and T two. You can see he's got a bit of a dark disc at 51. There's very subtle motor change over towards the right side. The other discs look okay. Nothing else jumping out. But if you look at our stairs, we come across again, we've seen that little bit of body exchange towards the right. You're wondering is this the cause of his back pain at the very edge of the field of view? We've got a finding. So he's got some bright signal in the left upper pelvis here. Very subtle, very easy to miss if you're reporting a stack of lumber, Emery's. And actually serendipitously in his actual scans. The field had come quite down. We would usually stop at 51, but he's actually got some imaging down at S 12. He's got this low signal in the area at the top of the sacrum. Uh The radiographer on duty that day had obviously had the coffee, they spotted this around some corona imaging, got a Corona lte one corona stare and we've got a diagnosis. So this guy's got a great for stress fracture of his left sacrum. So unfortunately, his marathon in four days time is not going to happen and he had to sit it out. Sadly, so interesting findings from a lumbar MRI. Um It's a well reported injury, it's said to be rare but very well described and I suspect it's probably very much under reported first described 1988 in the A J R. This is a British paper in 1991 of the first reports from bath in a female 10,000 m runner. You can see a really nice example of unclear medicine. Uh what I trained with. So thankfully, we've got memory now, lots of little case series in case reports as in these cases. Some of the earlier ones with CT uh interestingly in major and Helms's paper of the four cases, two were radiologist colleagues who were training for a marathon which led them to speculate is this speculate, this is likely a very under reported injury. You look at the case series. The presentations are often very vague. These um patient present with blue tailed buttock pain, low back pain. It's often mistaken for disk pain, rscg dysfunction. They may, may not have sciatica, um physiotherapist, talk about the hop test. Um I have no idea how good that is, but it's often referenced and certainly for athletes, the prognosis is pretty good with rest and rehab back in about 68 weeks. There's a nice review, a couple of years old looking at 49 published series 124 fractures. Lots of these were runners, small number of other elite athletes, military recruits. Um There is an association slight female preponderance with the female athlete triad and proportion of these females will have low bone density. And there also is an interesting series of elite athletes coming back from post pregnancy, postpartum who seem to have an excess of these injuries. And as with other stress fractures, there may be a relationship with vitamin D interesting if you look at runners um parts of the web, this is really well recognized among runners. There's an article here from runner's world from a few years ago showing these four elite collegiate national US athletes all with stress fractures in the sacrum in a short time. And there's lots of blogs and lots of red. It's among runners who are very well aware of this injury. So I suspect very much under recognized. So take some points from this case. Um We've got to be very careful when we've got these imaging restrictions and nice guidance and I refer decision support will, will take you there, but you have to think of the diagnosis. So looking back at I refer, if you suspect a fracture and a stress fracture, you will get the scan, but you've got to think of the diagnosis. Follow us. That would sort of a low threshold to scan. athletes and marathon runners. Ultramarathons are at risk of these injuries. We're often going to miss some of the standard Lumber Emery protocol. So in these low back pain cases, as in this case, it's edge of field of view. We should strongly consider in certainly the right cases including corona imaging and S I G imaging and low back pain, which will get us the diagnosis. So that's my case. I'm not gonna hand over hopefully to my colleague, Joe. Thanks very much. Thanks Richard. I'm just going to thank you. Thank you, Richard. So uh good. I mean, very good teaching points about, you know, several fractures. We think about inception, see fractures in the elderly, but you know, thinking about stress fractures in the young at least uh is as important. So, thanks Brett. Can you see my slide, Brett? Yes. Yes, thank you. Yes. OK. Thank you. So, um uh my name's Joe Papa Nikita's. I'm another um consultant musculoskeletal radiologist at Stoke Mandeville Hospital and I'm just going to talk to you briefly over the next um six or seven minutes about spinal infection and show you three quite interesting cases. So just a brief introduction, spinal infections constitute a demanding like treatment challenge that in most cases necessitate a multidisciplinary team approach. Um infections are usually caused by bacterial organisms. Although fungal infections may also occur. And the nomenclature for spinal infections is often complex and confusing. Uh since under the umbrella term, spinal infections, um heterogeneous group of infections is included. We'll have a look at the table on the next slide um to look at these. So the nomenclature correlates with several different aspects of the infection such as the causative pathogen, the underlying pathophysiology or the involved part of the spinal column. And as we know, um any part of the spinal column can be affected. Correlating two different terms such as sponsor disc itis or disc itis infection can also spread inside the spinal canal involving the dural sac and or epidural space as well as the para vertebral soft tissues. So here's just a small table with some of the most common um terms that we use in the context of spinal infection. We have disc itis, which is obviously involvement of the inter virtual disc, which we commonly see in Children spondylitis is another term that may be used where the vertebral body or virtual endplate um uh is involved and we often see this in the early stages of infection with in adults, spondylitis, Ghitis, um probably the most commonly used um term which uh essentially depict the involvement of disc and adjacent vertebral body. And then we mustn't forget also septic facet joint arthritis. Um and also epidural abscess, which we commonly see as a complicating factor of spondylar disc itis. So this is just a diagnostic algorithm for spinal infection. We won't dwell on this for too long. Um So once there's clinical suspicion of infection based on history and examination and the appropriate laboratory tests have been performed. Uh Really, we we want to move on to MRI is the gold standard for assessing for this. If MRI is contraindicated, then we may consider CT or radio nuclear radionuclide imaging. We've always got to consider a differential diagnosis um in back pain and spinal infection. Uh remember that symptoms of spinal infection can be very similar to those of other spinal pathologies, especially in elderly patient's when often fever um uh is not present and and misdiagnosis is very common. We need to differentiate differentiate spinal infections from spinal tumours, degenerative spinal stenosis, herniated discs and and muscular skeletal injuries as well as mentioned. MRI is the modality of choice in differentiating spinal stenosis uh and discs from infection. Since imaging findings are unique for each pathology. Um and uh the differential between spinal tumor's and infection is often very challenging and in these cases, biopsies required and is the only reliable method to distinguish between the two. So, this is our first case um uh from stoke Mandeville. So a 73 old male with a three month history of back pain, he presented with raised inflammatory markers and features of mild sepsis. Um And these are fairly um characteristic features of spondylitis Ghitis. So, on the left, we've got a sagittal stir uh image. Um and we can see um the high signal fluid within the inter virtual disc space. Um The fluid tracks anteriorly and posteriorly resulting in bulging of the anterior and posterior longitudinal ligaments with, with associated um uh collections within the space is we can see that there is M plate destruction here. And also we can see the, the high stir signal within the um within the virtual marrow. If we move to the central image, these are sagittal T one weighted images. Um And here, characteristically, we see low T one marrow signal change. So we essentially have marrow replacement. Um Here on the T one image is on our right hand side image. What we're looking at here is the epidural collection. And we can see that there is indentation and scalloping of the juror and slight displacement of the cord at that level. And then anteriorly, we're seeing fluid um um within the inter inter virtual disc space and um kind of paravertebral region. So, our second patient um 40 year old female, she presented with a six month history of back and leg pain, no specific features of sepsis. However, she did have raised inflammatory markers. She underwent an MRI of her lumber spine. Um uh And again, here on the very lateral image of the sagittals, we picked up something in um in the region of the S one vertebra with increased marat signal change. So high stare signal, this um uh we then went on to perform an MRI of the pelvis to look at this area further and delineate what was going on. And so here we have an actual stir sequence through the pelvis and the sacroiliac joints. We can see a see here centered on the left side joint. We've got florid, periarticular bone marrow, edema. We have widening of this left sacroiliac joint with fluid tracking through, we have a fluid collection extending out of the anterior joint and we have secondary inflammatory changes within the aisle, ISOS musculature going back to the patient's lumber MRI scan um Here on the right. Um We can see this heterogeneous, irregular um low to intermediate signal material um which is a facing the CSF within the canal here, we can see the normal CSF that you'd expect to see. Um And then if we go to the corresponding actual sequence, what we're seeing here is this area. And so this stellate structure here and the right of the canal is actually the dural sac which is being markedly compressed and displaced by this epidural collection. So this patient had features of infection within the left S I joint, tracking transforaminal e uh and into the epidural space. This is a ct taken at the time. We can see the extensive osseous destruction within the left side of the sacrum. We can see that this has been going for a while evidence by the, the scalloping and sclerosis of the margins. So, we went ahead um and performed a biopsy and aspiration within the left sacroiliac joint and we're able to aspirate past like fluid from this. Uh and this turned out to be TB just for our last case. Uh 56 year old male who presented with sepsis and bilateral lower limb weakness. He underwent an MRI scan here. We can see within the lumbar region at the um L4 slash five level. There is this large posterior epidural collection. Again, we can see the normal CSF signal approximately. Uh and this is kind of clearly not, not the same signal intensity and on the corresponding axel again here, posteriorly, we can see an epidural collection and it's causing indentation scalloping. Um of that posterior dural sac. Our spinal surgeons asked us if there was anything we could do with regards to trying to drain this. So we went ahead under CT uh and performed an aspiration. Um uh This is just a black spinal needle with the five millimeter lulac syringe. Um and we were able to aspirate about five mills of Frank pus from the collection. And these are the kind of pre and post images. So on the left, this is the initial image with the epidural collection. And you can see that you've got a face mint of the CSF around the quarter kind of nerve roots and within the drill sac. And this is the post procedure uh MRI scan. And here we can see that now there are, we can see CSF in between the nerve roots and also anteriorly within the dural sac. And there's a tiny, tiny bit of epidural collection left posterity. But, but clearly, um that area has been pretty well decompressed and this patient was, was there then um spared a surgical decompression. Okay. Those are the three cases. Thank you very much. Moving on to, moving on to David. Thanks Rajjo, uh and Richard. Uh So I'm just going to share my slides of what those are sharing now. Um um I've tried to cram it quite a lot, but I promise you should, I'm going to finish on time and give you plenty of time to get through your presentation as well. So, uh we've been asked to give you a talk on some interventional techniques for the treatment of back pain. And as you know, there's um back pain is very, very common. There's a variety of different causes. I think the treatments that you can offer can be broadly divided into the treatments for malignant disease and for benign disease. And uh in the time that we've got available today. I'm just gonna be talking about two areas. Really ablation of painful bony metastases, ease and a new technique, ablation of the battle local nerve for patient's with vertebra genic back pain. Now, bone mets are very common. Up to 70% of patients with cancer will develop bone metastases. And then up to 20% of cases, people actually present with their, the pain from the bony mets at their uh with their primary cancer. Now, the pain from these bony metastases can be very, very severe and difficult to treat. It's a complex pain, partly due to the structure of the bone release of inflammatory cytokines. You can get sort of fracture, you can get pressure on the cortex, you can get damage to the nerves, sort of do the infiltrating tumour or just compression and also you can get central sensitization. So, um um so it's a complex pain and can be very, very difficult to manage in the majority of cases. The aim is effective palliation is you're just aiming to reduce patients' pain, uh improve or maintain the level of function and provide a degree of mechanical stability. And in the vast majority of cases, the primary treatments are going to be open analgesia and radiotherapy. But it is important to bear in mind that radiotherapy doesn't work. In every case. In fact, about 30% of patient's get no benefit from radiotherapy. And then the 6% who get some some response. About 50% of those with recurrence of their pain in the weeks following the cessation of the really type of treatments. Now, the the response rates in patients who have stereotactic body radiotherapy is slightly higher. So it can be up to 4% of patient's get complete response of their pain. But please bear in mind that there are risks associated with stereotactic body radiotherapy, uh such as an increased risk of uh of fractures. These patient's often have the worst bone quality of any of the patient's. You're going to treat. Uh they're often elderly osteoporotic, the bone's been infiltrated. Um And then they've got further degradation of the bone from the radiotherapy. So they're very high risk of getting fractures. And in some studies, the rate of fracture following stereotactic body really radiotherapy can be up to 30%. So, what's the role for for thermal ablation? Well, um ablation is essentially a way to directly put a probe into the tumor. Keep the tissue up, denatured proteins, kill the cells, try and get some local control of the tumor before you usually uh augment the bone with some cement. Now, it can be used. Ablation can be used in a number different settings. Uh for benign lesion such as osteo osteo hmas can sometimes be used with curative intent for patient with organ metastatic disease. But in the majority of cases, it's a path of treatment. Uh but we have the advantage of providing fast effects of pain relief may reduce the risk of further fractures if you augment with the cement and you make a degree of local disease control. So in the time that we've got, I'm not going to be able to go into the evidence forward for consideration in very much detail. I've direct you to some of these recent systematic reviews, particularly work from Tom Thomas's Group over in Norwich. They published an excellent review back in 2021 the more recent study from leave ESL. So this was the opus one study. So this is a global multi center prospective study. They greeted 100 patient's with painful bony metastases, ease and they repeated with radio frequency ablation and then followed up for 12 months after that, although they published their data at six months and this showed that patient's had significant improvements in their pain scores almost immediately following ablation and that this was sustained all the way up to six months following the ablation. Um So, uh you had improvements in the patient's worst pain and improvements in their average pain and improvements in there, sort of assessments of their pain interference. And as I say, this was sustained for up to six months following the ablation procedure. There is some data out there to suggest that ablation can be used for local tumor control and may even have comparable results to stereotactic radiotherapy for small tumors under two centimeters. And there is uh some days out there that there are additional benefits to performing inflation beyond simply pain control. So, this study from Fredericton Schultz group over in Paris, looked at the incidence of vertical voice events and it showed that you got a decreased risk of essentially uh further pathological fractures, metastatic epidural uh tumor extension or called a Coin syndrome requiring surgery already. Therapy in patients who had really therapy is a patient who had really frequency ablation of their spinal metastases. So there may be some additional benefits, ablation beyond simply pain relief. Um It's important to remember that ablation isn't in competition with radiotherapy. Uh It's an additional treatments and adjunct and you can have all of your conventional treatments as well. So it doesn't preclude any other treatments. It's just an additional treatment you can consider. And uh the reason there's even some data to suggest that the combination of radiotherapy and ablation may result in the best patient outcomes in terms of pain response times, a pain response and complete pain response. So the so the combination of radiotherapy and very frequency ablation may may result in in in sort of optimal patient patient character. There's a number of guidelines have come out, but I'll probably direct you to the most recent nice guidelines that were published earlier this month, which essentially supported the use of radio frequency ablation and vertoplasty uh withstand arrangements if you want to do ablation without cement augmentation, then there's some special arrangements which essentially an emphasis on informed consent for the patient's given that there's relatively limited literature about that technique. I'm just going to pass over the different pathways for the sake of time. Uh Now, typically perform these procedures under fluoroscopic guidance. This is our, our old frost, the sweets, it's actually next door. And if you hear any hammering in the background is because they're currently replacing that with our, our new units. And so while that's been done, we've been doing these under CT guidance. So this was our previous dello as many a performing ablation in the pelvis. Uh This is my colleague, Joe who was just speaking, supervising her doing a different pelvic pelvic ablation. So can do under CT tickle down in floral, depends on your local set up. So, with that background, um I'll show you a few cases of what, what you can do. So this is actually the first patient we treated in our trust. This was back in 2017. So this is a 54 year old patient with a renal cell carcinoma, but she had a nephrectomy, but unfortunately got recurrence in the surgical beds and then very rapidly went on to get disseminated disease. So, innumerable, pillory mets and lots of bony metastases. But the lesion that was actually causing her, the majority of her symptoms was this pathological fracture to this in infiltrated fertile body in the, in the thoracic spine. And despite having the maximum fractions of really therapy that she could have and all the opiates that the medical team could throw at her. She was in such severe pain that she couldn't be discharged from the hospital. I couldn't even get to the hospice, uh unable to, unable to sit up in bed, unable to mobilize. And so the oncologists asked us if there was anything that we might be able to do. So we um we performed a re difficulty ablation at that level and then a cement augmentation to fill the body of cement. Uh And we got excellent, so mental and then we had to wait and see how well the patient responds and she had an incredibly response. So for her pain before she told us was about a nine out of 10, very rapidly improved. So she was mobilizing on the ward, were sitting up in bed the same day, mobilizing on the ward the following day and was discharged from the hospital to a hospice uh later that week. So a really significant response. Now, she only survived for, I think about 3.5 months following procedure. And that's essentially, I think what we would expect from this patient. It's a part of procedure is done for pain relief. Um But it can make a significant difference to patient's um quality of life at the end of life in, in appropriately selected cases. Um So this is a 41 year old patient with breast cancer she had a mastectomy and then um student with Adjuvant radiotherapy and Tamoxifin and her initial bone scan was clear. However, three years later in 2018, presented with a Met at L1. And um you can see here on the, on the MRI the infiltration and collapse of that virtual body. And the diagnosis was confirmed on biopsy that she had a mess at this level. And you see here the infiltration sort of the uptake sort of uptake on the pet CT scan of that metastasis. And so we were, we were asked to see if we could help with the pain that she was having. But also we were hoping to get a degree of local control of that metastatic deposit. So we performed ablation at that level and then cement augmentation you see here and then the patient went on to have radiotherapy. They had Zoladex waitress, all they had CDK inhibitors, they had denosumab. So she had all the treatment that we could give. And since then, she has been pet negative. So, uh negative on pet scans. This is the most recent report and this is from last month. So she still got no metabolic evidence of disease uh following her treatments. Now, this was not when I would not claim that this was simply down to the ablation, but the ablation certainly helps because we prevented that brittle body from collapsing any further. We gave her pain relief and we gave her degree of stability and a degree of local control. In addition to all the other treatments, I think that's a nice example of how you can use ablation as an adjunct to all the other people that are available um in patient's with all the metastatic disease. And she, she's continuing to do very well, very quick case here. This is a patient with cholangio carcinoma. You can see here large metastases within the spine and within the pelvis. We ablated the relations both within the pelvis around the acetabulum. And this is the cement fill that we got after that. And within the, the lower thoracic spine, this is the cement fill we got there. And this patient who had previously been unable to, to set up wasn't tolerating a brace. Um responded, well, we got control of her pain and she was discharged home, able to mobilize, able to walk upstairs. Uh And she survived for six months before she, she died of complications of her hypercalcemia. Um But again, a nice example of what you can do. So you're not actually limited to pain in the back. If you've got pelvic pain, you can potential for inflation there as well. So I'll skip over this case. This was just a nice one of um epidural tumor regression following ablation. Uh This was a nice example of some A CT subsidy guidance biopsy, destroying the position of the ablation pros within the vertical body and the cement feel that you can get following that. And this was just a nice case of a arino met in the pelvis. And the, the trick here was to try and avoid ablating any of the sacral nerve roots and then trying to avoid putting any cement into the sacral ala. But we got some nice, nice fill, nice disease control. Again, that patient did, did very well following following that procedure. Um We're not doing this here yet. This is a paper from uh Roberta Cusato and propagandize group over in Strasbourg where they're doing a lot of osteo census in the Pelvis. And this might be a further treatment that some, some units might want to consider. So for the last couple of minutes of the, of the presentation, I'm going to talk about ablation in another setting and that's in the setting of chronic low back pain, uh an ablation of the Bazaar vertical nerve. So there was a study which came out from fish ground at al back in 2018. And patients who have chronic low back pain is often associated with disc degeneration and that's often associated with reaction of the adjacent endplates. And these patient's often have these more which one or more h two changes. Now, those endplates are innovated by the buzzer vertical nerves. This is the nerve that comes in the back of the total body cluster, essentially within the vertebrae body and then branches up and down to innovate the endplates and in patients who have intractable back pain and who have these mortgage changes. Ablation of the nerve innovating in plates appears to result in uh may result in uh significant improvement in patient symptoms. Uh So that this is a recent paper from the correct uh tell in 2021. So they randomized patient's to either bath working there ablation or conventional treatment. And they showed that patients who have the password will never ablation has significant improvement in their pain scores. And in their Oscar street disability index, um following their bladder Burton nerve ablation and the patient's who were randomized to the control group who then crossed over to have ablation then had a very different response as well. So that's the dotted line there. So, um patient's so a greater than 50% reduction in pains reported in 72% of their patients' and up to 31% of the patients were apparently pain free at two years. Uh following the ablation procedure, I'll just pass over this just for time. But again, the, the combination of a 15 point reduction in your office to disability score and a two point reduction, your in your pain score was seen in 73% of patient's which is high that said it doesn't work for everyone. So even in their paper with very strict selection criteria, about 22% of patient's didn't really respond. So it worked well in some by no means everyone. So this is not a fancy uh but it's an interesting, interesting technique. So uh patient selections, obviously key. You're gonna want to make sure you're, you're picking patients who are going to be good candidates for. This can be performed under fluoroscopic guidance. This is the relieving device which is available in America. We perform this under CT guidance using the the Aleve a biotech needle, which is an ablation needle. Technically, it's easier than tumor ablation, but it does require very precise pro placement cause you need to get your ablation probes very centrally within the vertical body. Uh and at s one level that can be technically tricky because you're having to arch over the top of the eyelid crest and ankle down. So we angle the gantry of the CT scan er by about 20 degrees in order to get down into that S one. But it's, it's technically possible and we've done a refuted about 10 patients. So far we've got follow up data in on six, but we're going to collect the data and all of the patient's we've seen. And as you can see, um in our first six patient's for have a significant improvement in the pain scores. But to didn't and I think that's consistent with the previous published literature, doesn't work for everyone that can work well for, for some patient's and associated with improvement in the office to Disability index. And we're also collecting data on patient's um uh short form health questioner survey again, seems to show improvement in people's general general health following the glacier procedure. But more more data to follow on that. So we've had, we've had some visitors from Oxford and Germany and Switzerland to observe this technique. It's an interesting technique. There's certainly more work to be done. But um but promising results so far, so I'll just finish there. So if you take home message is radio frequency ablation of spinal mets may allow for safe, significant and sustained pain relief as as documented in the latest uh literature for focus one and the systematic reviews may result in fewer vertical complications and importantly, does not preclude conventional radiotherapy. You can have a urinal radiotherapy and does it hurt? The nerve ablation may alleviate chronic low back pain with literature suggesting improvement in pain scores and the Australian disability index. And so this may represent a new minimal invasive method of providing pain relief for patient's with intractable chronic low back pain. Although there's certainly more research to be done. I just want to thank Abraham Abraham did all the work for this presentation. So I just wanna acknowledge the fact that I'm taking all the credit that he's done all the, all the actual work. And if you have any questions, we'll be available at the end of the webinar to answer those. Uh I hope I finish sometime should uh and thanks for him for all your work on that. So I think we are trying to answer the questions on the as we go. So please post your questions on that. So, uh whether I do, I will uh welcome, should to present the uh B S and our perspective of factory. Thank you. Thank you. Am I audible Pria? Yes, yes. And you can see my screen. Yes. Thank you. Ok. Uh First of all, thank you B S S R. Thank you Bria for inviting BSN are to be a part of your grand round program. And uh as you were aware, uh spinal work, spinal imaging is a significant part of our work as a new radiologist. Uh and it encompasses all aspects of spinal disorders, uh the degenerative from a infection, new plasm, congenital vascular, um so on and so forth. And although the theme for today's Grand Round is back pain, um not all patient's uh present primarily with back pain, back pain may be a component of their symptoms, but a lot of the patient's represent with radiculo pain um and uh neurological deficit um myelopathic features. But yes, in most of the patient's back pain remains a significant component. Uh But today, um we are not going to talk about any advanced imaging techniques. Uh We are not going to discuss anything very novel or complex in my presentation. Uh I'll keep it simple and uh we will discuss uh some cases just focusing on a couple of areas of interest by demonstrating those cases and apologies in advance if I rushed through the cases, uh just have to be uh you know, mindful of the time. So without much, I do, I move on to the first case and is the slide moving freer? Excellent. Okay. So this is our first case. This is a 64 year old lady who presented with low back pain, radiating to lower limbs, she had reduced sensation and power in the lower limbs. Now, this is exactly what the clinical information said and she was scanned at her local hospital. And uh the main question was whether there was any core compression, although they did not mention anything about myelopathic features. But anyway, it was specifically mentioned in the request, whether there was any cord compression and this is the scan uh which she had at her local hospital, but she also had a history of uh breast carcinoma, which was treated several years ago. And she also had chronic break algia uh that was attempted to be treated by spinal cord stimulator implant, but that unfortunately had failed. So these are some of the selected images from her initial scan T two said it'll t one said it'll and stir. So I've just chosen a few images representative images that didn't show any spinal cord compression. You can probably see some changes at the upper thoracic region involving the posture elements that was from her uh spinal cord implantation. And also these are the images from the lower thoracic and the lumbar sacral region. Now, if you see anything from these uh images, feel free to uh post it using the checkbox button and pr and probably will be able to see uh if there is any um correct answer. So I'll just leave this particular slide in front of you for a few seconds. Okay. Moving on. So this was the report. Um Essentially, the report said that there was no fracture, there was no bone marrow infiltration. Uh And it mentioned about the degenerative changes. OK. Moving on. So the patient unfortunately decorated and she presented three weeks later, uh now with retention, she had uh left leg, parasthesia, diminished, perennial, perennial sensation and reduced anal tone and she was uh week along the L5 myotome. So the question now is whether there is any code a a queen a compression. So this is the repeat scan. Uh This was again done at a local hospital, but this was brought to us uh for a second opinion. So again, the cervical and upper thoracic uh spinal imaging did not show anything significant. But as I have highlighted it using these um arrows, uh you can see the code Aquinnah nerve roots are markedly abnormal. What you can see here. There are multiple tiny nodules spread all along the code Aquinnah nerve roots. So what did we do next? We give contrast rather the we advised the local hospital to get an imaging with contrast and you can see all the nodules enhancing and also on the XL images. You can see the announcing called ocular nerve roots. And uh with probably an io fate, the nodules uh are quite uh bigger compared to what you might have seen on the initial scan. So this was the initial scan and over the last three weeks, things seem to have deteriorated. So at this stage, what are your differentials? What are you thinking? What are the causes? Okay, again, feel free to put your comments down on the chat box. And what would you suggest? We have a few things? A BM query, ABM, query breast, drop mats, query flow voids around the corners. Fantastic. OK. And what would be your next set of investigations? What did you do? We have already given contrast? Okay. So what would be your next radiological investigation? Anybody coming up with answers lumbar puncture? This then look for max. Okay. Fantastic, MRI head. So the first thing we need to do is image the rest of the new axis. Okay. We need to see what's happening in the brain staging city or a pet city would be essential. This patient was treated for uh see a breast and she didn't have any issues still very recently when she presented with the spinal problems. And what did the uh MRI of the brain show? These are just selected images from the post contrast sequence and you can see enhancement along the seventh and eight nerves. And also you can probably appreciate this nodule along the right oculomotor nerve. So basically, there are now changes in the uh leptomeningeal surface of the brain. The staging city was pretty much unremarkable. And yes, as people have already suggested, um she should have a CSF study. She went for uh lumber puncture and that showed malignant cells consistent with carcinoma of breast. So this is leptomeningeal carcinomatosis or metastasis. I wouldn't call it drop metastasis. Drop metastasis is specifically the term um should be used if there is a primary in the brain and the metastasis is extending into the spinal channel. Okay. So this is another case of um uh breast carcinoma with leptomeningeal spread. And here you might be able to appreciate that there is also some dural based lesion's which is causing spinal cord compression and the patient actually went on to have decompression there. This is a very early post operative MRI and therefore, you can see some swelling of the cord. And this was again proven to be uh metastatic, see a breast, I promise this is the only um case I have got from radio pedia. Uh So this is a patient with these nodules in the midst of the cardiac weena love roots. And also you can see this large mask in the within the spinal channel intradural. And what has the patient got? There is a lesion in the posture fossa this is actually a drop metastases from intracranial ependymoma. Okay. And at this stage, it might be worth just revising particularly for trainees for people who are going to take a far see our final or even to be what are the causes of drop metastases? Medalla Blastoma is not curious to do that. Okay. Ependymoma is due pioneer malignant pioneer tumor. So it's probably worth remembering the top five or six of the pathologist which can cause drop metastases. Okay. Another case patient presenting with codeine queen a like um symptoms. But in this patient, there were some uh upper limb symptoms as well. And on questioning, it was found that the patient also had some cranial nerve issues. Okay. And what do we see here? The code A queen a nerve roots that looks shaggy. They are not normal at all. You can probably appreciate some tiny nodules all spread along the cauda equina nerve roots. So what do we do? Again? We give contrast and you'll probably be able to see all these tiny nodules are enhancing as if their sugar coated. Okay. That's the classic description given to such an appearance and the precontrast there is no enhance about, they look okayish on T one probably taken but postcontrast the enhanced like mad. So we need to image the rest of the new X is very, very important. And what do we see here enhancement along the surface of the spinal cord extending all the way to the brain stem and along the margins of the cisterns, you can see the enhancement along the surface. This is again, leptomeningeal enhancement. Okay. What did the brain show? There was announcement along the seventh and eight nerves along the service of the brain stem? That's the enhancement along the interpreting color cistern going into the pyramids and catholic cisterns. So, this patient had lumbar puncture which was results were equivocal and uh all other tests were done city uh staging. Um uh CT there wasn't anything significant no history of malignancy. Um So as a last resort, the patient actually went for a meningeal biopsy and the result was sarcoidosis. So remember sarcoidosis as an important differential for cardiac queen, uh abnormalities know duller enhancement of curricula. And what goes hand in hand with psychosis lymphoma? Okay. Radiologically, you may not be able to differentiate between the two, but for example, purposes or for your day to day practice, uh this would be an important differential. Another case, this this particular patient has had problems for many years, okay. But finally, he had an MRI done. And what we see here particularly on the postcontrast scan, multiple well defined lobe related lesion's, they enhance very homogenous li they are very bright postcontrast administration and uh these, these are multiple astronomers, okay. This patient actually went on to have surgery and this was confirmed histopathological e as well. There's a tiny remnant as you can probably appreciate there. So when you see multiple traumas screen the patient for N F two and Schwannoma tosis. Schwannoma doses is a different group of uh it's a different disease. The other features of N F two will not represent on uh in a patient with Schwannoma tosis. Okay. So again, particularly, for example, pus very important unlike the previous case or cases rather, uh this is a solitary lesion within the spinal canal, uh intradural hanging in the midst of the cardiac unit nerve roots. And I'm just showing you the T one weighted axle and you can see t one hyperintensity indicating that the component of the lesion probably has some fat within. And when you see something like that containing fat, think of dermoid okay, that's an important differential. But unlike the previous cases, this is a solitary lesion. And when you see dermoid check for signs of spinal dysraphism, so they're very common. Uh look for the position of the Conus, whether there is any scattering of the cord, whether there is death, hematomyelia screen the rest of the neuro access, whether there is Syrinx involved, whether there is any um chancellor herniation of the cerebellum, things like that. Okay. Moving on next case. Okay. Now we've been talking about changes in the code equity nerve roots in form of masses. No deals. Okay. But what is also important is to look at the configuration of the nerve roots as well. Howard the nerve roots spread out. Okay. This is clearly abnormal. You see the nerve roots are kind of pushed anteriorly and they are clumped, you can probably appreciate here. So that's how normally the cardiac in the nerve roots should look like. Okay. The patient is lying supine. So the the the nerve roots would probably be uh you know, they will be displaced posture really due to gravity and they are sort of evenly spread out. Unlike in this patient who had presented with back pain, reticular pain, and you've probably been able to uh see it already, there are some postoperative changes. So patient had surgery in the past. So this is these are the changes secondary to arachnoiditis. Okay. And most common cause is of course infection including POSTOP infection and hemorrhage. And in this particular patient, when we went back three months ago, patient had surgery which is complicated by infection. Patient had post them are a post contrast MRI at that time. And you could see extensive enhancement of the cardiac we ne nerve roots that was three months back. And now as a sequela of the previous infection, you see all these changes now expedited or recognizing ethmoiditis is very, very important because if you are thinking of failed back syndrome, think beyond recurring this think beyond fibrosis. Okay. We always, we are often sometimes I don't want to use the word but simply fixated by looking, looking for recurrent disk fibrosis, but look for changes of arachnid itis. Now this is a gross example of arachnid itis changes may be very subtle, okay. And these patient's may not benefit from any form of decompressive surgery. They may need to go for neuro modulation. Okay. Um Just in this case, patient went on to have a spinal cord stimulator, uh put in for the pain. Okay. Now, if you see changes in the coquina, it is worth giving contrast whether we should give contrast to uh everyone. Well, unless there are changes which are seen on the initial scan, there are very specific situations when you might have to give contrast to evaluate the cord uh routes, particularly if you're suspecting something like uh well, I'm not going to give give, give it out right now, but this is a similar situation. So this is this came from a neurologist and the patient has quadriparesis with areflexia neurologist had already done the lumbar puncture and it showed signs of inflammation. So the neurologist is specifically asking for us to look for thickened or announcing saraca number nerve roots because she is suspecting an inflammation along the cardiogram nerve roots. So when there is suspicion of inflammation, even if the cord quinton nerve roots look seemingly okay give contrast and that's what we did and you can see enhancement of the nerve roots. Now, this is a bit of of volume artifact from the facet joint arthropathy. So please ignore that. But postcontrast, you can see uh this avid enhancement. So this was a patient with CIDP chronic inflammatory demyelinating polyneuropathy, which is essentially a chronic form of Gillian. Very okay. So yes, depending on the clinical information, we may be prompted to give contrast and look for changes in the kodiak weena. Um quickly moving on longstanding back pain in this young patient. Uh we have been talking about morphological changes in the cardiac weena but is there a code a queen rather can we see the cardiac queen and nerve roots in this patient? Well, where are they? I can see them? Okay. But if you look carefully the signal in the lumbar spinal canal is not quite the same as CSF, there is some scalloping of the posture margins of the um lumbar debris again on the axles where the Coreg the nerve roots we give contrast and what do you see lo behold, there are areas of announcements. So basically the whole lumbar spinal cannel is being replaced by a mass, okay? And you can see it very well on this post contrast XL. So this is mixed popularity ependymoma. Okay. Uh The only a typical feature of this particular case is that the announcement is not very avid, generally mixed papillary, ependyma was the light up like a light bulb, okay. The announced very avidly. But this is probably the only case I've come across where the announcement is uh not as much as we generally expect. I know we're running out of time. Last case patient presented with codeine equity like features. This 10 osis was reported but the patient continued to worsen uh with the symptoms four months later, was scanned again. Now these are again from not from our hospital but from the local hospital. And you can see this mass in the cul de sac of the lumbar sexual spinal canal. Was it there before? Yes, it was okay. Unfortunately, it has grown and uh patient had a dedicated MRI of the pelvis which showed this ab nominating the piriformis muscle. So the mass had infiltrated with the muscle, had biopsy and uh the diagnosis was lymphoma. Okay. Had a pet scan uh which showed this high uptake of radiotracer. Patient had treatment eight months later, had pet again and this has all disappeared. So, patient did very well in terms of response so called equina syndrome, we tend to look for compressive pathologies, okay, whether there is a disc, whether there is fracture, whether there's an epidural hematoma collection, but it's not just about compressive pathologist. Look at the Kodak and nerve roots, the morphology. Are there any nodules? How does the, how do they look like? Um Is there any announcement give contrast if need? Uh you know, if you think they should. So, Kodak and a nerve root should be treated as a review area. It is a potential blind spot. I have to say I've come across quite a few disturbances involving this particular area. So uh it's probably useful to customize, spend a couple of extra seconds uh to look at the calorie count and nerve root. Similarly, the cul de sac of the llama sexual candle. So, yeah, I think, uh I've been able to give you a whistle stop tour of some pathologies involving the cold air cleaner, nerve roots and the cul de sac. Uh Hopefully it should help in your exam preparation and also helping your day to day practice. Uh Thank you very much. Thank you. Thanks a lot. Uh You have, you have Brian kept the time um is Richard on stage as well, David. Uh And yeah, uh if you can, uh thank you. Okay, thanks a lot to all speakers. And uh that was really good, but we went from uh guidelines uh from Richard and you know, some unusual cases of uh stress structures that should not be missed and what you look for. Then we went to intervention. What are the different types of intervention there? And then she uh said what we as Ams Care radios should not miss when we are reporting uh emitting so excellent and uh has been very good infection here. And I would like to thank uh cake because she designed, you know, the wonderful poster for the thing Kate is here. Okay. Do you have camera? You can say hi, please. And Sue has been great in getting all the intellectual global, uh you know, dedicates uh because we have people from Ukraine and uh from Egypt and you know, from India. And so so has been really inflammated in uh making it possible for them to attend. So thank you once uh once again and uh for the delegates don't forget to look at, you know, the uh image, there's always a case there. So every grand rounds I post an image and that is actually a case that, you know, you can think about the words I have to have a diagnosis. And I think this time we're giving you the link for that. So please uh get that and hopefully we'll have more collaboration. So next, we will move on to maybe neck pain. Uh So we are on a, on a team for pains and hopefully we then collaborate with uh again, maybe BS and uh and uh emerging group. So once again, thanks a lot to all our speakers uh speakers. Do you want to uh say anything before we process session? Just thanks very much for organizing prayer. It's um yeah, some nice cases. Uh Thank you. Thanks a lot. Yeah. Yeah, with the B S S R E S S R N BSN. Um Thank you. I can't sleep like you open. Thanks everyone. Bye. Thanks.