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Old 04-20-2009, 09:32 PM   #1 (permalink)
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Default latest thoracic MRI

So...does this mean that they're saying this has now turned into a myelopathy? What exactly does "remodeling" mean? I would think it's not good...but any insight?

We also had his blood thinner dosages "upped" today..his levels were too low.

Anyway...wouldn't this in "normal" situations call for immediate surgery?

Anyway...what do you think?

Examination: MRI thoracic spine without contrast

Indication: Thoracic disc w/suspected myelopathy

Technique: Sagittal T1, T2, STIR, axial T1 and T2 images were obtained. In addition sagittal real-time TRUEFISP images were obtained the cervical spine, during active flexion and extension

Findings: There is normal vertebral body height and alignment. Marrow signal is normal

Focal central disc extrusion at T6-T7, resulting in effacement of the ventral CSF space and remodeling of the ventral cord is unchanged from prior study. Subtle increased T2 signal in the ventral cord is again noted. No formaminal narrowing is noted at this level.

Remainder of the intervertebral discs are normal without bulging. Visualized abdominal and paraspinal soft tissues are unremarkable.

Dynamic flexion-extention imaging of the cervical spin demonstrate no evident stenosis.

IMPRESSION: Unchanged focal central disc extrusion at T6-T7, with effacement of the ventral CSF space and cord remodeling. Increased T2 and STIR signal in the ventral cord at this level, is unchanged, and likely secondary to compressive myelopathy.


THANK YOU!
Tracy

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Old 04-23-2009, 12:36 AM   #2 (permalink)
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Hey Tracy

They indicate that he has a disc that is bulging into the cerebrospinal fluid (CSF), which is the fluid that surrounds the spinal cord (as well as the brain). They don't indicate that it is protruding into the spinal cord itself in this report, but given the spinal cord is remodeling, it most likely is or at the very least had at one point. Furthermore, the final impression of the MRI report does state a myelopathy is present.

Remodeling occurs because there is damage to the spinal cord (once damaged, it cannot be fixed) and those undamaged areas adjacent to the damaged areas, attempt to take-over the function of the damaged areas. Function can therefore be regained. How much function is dictated by the extent of the damage.

The protrusion and damage are on the ventral surface, which is where the motor neurons are located. This could very well explain the painless weakness in his legs. It appears as if the nerve roots have been spared and there is no finding of damage to the dorsal side of the spinal cord. If those were affected, then he would have some sensory symptoms on top of the weakness.

I think they're still trying to decide whether or not this could explain his symptoms. I can't really comment on whether or not this would warrant emergency surgery, because I can't see the protrusion. Having said that, if he isn't having urinary or bowel control problems, it might not be an emergency situation. I would ask the neuro to see what he would do if there wasn't an ALS diagnosis on the table.

Hang in there and keep hoping as we all are for you.
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Old 04-23-2009, 08:14 AM   #3 (permalink)
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Thanks Wright!
The last couple of thoracic MRIs stated that this herniation was prouducing "mass effect" on the cord...and while this one says "effacement of the CSF space"...it also says that the "focal central disc extrusion is unchanged from the prior study"....so I'm not sure of the change in wording.

We're hoping that this neuro and ns are going to be looking at this in combination with his last lumbar MRIwhich states that he still has a persistent grade 1 to grade 2 anterolisthesis (about 7mm) at l5/s1 (where he had his fusion for the broken back and stenosis), there is stlll small loculated fluid intensity collection extending into the proximal left nerve root foramen which is moderately narrowed and the right nerve root foramen is mildly narrowed.

It just seems sad that this doesn't call for surgery because there is no bowel or bladder disfunction....so they'll let him continue to lose his legs as long as he can pee and poo (sorry..trying to not be crass)...this doesn't seem right!

This has been 2.5 years of lower body weakness/atrophy with no progression into his upper body other than the dirty emg on the thoracic paraspinal muscle (wouldn't this be explained by the herniation with spinal cord damage at t6/t7?) and fasciculations (which btw have lessened now...maybe due to anabolics being out of his system?!?)...and this 2.5 yrs started with the ski accident that caused both spinal cord injuries.

We have an ankle/brachial index to test blood pressure between upper extremities and lower extremities this morning, a blood test to check the level of the blood thinner today, and another ultrasound to check the dvt in his left knee this afternoon. Who knows after that...but I'll keep you updated.

Tracy
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Old 04-23-2009, 08:55 AM   #4 (permalink)
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Tracy,
It makes me feel worn out just reading your posts describing the procedures he has had, or has yet to come!

You're a real trooper. As usual, I look forward to hearing the next findings.

I know you want ALS taken off of the table, but also want to have the offer of improvement for him. Just hang on to that hope!
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Old 04-23-2009, 10:19 AM   #5 (permalink)
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Hello again Tracy

If they say there have been no changes and it showed severe compression in previous MRI's, then yes, he definitely has a myelopathy. I certainly didn't mean to imply that surgery on spinal cord compression is only done when someone loses bladder and bowel control. Rather, I was saying that those are things used to determine emergency surgeries . . . emergency meaning . . . immediately. I think they're not rushing him into surgery because of the insidious nature of his condition, which unfortunately is also how ALS presents.

So let me get this straight (and I apologize for not remembering): Only his legs showed denervation? Was it equal, bilaterally? His upper body, except for his paraspinals, was clean during the EMG? He had no denervation in his arms in a span of two years?

P.S. If his nerve roots are being impinged in his sacral spine, then he will more than likely have some sensory issues in his legs. Does he? Again, I apologize for not keeping up with your story but I've been incredibly busy.
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Old 04-23-2009, 06:20 PM   #6 (permalink)
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Thanks again Wright!
No..that's ok..I'm a bit sensitive today due to some of the reports that we got back from his original back surgeon! UGH!

All weakness and denervation has always been l>r.

Our new neurologist said the als dr.'s notes were not clear. He did an emg in one spot each in his right tibia, right hand, right forearm, right bicep, right neck, right cheek, left hand, and once in the thoracic paraspinal muscle. The notes described diffuse denervation in the thoracic paraspinous muscles, but didn't specify if it was also noted in the upper extremities (GEE...you'd think he'd be VERY clear in his notes when making this diagnosis). Review of the study itself reveals normal nerve conduction velocity on the right leg and the only fibs noted on the emg were sustained in the right anterior tibial (which it would be), and unsustained in the low paraspinal muscles. The new neuro is planning on having another dr. other than the als dr. do a new emg at some upcoming date...but not right away.

He has had NO weakness or atrophy in his upper body for the 2.5 years that this has been going on and continues to even play 6 and 12 string guitars and sings for several hours at church every week with no problem. He's had no swallowing issues, no vocal issues, no breathing issues, no facial issues, etc.

My husband has started having some sensory deprivation in his left leg below the knee (reduced pin prick, reduced temp sensitivity, slight pins and needles in the foot, and slightly reduced vibration sense in the toes).

We saw a vascular dr. today...his ABI showed normal so they don't think he has a major vascular problem...and his cold leg and purple foot is consistant with a myelopathy...

IF he has a DVT (they couldn't confirm that on his new ultrasound today?!?!?!)...he thinks it's because of the muscle atrophy in his legs...thus they are not pumping the blood OUT of the legs sufficiently.

Our goal obviously is to get this herniation causing the myelopathy fixed before it causes more damage (and possibly the foramen in the l5/s1 region)...which thank God it's now showing that it is causing some. This will hopefully relieve some/most symptoms and point away from als.

Thanks again Wright...I really appreciate your viewpoints!
Tracy
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