Good morning, everybody. Thanks so much for joining us early on a Saturday morning. Really happy to have those of you in person and live on stream and being recorded. We're collecting questions that we're going to be happy to discuss at the end. We're hoping to have a lively discussion, both on the panel, but also with the audience as well. So this is Spine Rounds, Challenging Case Reviews with an Expert Panel. I'm honored to introduce my expert panel, some of my best former fellows. Dr. Namish Baksy is an assistant attending physiatrist at the Hospital for Special Surgery in Paramus, New Jersey. Drew Creighton is also an assistant attending physiatrist at the Hospital for Special Surgery. Jesse Charnoff, assistant attending physiatrist at the Hospital for Special Surgery, all are also assistant clinical professors of rehabilitation medicine at Weill Cornell Medicine. And Roger Liu, who's an assistant professor at Rutgers New Jersey Medical School. We have no relevant disclosures. So we're going to jump right in. We have a couple of cases for you that at least we found pretty challenging. So this is a 74-year-old lady with a complicated medical history. She was referred to me by a colleague. She has a remote history of breast cancer, stasposal lumpectomy, lymphectomy, radiation, a former smoker, now with emphysema, and a small lung tumor that subsequently was removed during the course of her treatment. She has a prior history of axial low back pain, treated successfully with intraarticular facet injections. Now she's presenting with back pain and severe bilateral thigh pain, mainly anterior thigh pain. It's worse when she's standing, walking, a little bit better when she's supine, but she still has pain basically in all positions. Neurologically, she's intact, but extension and bilateral oblique extension cause concordant back and her thigh pain. She's already on a lot of medications, so we're going to try to avoid medications at this time. Unfortunately, she's on opiates from a prior provider. She's on gabapentin. She's on tricyclic antidepressants, so the medications are more or less optimized. So at this point, given her complicated history, we want to get advanced imaging, and this is what we see. So this is a T2 sagittal-weighted image on the left, and then an axial T2 slice through the L2-3 segment. And I apologize if it's a little bit dark, but what we see here is a cyst emanating from the L2-3 segment. And then here you can see the cyst is relatively midline. So the differential for this at this point is a facet cyst, ligamentum flabium cyst, intradiscal cyst, intradural cyst, perineural cyst. So it turns out this is a facet cyst. So to my colleagues on the panel, how do we typically attack these? I think in this case, it's pretty clear that the cyst is causing the radicular symptoms due to its direct compression on the nerve root. So oftentimes, we try to address the cyst either by rupturing or aspirating or both, or trying to do both. Oftentimes, we try to do an epidural serine injection just to help reduce some of the inflammation. Sometimes we do a combination of the two. Oftentimes, we consider surgery if there's some sort of progressive neurologic defect. Dr. Charnoff, how do you approach these? So depending on what I'm trying to address, I may just do an epidural injection if they're coming with radicular symptoms as the primary on the initial, and then consider more advanced techniques such as rupture concurrent with the epidural if they fail the initial injection. And then Dr. Creighton, how about you? So I think there's good evidence to use both thoracic or CT guidance with these procedures. I personally like CT guidance, one, because you're able to visualize the cyst quite well, and also because it allows for sort of the best way to kind of define the bony anatomy. So aspiration or rupture, and then I would order an epidural at the level below. And then Dr. Liu, what would you do? I would probably just manage the symptoms first and go with an epidural. Yeah, so often these cysts can recur. And in this case, the patient, I had treated her before, and she's very sort of sensitive as far as the needle and tolerating procedures. So number one, do no harm. I was trying to treat her radiculopathy first, figuring that these cysts tend to wax and wane and may get bigger or smaller in the future. So my initial goal was not necessarily to either aspirate or rupture the cyst, but to hopefully provide symptomatic relief. So I performed an interlaminar epidural steroid injection at the L5-S1 level. This was the contrast pattern. She had greater than 75% relief of her leg symptoms and was very happy. The relief lasted for several months. Unfortunately, however, the day after the procedure, she called me, and she developed a whole body rash and hives. So I took a look at her. I had her send me some images and also had her contact a dermatologist, and it turned out she had a contrast allergy. So it was a pretty significant contrast allergy. She was treated with oral steroids, and it went away. So this is going to lead us to some background information from Dr. Charnoff on facet cysts. Yeah, so facet cysts are generally described in a lot of the literature as synovial cysts. Looking at this in greater detail, it seems that that may be a misnomer. So specifically, the Kusakabi paper from 2006, they were able to identify 46 patients who had juxtasys, so cysts in the spinal region. In being able to look at them at a histological level after doing medial facetectomies, they were able to find that there are actually zero synovial cells in the cystic structures. Instead, what they described was ligamentum flabum degeneration. So their theorized mechanism for how these cysts form is that the ligamentum flabum generally has about 80% elastin and 20% collagen. When you're at a level where there's degenerative changes and some instability, the inflammation and degeneration of the ligamentum flabum causes a cellular change to about 50% collagen and 50% elastin, creating some instability and loosening. With that degenerative changes in the joints, we'll get fluid and fibroblasts, which may fill up this loosened area and get the cystic structure that we're ultimately dealing with clinically with either radicular symptoms or just pain at the level. Yeah, and often these tend to be at the level where there's some instability. Typically, these are current degenerative cases. A third of these are associated with spondylolisthesis, and a third tend to get better with non-surgical care. Yeah, so as you said, most of these we're seeing at L45 because that is the most common level that we'll see spondylolisthesis or degenerative spondylosis. We see them in women more than men. Although to us, they're quite common, there's a low incidence. And then what are some of the factors that we think about when determining the best approach to treat these? So in general, what I'm looking for is I want to see if I have advanced imaging, is the cyst got a high T2 signal? That correlates with more of an aspiratable fluid as opposed to something that's thicker. I want to see if it's calcified. That would also cause it to be more challenging. The two areas that are described in these papers in terms of where the cysts are most commonly found are going to be interlaminar or in the foramen or capsular they describe. So based on their geographical location, it may alter our approach. There are a couple papers that describe these altered approaches. There's a direct approach, which is characterized as an interlaminar trajectory, where you access the cyst directly or an indirect approach where you just access the joint itself and pressurize it, causing ultimately the cyst to rupture. Yeah, so one of the considerations is the location of the cyst. And we can see here, this is from a paper where they do this direct or interlaminar approach. And you can see the cyst is relatively medial. However, often the cysts are more at the anterior capsule or in the foramen, which may make them more inaccessible from that direct interlaminar approach. And then what about using steroids or sedating the patient or doing a concomitant epidural at the same time? Yeah, so in general, we tend to use steroid. The question of whether or not to use a particulate or not is something that is debated just because after rupture, there is thought to be some epidural flow, especially if you're getting that ligamentum flavum, you know, access. So that's something to consider that there may be some epidural flow. But in general, particulate steroids are used. And that can help with theoretically decreasing inflammation and the return of cysts. Yeah, many people do, excuse me, a transforaminal epidural at the level below. Alan did a study where he had 32 patients and 17 received a transforaminal using just local anesthetic as the cyst was ruptured. There was no long-term change in outcomes. The patient tolerated the procedure better. Some people are concerned that if you anesthetize at the level below, they're not going to feel you as you're trying to rupture the cyst. And unfortunately, sometimes if the cysts don't rupture, you're blowing up like a balloon and it's just staying there. You may create worsening problems. So we definitely don't want to cause any iatrogenic injury. So one of the studies that we want to highlight is LUT's study out of HSS. This is one of the only prospective studies. Essentially, they pulled 35 subjects. And what they found was about 40% needed a second rupture. Out of that 40% population, about 30% ultimately progressed to surgery. So the way that I like to explain this to patients is when we will do a rupture attempt that there's about a 40% chance that we're going to have to repeat it. And then even if we have success, ultimately it can recur. So there is a chance that we would have to do multiple ruptures. And there is ultimately out of that group 30% that progress to surgery in cases that are difficult. And in the LUT's paper, they used the indirect approach going through the facet joint. And they expanded and tried to pop the cyst as opposed to aspirating it. My personal preference usually is to try to aspirate because I don't want to make things worse. And then tell us about this paper. OK, so Dr. Chazen and Dr. Singh were part of the paper here where they described a direct approach under CT guidance. So these were 11 patients that had presented with symptoms consistent with radiculopathy secondary to having a facet cyst. They described two different approaches. So the direct, as we said, where you're going for the cyst in the interlaminar space. They used a two-needle technique. So they access the joint itself, use contrast to illuminate the cyst, and then access it via interlaminar ipsilateral approach. They commented that they made sure not to use a contralateral approach as they did not want to pierce any epidural space or dural space in the attempt. The indirect approach is just pressurizing via the joint itself. In this case series, what was interesting was about five of the patients had already failed fluoroscopic-guided rupture. So those were people who had failed an indirect approach via fluoroscopy. And 80% of those patients had success at one year via the direct technique. Just curious, just raising hands in the audience, who performs facet cyst either aspirations or ruptures with fluoroscopy? OK, great. And then who refers these out for CT? OK, great. So for those of you back home, 90-something percent of the audience performed these procedures themselves, and about 5% referred for CT guidance. OK, so let's fast forward. The patient returns. This is her new pain diagram. So the bilateral symptoms have resolved. Now she has left-sided radiculopathic symptoms involving the whole left leg. So reading from the low back, posterior, and anterior thigh down to the anterior leg. She had 75% relief from that prior L5-S1 interlaminar, but developed that contrast allergy, as we mentioned. Since then, unfortunately, she's fallen twice. The gabapentin is no longer helping. So we order a new MRI. Before we do that, of course, we re-examine the patient. Now she does have motor weakness, 4 out of 5 left hip flexion, ankle and great toe dorsiflexion weakness, also weak knee flexion. Sensational light touch, interestingly, is intact. She has absent reflexes. Sensational light touch, interestingly, is intact. She has absent reflexes in the lower limbs. And left oblique extension causes concordant left anterior thigh pain. So just based on her physical exam, where would you suspect pathology to be? At the level of the cyst. What's that? At the level of the cyst. Uh-huh. But as far as pain with extension and reproducing pain. Concordant radicular pain. Yeah, I think when you have radicular pain when you're extending and rotating patients, sometimes that could be consistent with more of a foraminal issue compared to neural compression that's more medial. So I worry that, especially in this case where maybe there's a new neurologic deficit, there's some co-ordinated pain with rotation and extension, there might be a new or progressive foraminal herniation, either at the level of prior pathology or maybe there's some new pathology. Yeah, so the fact that you have here the oblique extension we call the Kemp's test or Kemp's maneuver, I was suspecting some sort of foraminal pathology. So we order a new MRI and unfortunately, no surprise, the cyst is still there. So it looks pretty similar to before because we didn't try to rupture or aspirate the cyst previously. So at L2-3, we can see the cyst here. It's still very medial, very midline, very central, taking up the spinal canal. So at this point, what are our considerations for trying to treat this? Yeah, I mean, so I think because she responded so well to the prior epidural serrate injection, just from a pain relief standpoint, it could be worth considering just repeating the procedure. Certainly, the cyst may be more amenable to a rupture or aspiration or both. So at this point, it might be worth considering actually addressing the facet cyst itself now that it's become recurrent. Between the two, I think I personally would try to aspirate instead of rupture. You know, she already has severe stenosis at this level. Prior, I think it also merits consideration, spending a couple minutes talking about interlaminar versus transforaminal approach for the original epidural. If you guys recall, she presented with bilateral leg symptoms. And so, you know, typically, you know, interlaminar injection, it's quicker, it's simpler, it's less, you know, fluoroscopy. It gets the medication there. Also, in terms of planning for the procedure, you know, typically, I like to go to the T1 and look at T1 and T2 and sagittal to see how much space I have and how close the fecal sac and the CSF is to the ligamentum. So if you guys recall, Dr. Kirshner did an L5-S1 level, which is below the level of the actual cyst. But at that time, you know, a relief of symptoms. Also, we have evidence that an interlaminar injection with, you know, six cc's of injectate will go up four levels and go down two. So that was adequate coverage given her response as well. Additionally, with this MRI, you can also see advanced degenerative changes. So I always worry about, you know, access, you know, through a transforaminal approach, you know, in terms of the foraminal stenosis that's already present from spondylosis. And then, Dr. Creighton, how does the contrast allergy play into this? Does that affect the approaches that we have? In short, it does sort of, you know, bring in a little bit more of a discussion with the patient. In general, what we know is that there's not great evidence to support premedicating, even though it's frequently done. And you have to keep in mind that typically with these injections, the patient's getting steroid anyway. So now you're premedicating with steroid and then they're getting more steroid. That's a consideration for sure. And then, really the best way to avoid a contrast allergy is the recommendation is to remove the offending agent. So that brings in the discussion of gadolinium, which as we know, you know, there's a now IPSIS 2021 statement that really highlights the risk of gadolinium deposition in the brain. It's rare, but it can occur. And so these risks need to be explained to the patient. And if it's deemed necessary to use gadolinium, you really want to use it in a scenario where there's low risk of intrathecal spread. If there's high risk of intrathecal spread, additional recommendations against gadolinium really should be employed and extra measures taken to avoid intrathecal spread if you need to use it. So in this case, I'd be looking to, or I'd be considering not using contrast and potentially just the loss of resistance technique with an earlier program. So I previously used to use gadolinium. I didn't think the visualization was so good. And then I had a colleague who had an issue with a case of encephalitis, and then this statement came out. So I no longer use gadolinium. So it definitely affected, you know, the approach we could take in this case. You know, we can't go into the facet cyst and try to opacify it if we can't use contrast. And then, you know, it makes the other options more challenging. I mean, here, if we're going to try to rupture the cyst, and it is very midline, there may be adhesions to the thecal sac, so there is risk of intrathecal spread. So for that reason, I didn't want to use gadolinium. So in this case, I did take a direct approach using fluoroscopic guidance and multi-planar imaging. I used a loss of resistance technique, figuring that my first loss of resistance would be into the cyst as opposed to the epidural space. And I've learned from the past to wait and aspirate first before injecting anything. So we wait. We got about a half a cc of yellow mucinoid fluid, so confirming that I was able to rupture the cyst. And then I put a little bit of dexamethasone, preservative-free non-particulate, and some lidocaine, and the patient did very well. All right, so now she comes three months later, near resolution of her symptoms, so really happy. So now she comes back six months later, but now she has, again, severe left thigh and knee pain, but it's different than before. So it's not going down to the lower limb and shank, it's just staying in the thigh. She still has left ankle dorsiflexion weakness, four out of five, exam is otherwise the same. Hip range of motion does cause some concordant pain, and again, left lumbar, lateral flexion, extension, rotation, oblique extension, all reproduce concordant left anterior thigh pain. Of note, she has had a total knee arthroplasty. So what's our differential now, and how would we approach it? Man, what a pain-in-the-butt patient. We always try to think of our differential based on presenting symptoms or a physical exam. In this case, certainly the knee jerk would be to think about, again, a recurrent cyst, knowing that a significant portion of the cyst can reform, especially if there's instability at that level. Look, this could be a hip issue. I mean, she could have hardware loosening in the knee, so I think anything's on the table in terms of figuring out what the underlying cause is. So I would probably work up her hip, and maybe even make sure that there's no issue with the knee before concluding that this is just a recurrent radicular problem. So unfortunately, my schedule's a bit backed up. Her surgeon was able to accommodate her a little sooner, and he obtains radiographs and a bone scan, and there were no abnormalities within the implants. They look great, they're in place, no signs of loosening. And we do a diagnostic hip injection, and it is negative. It does not reproduce concordant pain. So some of the considerations that we're thinking about, you know, do we adjust medication? She's already sort of topped off on tricyclic antidepressants, gabapentin. She's still on her low-dose opiate. She can't really take NSAIDs because of her gastritis history. She's been to extensive physical therapy, and at this point is really in too much pain to continue to go to PT, and she's exhausted her Medicare allotment of PT for the year. So, you know, what would we do at this point? So I would get a pneumorite. That's what we did. And, you know, thankfully the cyst did recur. So, you know, pat on my back, but who cares because the patient still has pain, so so what? But unfortunately now, she has one of the biggest disc herniations I've ever seen. Unfortunately, it's not projecting too well, but you can see here at that same L2-3 level, which is not surprising because we assume there's instability at that level because that's where the cyst is. She's got this very, very large herniation. And you can see here, it is central slash foraminal, which makes sense and is concordant with the physical exam where the oblique extension reproduced pain. All right, so next steps to my esteemed panel. Dr. Liu, what would you do? I still would favor the interlaminar approach right now. She's responded well to before. You mentioned earlier that she's a sensitive patient. So I tend to go with the momentum of that. Additionally, too, I mean, there's multi-level, even given a disc herniation, it's a large one. So it may be affecting multiple nerve roots. So I think that's the most efficient way to handle this. Yeah, I think- Oh, sorry, go ahead. I know it's been a point of contention with interlaminar versus transforaminal epidurals, getting more anterior spread. But I do think that there's enough evidence that it's not inferior when it comes to actually having the medication go to the anterior portion of the interface between the disc and the nerve roots. Thanks, I forgot when I introduced Roger to mention his middle name, which is interlaminar. Roger, interlaminar Liu. I think the other component that we have to factor in is just the contrast allergy component. So potentially feeling more comfortable with the interlaminar approach with that loss without having the contrast, but being able to use multiple view imaging to confirm that. But if I was gonna do a transforaminal, I would consider doing a test dose to try to ensure safety and waiting a couple minutes to make sure that there's no vascular flow. Great, so I also went with the interlaminar approaches based on the feel. I felt more comfortable doing that with the loss resistance technique. And unfortunately, three weeks later, she's still no better. So what do we do at this point, Dr. Baxi? Yeah, at this point, I mean, I think it could be worthwhile considering a different approach or a different steroid or both. Obviously, the challenge with contrast is you certainly don't wanna... Part of the equation is using a particulate versus non-particulate. For many folks, I think when you have a contrast allergy, we maybe may wanna avoid the particulate steroid. So a different approach might be more effective in her case, especially given the extension of the disc into the foramen. So I did end up doing a transforaminal approach and I did not use contrast. I'm just curious, show of hands, who would have pre-medicated the patient and used contrast here? So maybe 10% of the room. And then who would have done the transforaminal without contrast using dexamethasone, using a test dose? Okay, so the remainder of the group would do that. So that's what I chose to do. And thankfully, the patient got better. So happily ever after. All right, so we're gonna move on to our next case with Dr. Baxi. Thank you. Man, that was a rollercoaster. Okay, this is gonna be a series of three cases. There's gonna be some audience participation. So I just have a couple of surveys. You can easily access it through your phone. The website's gonna be up there. You just gotta punch in a code. Wanna kind of get everyone's take here because the cases involve, yeah, some variability in treatment. And I think it'll be interesting to see what everyone in the audience and at home thinks. So, here we go. First case is a 15-year-old kid. He's a wrestler, pretty high level. He had two months of low back pain, which was worse during training, but it was manageable. A month prior to coming to see us, he had cleaned a heavy sandbag. So clean is taking this heavy oblong object and hoisting it over your shoulder. People see that in CrossFit gyms and strongman gyms. So after this incident, his pain acutely worsened. And at that point, he was experiencing pain into his leg affecting the posterior and lateral aspect of his leg. But he still kept going. And he had, really the tipping point was when he had a severe pain exacerbation during a wrestling match. And at that point, he could only run half a mile in gym class and had to stop. And he was in pretty constant pain. Second case is a 16-year-old kid, lacrosse player. He had low back pain for about a year, which was manageable and he was playing through it. But it had acutely worsened about a month before he came to see us while he was participating in a lacrosse clinic. Initially managed with NSAIDs. He did not have any radiating leg pain. His pain was primarily on the right side. His primary care had given him a brace, but he had not worn it. And the third case, again, 16-year-old, high-level soccer goalie. Right-sided low back pain for a couple months, no particular inciting event. And he did have some episodic paresthesia extending into the right lower limb, but largely the pain was in his back. And it was worse with extension-based activities. So, case one, diffuse low back pain, some radiating right leg pain in a wrestler. Case two, right-sided low back pain for two months, but about a year of generalized low back pain affecting both sides. And case three is a right-sided low back pain for a couple months with episodic paresthesia. So, these kids are in our clinic. We're gonna get some baseline X-rays. So, the question to you all is, what X-ray views would you order? So, go to Slido. And let's see what, this should update live, I think. These things, I don't know. Hopefully this will work. I'll give this 30 seconds. This is getting interesting. All right, so, you know, the majority are, I would say, you know, close to, this is changing, this is good. So, half of us, about half of us said that we're going to get an AP lateral as well as an oblique and flexion extension. 30% have AP lateral with FlexX, 17% AP lateral with oblique, and 9% of us said just an AP lateral. So, Dr. Kirshner, can you take us through, you know, thinking about what x-ray views are relevant here and the role of oblique views, the role of flexion extension views and guide us through what your decision making would be when we're ordering x-rays for these kids? Sure. So, the things I want to think about, you know, the age of the patient, these are adolescents, I don't want to over-radiate them, and often there's a lot of radiation exposure with oblique radiographs. I want to see, do they have a spondylolisthesis, is it unilateral or bilateral, is there a spondylolisthesis and a significant degree of slippage at that point. So, this is a nice study done by Beck where they were assessing the value of oblique views, and it turns out that the oblique views are great for increasing cost to the medical system. So, if you own x-rays, it's a good business, but it increases the radiation dose by 50% and actually leads to less sensitivity and specificity. So, it does not help diagnostically and just increases radiation and cost. So, for that reason, I tend to not get oblique views. And then as far as flexion extension views, you know, I tend to just get a standing AP and lateral because I like the views weight bearing, I sort of want to see, you know, with gravity what's going on with the lumbar vertebral bodies. When you lay a patient supine, often whatever's happening standing can reduce. So, Lee et al. looked at a study where they did standing radiographs and compared it to supine MRIs. Because the patient's supine, whatever it was that they had did reduce. So, they found there was more sensitivity comparing the standing x-rays with the supine MRI, and you can do that with a CT too, as opposed to a flexion extension. I don't know about you, but when my patients are in a lot of pain, they don't really move a whole lot when they're doing the flex x-view, so I don't find them to add much value. They also add radiation and cost. So, we'll talk about advanced imaging soon, but because a lot of these kids are going to get advanced imaging, I tend to just get the plain x-rays. I mean, if I see instability on the plain x-ray, maybe then that will clue me into getting the flex x x-rays, but otherwise I skip them. Great. All right, so let's go back to the cases. In the wrestler with, again, some radiating right leg pain, you can see on his lateral projection here that there's a clear defect at the PARs at L4. I did get flexion extension views in this patient, and you can appreciate, again, the PARs fracture, and there's really no instability with flexion or extension. Case two in the lacrosse player with unilateral back pain, but a year of diffuse low back pain that was managed with just activity modification and NSAIDs. He has unremarkable x-rays in case three. The soccer goalie, unilateral back pain, episodic leg pain, again, unremarkable x-rays. All right, so I guess the question is, what do we do next? If there is a consideration at this point for ordering advanced imaging, I want to know what y'all think. What imaging modality would you order, if any, for case one? Case one is, again, the low back pain and some radiating leg pain. So would we get an MRI, CAT scan, both, a SPECT, nothing? Oh, yeah, so majority of us said an MRI, 80%-ish. Many of us, 16% said none. Some of us said CAT scan, and 2% said SPECT, and nobody said CT and MRI. All right, for case two and three, I kind of lumped these two together, because both had unremarkable x-rays. Would your decision change when someone doesn't have any findings on x-ray? All right, so yeah, the majority of us said MRI. 20% said nothing, and 6% we have CAT scan. So it's interesting to see the variability here. All right, so the first case, we did end up getting a CAT scan. The patient had a bilateral L4 PARS defect. You can appreciate here that there's what we call a terminal defect. This classification was described by Fuji based on CAT scan imaging. A terminal defect has wide margins with sclerosis. An early defect has just fissures in the PARS, and a progressive has a narrow defect with rounded edges. So here we have a terminal defect bilaterally. We also got an MRI, actually, for the first case. We got an MRI largely because he had some radicular symptoms. So we wanted to see if there's any concomitant disc pathology that might explain some of his radiating leg pain. So here you can see his disc looks relatively okay. He does have some facet effusions bilaterally, which could be part of the pain generator. It could also indicate some amount of instability at that level. Also, this is the STIR sequence here, which again, you can see the bilateral L4 PARS defects with bone marrow edema extending into the pedicles, extending into the superior and inferior articular processes. You can see some straightening of his lumbar lordosis here as well. Case two. So we got an MRI for case two. You can see, again, appreciate the marrow edema in the right L5 pedicle, extending from the PARS. There's a little bit of adjacent soft tissue edema as well. On the left side, there's no bone marrow edema. This patient had unilateral pain just on the right. So this correlates with the symptoms. But the CAT scan was also done for this patient. And here you can really appreciate that there's actually a bilateral L5 spondylolisis. And this kid had pain for about a year. So this could explain why he was in some amount of pain that was a little bit more insidious. On the left, you can see a wider PARS defect compared to the symptomatic right side. And there's maybe some traceless thesis there. I would describe the PARS defect on the left as terminal and on the right, maybe progressive. In case three, just an MRI was done. Case three had unilateral back pain and there's some bone marrow edema again rising from the L5 pedicle. There's some low signal there in the inferior margin which could reflect a fracture line, but largely this would be characterized as a stress reaction. So Dr. Charnoff, can you take us through advanced imaging and the utility of CAT scan and MRI and maybe other imaging modalities and when and why to consider these? Sure, so the x-ray has a relatively low sensitivity as compared to the advanced imaging. So for CT scan, we're gonna be trying to assess some of the bony posterior elements with more detail. It's better at identifying lytic defects. So if there's a question of whether or not there is a spondylolisis, that could impact whether or not in terms of bracing and other treatment modalities, how aggressive we're gonna be. For the MRI, the way that I use it is to detect earlier stress reactions. So that's been proven to be superior at detecting those earlier inflammatory findings as compared to the CT. Yeah, thanks. So with all this information, the question is how are we gonna manage these kids and does it change from case to case? So the things that we think about, the things that I think about when they're in our clinic, how are we gonna manage their, how are we gonna guide them on activity modification? Of course, we're gonna shut down their sport, but we have to think about timeline and gradual return, the cadence of follow-up. Certainly, we're gonna think about physical therapy, when to start, what therapy should consist of. One of the important things to consider is bracing and kind of the nuance of when to use a brace, what kind of brace. Certainly from a pain management standpoint to perhaps facilitate therapy, we may think of interventions, injections to help with some of the underlying symptoms. And always in the back of my mind, thinking of when in my algorithm to consider a surgical referral. So back to you. For case one, I wanna know actually if you would brace. So for case one, bilateral terminal spondylolisis, would you brace or would you not brace? Great. So about a quarter of you said you would brace and three-fourths said no. Does this change for case two, which is bilateral spondylolisis, unilateral symptoms? About the same percentage. Twenty-nine said yes and about seventy percent said no. And what about for case three, where you have a unilateral PARS stress reaction with unilateral symptoms? This is some solid participation. Thank you all. Gives you a break from scrolling. Good. So about the same percentage. About three-fourths of you said no and a fourth of you said yes. Okay, for those of you that said that maybe you would brace, which brace would you choose out of curiosity? So a lumbosacral orthosis, a TLSO, an LSO with a thigh extension brace or a Boston brace? All right. So, yeah, about, you have 33 people responding, and the majority said an LSO. A small percentage, 3% of people said LSO plus thigh extension, and there's some that said TLSO in Boston. So Roger, take us through some of the discussion around bracing and how it's applicable to these cases. Sure. So, firstly, at the outset, we have to acknowledge the fact that the evidence is limited, and, you know, studies have not been perfectly done, but that's not a good enough reason to not get into the weeds a little bit and sort of parse things out and figure out there are nuances. So, in general, there is evidence for and against bracing. You know, in our review, we came across some larger studies. A landmark trial in 1985 by Steiner, they took 67 participants, patients. All of them are young with spinal lylosis. They used a Boston overlap brace, and they actually braced them pretty aggressively for 23 hours a day for six months, and then after six months, they gradually weaned them off, and then during the second half, they kind of returned them to sport. They had excellent outcomes, you know, 80% were able to return to sport without pain. These results were actually repeated a few years later with 75 patients, and they actually moved up the timeline, and they returned athletes to play at around four to six weeks, but they were also wearing the brace for the six months, and again, they had a pretty robust response to that, and then you had some smaller studies that also supported, you know, return to sport at around four to seven months. So next slide. However, you know, there also is evidence that it's actually important, potentially, to get advanced imaging, and also to worry about the timeline and the nature of the injury. So Serio in 2012, they took 23 patients, and amongst them, they have 41 PARS defects, and they managed them with a soft TLSO, and they used CT and MRI to sort of quantify and sort of see what's going on with their lesions, and they sort of characterized the groups into three, using two parameters in three different groups. In CT, they determined whether or not someone had an early or hairline crack, early injury, and progressive, you would see a visible crack, and terminal, you know, formation of a pseudoarthrosis, that would be the last stage, and as you can see, most of the individuals in this study or most of the defects were hairline or progressive. They also got MRI, and they characterized it in terms of high signal change versus low signal change. So if you look at the right side of the slide, you see at the second picture down from the top, that would be high versus low signal change, using T1 versus T2, you know, T1 being what it is, fluid is darker on T1, and, you know, signifying a more acute reaction, and so a little bit more specific, and you would actually, you know, if you see that offset, that would be characterized as high, and it has some interesting results. Turns out that, you know, at three months, with very conservative care, meaning that they, you know, they had a lot of rest, activity modification, they kept the brace on, they had 87, they observed 87% healing if it's early, you know, hairline crack, and high signal change. They observed 60% healing if you had progressive and high signal change, but no healing whatsoever at three months if it was negative high signal change or terminal. So these are some interesting findings. It kind of brings into the question, you know, how important is advanced imaging, and I would argue it's fairly important, especially in a younger individual with a more acute injury. So I'm moving on to the next slide. So there are some smaller studies, too, that kind of negate this. You know, born in 2019, there was a cross-sectional study of 23 patients suggesting that patients can improve with activity modification and PT alone without bracing. Cell Horse did a retrospective review of 121 patients, bracing did not have any significant long-term difference in outcome versus not bracing. But perhaps most interestingly, in 2009, Klein did a meta-analysis of 15 studies, you know, capturing 665 patients, and demonstrated that, you know, kind of no matter what was done, they all kind of improved. But a subgroup analysis comparing 137 patients who did not brace versus 334 with a brace, they kind of revealed comparable outcomes. So what is the right answer, right? I think it kind of depends on a lot of different things. So things to consider, well, some of these landmark trials, they, you know, there was no control group, and also the patients also got physical therapy and activity modification in conjunction with the bracing. We also know that radiographic evidence of healing does not really correlate all the time with clinical outcome. You can have spinal glyces that are asymptomatic, you know, unilateral and bilateral, and actually there's evidence that this is also, you know, people have a genetic predisposition as well. So with certain groups demonstrating like 30 to 40 percent asymptomatic prevalence in spinal glyces in their population. So treating the picture isn't always treating the patient. But we do worry patient by patient. So I would encourage people to think about your patient, you know. Is this bilateral versus unilateral lesion? We know that bilateral lesions are at higher, you know, higher risk for slippage, especially in the younger individual, and also depending on the sequel slope. You know, whether or not the spine is immature versus mature, and whether or not this is acute versus more chronic. And so we can characterize that usually fairly well with advanced imaging. So also, too, in terms of motion restriction, you know, these studies use a Boston race, except, you know, with the stereo studies use a TLSO. But in reality, if you want to truly limit range of motion at the L5-S1 segment, which is the most common level, you would have to add a thigh extension. So that's something that, you know, is interesting to note. And I personally would not be adherent to this treatment. I don't know if any of you would be, all right, especially in a younger athlete. But also, too, you know, well, we want to do no harm. So would bracing an individual actually harm them? Probably not. It might be a little sweaty or smelly. But I think that, you know, if you're thinking about your own children or yourselves, it's probably reasonable if someone wants to, you know, maximize their return to play and chance of healing for an acute injury to use it. But the evidence is not, you know, definitive either way. Yeah. Thanks. Thanks for going through that. I think that's an important discussion. And certainly, I imagine it's challenging to convince a patient to wear a TLSO with a thigh extension brace for 23 hours a day for six months. So some things to consider. So Dr. Creighton, tell us about your recommendations for physical therapy and what the data suggests. Yeah. So before even touching on this, I don't think we have a slide on this anywhere throughout. I think it's important to mention that, you know, you look at modifiable things, one being vitamin D. And I think that that should be highlighted, that that should be checked on our patients as something that's modifiable and good for optimizing bone health. But in terms of the physical therapy, I think when you're thinking about timing for introduction of physical therapy, it's a little bit all over the place and variable in the literature. And recommendations on timing are really based on low-level evidence. But the study by Selhorst was a retrospective review that looked at patients. Sort of the 10-week mark was what they looked at. And patients that initiated physical therapy earlier than 10 weeks were able to return to sport sooner than patients who physical therapy wasn't initiated until after 10 weeks. And that time frame, I believe, was 25 days. And in a high-level athlete, that's a big, you know, that's a very significant amount of time. I think that the take-home here is that, you know, waiting until after 10 weeks is potentially not optimal. In terms of individual studies looking at or papers looking and addressing the physical therapy itself, O'Sullivan in 1997 did a study where they found that a flexion-based program strengthening the deep abdominal muscles and lumbar multifidi, along with stretching the hip flexors and hamstrings, was very effective. Dr. Standard had a paper in 2005 that I think nicely walked through a rehab progression. So from an acute to recovery to functional stage of rehab before thinking about return. And that really involves sort of at each stage a discussion on pain-free range of motion, fluid conditioning, resistance strength training, starting in the recovery phase. And then this discussion of neutral to sort of dynamic multi-planar spine stabilization. We have to think about our athletes and the fact that they're not single-plane individuals and we need to think about the sagittal plane, coronal plane, transverse plane when we're going through the rehab. And then after progressing through that, that progression, only then can you really think about return to play. So I thought that was a great paper. And then a couple of recent papers address this discussion as well. One by Hamada et al., which suggests the need to focus on trunk extension strength is one of the factors related to return to sports competition. And then a second paper that was focused more on baseball pitchers specifically felt that physical therapy should really focus on alignment parameters. So correcting hyperlordosis in the standing position where their hands are down and then in the maximal elevation position with both upper limbs sort of raised up overhead. Sacral hyperslope alignment, correcting that in the standing position and then the decreased sacral slope motion. Great. Well, one of the other things that may be in our equation of when we're treating these patients are the role of external bone simulators. What are your thoughts on this modality and what's the data suggest on its efficacy? So there's not a lot of literature out there on this. I think one of the things to consider is that as far as I know, I have not been able to get an insurance company to pay for this and they're usually around $1,000. But I think it's not unreasonable to explore anything that potentially could enhance bone healing. And so there was a recent paper that was done that certainly had some limitations but was probably one of the more recent and one of the few papers out there speaking to potential benefit with using a bone stimulator. In this study, they found a higher rate of radiographic healing in the bone stimulator group compared to the group that didn't utilize a bone stimulator. But you can see that there was no difference in terms of return to sports participation. So I think the jury's still out with that. But if you're looking at doing anything possible to optimize bone healing, I think it's a reasonable thing to consider. Great. So after all that, sometimes we may want to consider follow-up imaging. Sometimes it's not necessary. Dr. Kershaw, take us through some of the logic that you may use in a practical way on a potentially case-by-case basis on when, if and when you'd consider follow-up imaging and what imaging modalities would you consider? So I prefer to follow the patient clinically. If they're doing well, I don't really want to look for trouble. I mean, outcomes, as Dr. Lu mentioned, don't necessarily correlate with radiographic healing. So if there's a question of there's an incomplete fracture and has it fully completed with fully sclerotic edges, then perhaps maybe I would get a CT. If they had new or different symptoms, new radiculopathy, perhaps there's a herniated disc or some other pathology, then perhaps I would get an MRI. But assuming the patient's doing well, I do not get repeat imaging. I return them to sport. It's always a challenge, especially in these cases where you have parents in the picture. And there's always potentially, in their minds, some utility of knowing if there's some bony healing. Actually, the first case is my patient, and again, terminal bilateral L5. We know that the likelihood of union is extremely low. But the parents just essentially demanded to have follow-up imaging, and they were going to get it done one way or another. So I imagine that all of us kind of deal with that, and those of us that see adolescent spondylolisis. So from a practical standpoint, it's difficult to manage. But certainly, in these asymptomatic kids, there's probably not a whole lot of utility in getting follow-up imaging. When do we get these kids back to playing? What's the data showing about return to play and prior level of function? So when you're thinking about return to sport, there's a number of variables that impact this question. I think treatment modalities, surgeon-specific protocols, other factors such as pre-injury performance, competition schedules, where an athlete's at in the season, for instance. There's a recent meta-analysis that was done by Overlay et al., which found that in adolescent athletes with spondylolisis and no leases, return to play was 92% with non-operative management and 90% when treated operatively, though, as you can see, both treatment groups strongly favored return. And then a recent systematic review by Grazina et al. in 2019 showed that even the criteria for return is variable and really reliant on the clinician in many cases. But in three studies, it was symptom-based. In two studies, it was time-frame-based, and in two studies, it was imaging-based. So overall, the conservative approaches used more symptoms-based when return to play and surgical more time-based. The overall return, the overall mean return to play at any level, surgical or non-surgical, was 92%. 88% return to pre-injury level, and mean time to return was 4.6 months. When you subgroup that out, 92% returned after conservative treatment and 88% after surgical, 89% return to pre-injury level in the conservative group, and 81% in the surgical. And then athletes returned to sport at 4.3 months with conservative management, and then those that ended up having to go down the road of surgery, it was at 6.4 months. Yeah, this is great because, you know, we have, we can hang our hat on this when we're talking to patients and parents and telling them, look, kids can likely get back to playing. We just got to, you know, take the appropriate measures, give it time. But it helps to have some of the literature that actually objectively shows the high rate of return to play. So, Dr. Charnoff, take us through some interventions that you might consider from a pain management standpoint in treating these kids. Yeah, so this is one of the challenging things that I think we see a lot with this patient population. Just this week, preparing for this talk, I got a referral from one of our spine surgeons asking for a PARS block to determine if that was the pain generator and potentially could have surgery as a result. So it's a challenge just because there's not a ton of literature that supports the, you know, how specific those injections really are. So what we do have in the literature are some case series where there are intra-articular facet injections that have shown about 50% relief at two months post-injection, though it doesn't necessarily answer the question of what is the pain generator. Is it the fracture itself or the facet joint and instability that is kind of all contributing to a degree? Medial branch blocks theoretically may have a role as they likely innervate the pain emanating from the PARS. So whether or not, you know, they have a role in diagnosis is one question. RFA is debated in that patient population, so that makes it difficult. McCormick did a study looking at flow from an arthrogram with someone who has a PARS fracture and has noted that you're going to get ipsilateral flow into the ipsilateral facet joint because the inferior or superior border is the PARS itself. You're also going to get some retrodural flow and concurrent contralateral facet involvement as well. So it's really nonspecific when you're doing those injections, but they can help therapeutically. In CHOI's large 200-person case series, they showed about 18% of people underwent injection. They were very nonspecific in the sense that they didn't really parse out who received just the facet injection versus facet injection plus epidural, though they did say they only did the epidural for patients who had also a disc herniation with radiculopathy. So there's a lot of options, but still a lot of work to be done in terms of research. Yeah, and certainly in these specific cases, you could appreciate on MRI that there were facet effusions, there was edema in the facet joint, there was some soft tissue edema. So all of those findings could be contributing to some of the symptoms, and maybe there's a role for interventions in terms of helping to facilitate the rehab, potentially. Great discussion. So key points here, 80% of spondylolyses are bilateral, with L5 being the most common bilateral defects are more likely to slip, but Aoki in 2020 showed that 90% of bilateral spondylolyses in the subjects older than 60 exhibited spondylolysis, however, none had surgery. And Buehler in 2023 showed that bilateral defects typically follow a clinical course comparable to the general population. When we're looking at x-rays, it may be worth considering avoiding oblique views due to the lack of utility and radiation exposure, and potentially we can rely really on supine advanced imaging as a way of assessing for instability in listhesis. Certainly with advanced imaging, MRIs can pick up stress reactions and early fractures that CAT scans can miss, and CTs can be helpful in visualizing the cortical integrity, which helps with prognostic information. For instance, chronic non-unions will likely not heal, but certainly there's a radiation consideration with CAT scan, although with limited CAT scan protocols, the radiation exposure can be reduced, and certainly there's many controversies in bracing and external bone stimulators. So this is a great discussion, and we have about 15 minutes. We have some more cases, which we can try to run through here. All right. So as we know, for this last sort of topic, transitional anatomy, it's pretty common. We see it a lot in our clinics. It can pose challenges when clinically assessing patients and identifying where the pain's originating from. We're going to discuss a few cases that highlight some important objectives when it comes to helping patients with transitional anatomy. We're going to talk about identifying the correct level to inject, identify how dysplastic posterior elements and side-to-side anatomical differences can make for challenging intervention, and discuss what to do with potentially symptomatic pseudoarticulation. So the first case is a 38-year-old female, 10 out of 10 debilitating leg pain down the posterolateral thigh and into the calf, diminished Achilles reflex, positive seated slump test, no motor weakness, large disc herniation at L5-S1 on our assessment, causing S1 nerve root compression. The patient saw the surgeon the day before. You didn't read their note because you didn't want to be biased until you saw the patient. You saw the patient. They also noted a positive seated slump test, but they noted a large disc herniation in L4-5, causing L5 nerve root compression. So Dr. Kirshner, what are some things you look at on X-ray to sort of say, okay, does this patient have transitional anatomy or not? And what's the deal with that X-ray to the far right there? So first thing I'm thinking, do they have five lumbar type vertebral bodies? So lumbar vertebral body with a transverse process and not a rib. Unfortunately, some people have riblets, as we call them, where they're small ribs and you can't tell is it a small rib or a big transverse process? Do they have four lumbar type bodies? Do they have six? And then is there any sort of pseudo-articulation with the sacrum? The image on the right is an up-tilt view or a Ferguson view, so it's a better way of assessing the lumbosacral junction. About 20% of patients can have transitional anatomy either at the thoracolumbar or the lumbosacral junction, but it's not enough just to count the bodies because some patients have 11 ribs, some I've seen have 13. So it's really important to ideally count from C2 down and get some sort of scout film. So either, we have access to EOS x-rays, which are low radiation whole body x-rays, or even advanced imaging, get a scout view on an MRI. But it's most important to really think about where's the pathology and then correlating that with the patient's symptoms. Whether or not we're labeling it the same as the surgeon, we wanna make sure we're treating the same level that the surgeon is. Excellent. So Dr. Kirshner, this patient's insurance company is only gonna cover one level epidural injection. What are some pearls to consider for injecting the correct intended level in this patient? So one of the things we look for is, where's the actual pathology? Do we wanna approach it at the level or below the level? Not to pick on a radiologist, but sometimes they pick arbitrarily the most inferiorly formed disc space at the L5-S1 level, then just count up from there. So I'll start maybe with their nomenclature, but I like to count for myself. There are different clues to tell you what level you're at. I mean, part of it is on an axial slice, how much of the sacroiliac joints are you seeing? If you see too much of them, you're probably a little inferior, which may suggest transitional anatomy. You know, some people use the iliolumbar ligament as a marker for L5. Fortunately, people have iliolumbar ligaments at L4, L5. Sometimes they have multiple ligaments, so that's not a good way of counting. Sometimes on the lateral, I'll use the iliopectinal line, which tends to go through S1 to indicate the S1 segment. That also, however, can be variable. So in this case, I'm sort of counting from the bottom up. It looks like the pathology is at the second disc from the bottom, and then that's what I would correlate with plain radiographs, which I would have in my room if I'm gonna be doing a procedure. So that tees up this slide quite well. So this was the saved flow pattern from the epidural, and if you just look at this, you sort of think, geez, I hope that's the right level. It looks like the right level. But then in the fluorosuite, to Dr. Kirschner's point, one of the tricks that you can use is, again, sort of using your lateral as a further confirmatory view. So again, as he mentioned, the disc that we're trying to treat here is at the second last-formed disc space, and we're trying to treat that by going to the last-formed disc space. And so clearly, we've confirmed that we're at the correct level there. So second case, posterolateral leg pain returns on a 30-year-old female patient who did well with a prior L5 and S1 transforaminal epidural injection. Your colleague requests that you inject the patient because you're out of town at the AAP Menard Conference in New Orleans, and they tell you the S1 level was challenging despite obliquing and accounting for the bony phalange that can often obstruct the path for an S1 epidural. So Dr. Charnoff, are there any things that you're noticing here on the x-ray here that, before you go in, that may give you a cause to pause here? Yeah, just looking for that S1 foramen, it seems like you can see it on an ipsilateral, or on the contralateral side to the pathology from the AP. We know if we get a little bit more oblique, we may have some opening of that foramen, but that would initially have me a little bit concerned if I was thinking about doing an S1 approach. So then you have the MRI, and again, there's two pictures here. The one on the left is the one where the level of the pathology, basically, that you're trying to treat, and where you're trying to treat is from the level below. Is there anything, Dr. Charnoff, that you're noticing here on the MRI that might speak to a challenge with the procedure here? Just the variability in how oblique it may require to get to that right S1. So when I'm doing a transitional case, or oftentimes any case, I'm gonna try to check what obliquity would be the ideal and most efficient approach. So we can see on that bottom right image that it's gonna be a higher degree oblique to get in that foramen as compared to the contralateral side, where on the AP view, it appeared to be open. So this was a saved flow pattern from the procedure. Can you make some observations about the flow pattern of your colleague and how you might attack it differently? Yes, it looks like it's partially getting epidural flow. You definitely seem a little dorsal in the lateral in terms of the final position from where we'd ideally wanna be, but you likely got some anterior flow from that position into the epidural space. Because this is an AP, it looks like there was just minimal obliquity used with your approach, because maybe like five to 10 degrees, when it probably required more like 15 or 20. So potentially coming just doing that MRI review prior could have helped get a better flow pattern and a little bit more ventral. Excellent. So last case, 18 year old male, competitive soccer player, left-sided low back pain, buttock pain, stiff, achy, no radiating symptoms, greater than three months of pain, but increasing in the past four weeks, pain with running, no directional preference. Exam was notable only for tenderness at the left paraspinals and PSIS. Dr. Bakshi, what are some of the key points with this imaging here that you notice? Yeah, so here you can appreciate that the patient has transitional anatomy and there's the Castelvi classification, which helps us describe this and keeps our language uniform when we're describing the radiograph. So here you can appreciate a 2A segment where you have the transverse process of the lowest lumbosacral segment articulating with the sacrum. So when it's symptomatic, it could be referred to as Bertolatti syndrome. And on the MRI, you can appreciate that there is a bone marrow edema on the symptomatic right side where the pseudo articulation is. This patient had concordant tenderness right over that area. And given that there's isolated pathology on MRI, you could safely conclude that this is probably the pain generator. So you decide to do an injection of the pseudo articulation. What are your perils for injecting in this area and how might it guide kind of the next steps? Yeah, I mean, I think the role for injecting the pseudo articulation is to help confirm the diagnosis if it's unclear. In this case, we injected with an anesthetic and steroid, hoping that it might take him through the season. But certainly the important thing for him was to do some of the movements and activity that exacerbates pain immediately after the injection to really get a good understanding of how much this was causing his symptoms. So he did pretty well after this injection. I mean, the approach is mostly done through the AP trajectory, sometimes oblique and contralateral and playing with the obliquity can help better visualize the pseudo articulation. Treatment options? Yeah, so I think it's variable. There's not a whole lot of data on this. There's a few case reports describing radiofrequency ablation at this transitional segment. There was one report that described a bipolar lesion that helped this particular patient in this case report for an extended amount of time. I think that particular patient was in her 50s. So I think the data is really sparse. There's certainly a role for surgical consideration and really the two surgical options, I think historically have been either resection or fusion. In this particular case, the patient underwent a resection and he did quite well. I think there's an older study in 1993 that described fusing these segments when there's underlying disc degeneration. But certainly in this 2020 study where they looked at 30 patients that underwent resection, there's some pretty good outcomes seemingly. So something to consider when you have symptomatic Bertolatti syndrome. And Dr. Liu, last word here. Now that this patient has freedom at their lumbosacral junction, as the rehab guru I know you to be, what would you think about in terms of advising this patient now? Well, I mean, I think generally, we freed up a lot of space, but also in terms of his kinetic chain and how he participates in sport, that's likely to change at one point, probably for the better. I mean, generally, if we restrict motion at one segment, it's gonna be carried forward and you'll get more overload or stress or strain at another segment. Here, the opposite's occurring, but I would still worry about having him get used to low pelvic control, neuromuscular control, return to sports. So I would probably be sending him back to physical therapy and counsel him that he'd maybe have to relearn some of his sport-specific things. All right, thanks so much, everybody. We have some time for questions if you wanna come to the microphones. As far as our online audience, Michael Danto asks, there are detrimental effects of bracing, largely muscle deconditioning, and I'm guessing that none of you routinely brace these athletes. What criteria would you use for bracing these athletes? So I'll just start. I don't typically brace these athletes, but if they had a stress reaction that hadn't quite fractured, that would be someone that would probably, probably give an LSO more as a kinesthetic reminder to move too much, but I think it's less cumbersome and burdensome, and a strict PT protocol in neutral spine or flexion-based for avoiding hyperextension. Yeah, I would agree. I think unilaterality would play a role just because we've seen better healing in unilateral lesions, and parser action or stressor action would make me consider it, and then also taking into account the patient and personality, if he thinks he's gonna, you know, and the parents, is he gonna be able to not horse around with his friends, and could it be a reminder to people to kind of stay away, and he's injured or she's injured? So that's something that I consider also. To the question in the back. Two questions, two questions kind of dovetail off of that case. One, you mentioned during your talk, for me, flexion-extension views are almost purely like a surgical view. It's to help the surgeon determine, hey, is there a two millimeter or greater listhesis that reduces an extension? So for me, I never get it, but you mentioned there may be some circumstance where you get it, so I was hoping you'd comment on that. Then the other thing you guys kind of mentioned, and I may have missed it, as someone who has bilateral PARs and a high sacral slope, I am slowly watching my own L5 slip forward a little bit. What's the rate of a true listhesis that gets to a point that you have such significant stenosis that they're gonna be going to surgery, and does that play a role in your decision to, as you mentioned, catch these guys early enough before a fracture happens, so you do brace them to prevent that particular sequela? Is there enough data? Do you know it off the top of your head? Yeah, I mean, if it's less than a grade two spondy, they're not likely to slip. We've all seen people who do. As far as the flexion-extension, I mean, I basically don't get flexion-extension views. I'll get, well, the study I quoted was a standing x-ray and a supine MRI. I typically will just get a standing x-ray and maybe a supine x-ray, but if they had a significant slippage, then perhaps I would get a flex-x view, but typically I don't, and as far as the rate of progression. Yeah, one of the studies that I cited, this study looked at, I think, several hundred patients of kids that had undergone abdominal CAT scans, and incidentally, we saw, incidentally, the researchers saw bilateral L5 spondy, and in that study, even though there was the vast majority, I think 90% of those subjects after the age of 60 developed some level of spondylolisthesis, none of them underwent surgery, so those are some of the parameters, and I think the other study that I also quoted showed that the clinical presentation of bilateral spondylolisthesis patients follow the same general path as the routine, the general population in terms of symptoms and management, so hard to say. I think, I hope yours doesn't become overly symptomatic, but there's a good chance that it won't. Go ahead. Hi, I have a couple questions about the injections in the first cases, and I apologize, I missed the very first start, but I was assuming you were talking about adolescents or very young athletes with the spondylolisthesis, and so my question would be about the concerns you might have if you're doing a facet injection around the area where you think there is an active fracture. I can't think of anywhere else in PM&R we might use that thought concept of putting steroids in when they're trying to heal a fracture. My other question is about if these are adolescent athletes in the 18 to 22 range, let's say, doing ablation procedures in a young person, would you comment on what your concerns are about future atrophy? I mean, going back to the bracing, if you put them in a brace in the atrophy, I'm gonna assume you can still re-strengthen them, but if we actually ablate them and there is multifidus degeneration or atrophy, that's a concern in the athletes, so I'm really questioning a little bit of some of the interventional part in that area. Thank you. Yeah, so in terms of the ablation, just to address that first, that would be the biggest concern would be atrophy of the multifidus. In this case series that I discussed, there was only one that progressed to RFA. That, for me, I would only do that in something where you have a long discussion and it's really recalcitrant pain that's just not responding to anything else, but that would be a major concern, particularly in an athlete, even though there's no research that says it would potentially cause more pain down the road. I still think just logically and functionally that would be an issue, so I hesitate to do that. In terms of the steroid with an active fracture, if there is suspicion that this is an active fracture, the first thing would be to shut the person down and potentially brace, depending on what we discussed. Injection would not be, for me, in my algorithm initially as a first line. This is for patients who are down the road now, not actively inflamed or having signs of stress reaction on imaging where we're trying to get them to return, or patients who have symptoms consistent with the spondylolisis, but there's no radiographic evidence of an actual fracture where we think it's just some instability and irritation of the joint itself. So I agree with you, and I'm happy you pointed that out just so I could clarify. Yeah, Dr. Charnoff was trying to be very comprehensive, but in no way is he endorsing a steroid injection for someone with an active fracture. Yeah, I think we do this calculus a lot, right? This comes up in our elderly patients that have compression fractures and have concomitant disc issues, and the question is is there pain coming from the fracture? Is it coming from some of the retropulsion that might be causing some neural compression? Do we do an epidural to make them feel better? Are we risking bony healing? So it's kind of the same calculus that goes into these cases. None of these subjects had any interventions done, but I'm with you. I think the calculus is complicated. Having treated synovial cysts for 20 years in the setting of list thesis and Medicare group, you're never gonna, it's gonna come back, and the thickness of the wall of the synovial cyst and the actual synovial fluid in it. So I wanna offer you an alternative treatments. For those of you who do mild procedures, we are doing a small series that we're gonna publish. Our institution directly goes to mild procedure. We decompress it. We actually go decompress. So you are having corrective actions. We do not use steroid injections around, and we stop poking at it. You go in with a small trocar. You remove that synovial cyst. The symptom will resolve. So it is newer. Not any institutions are doing these procedure. Mostly is applied to spinal stenosis, but if you have 2 3rd of the synovial cysts are generally either where you had it centralized or along the lamina. You can't get to it if you're all the way to the foramina, but anywhere along the length of the ligament of flavum is accessible, is removable. It's about 20 minute procedures, and your patients will be very happy. So you will stop poking and probing them. Just an alternative thought process. Yeah, I mean, even with surgical resection, there's still recurrence rates that are up there in 30 to 50 percentile. Have you noticed any recurrence rates? They don't have recurrence. Actually, two of them that we were publishing on, they actually had foot drop. So it was to a point of foot drop. So now our surgeons are actually referring to us to remove the synovial cysts without opening them up. So it is an option for those of you who are skilled in it, and or do them for your patients with spinal stenosis and ligament thickening. It is an option because you can access this, but you have to be very, you have to probably put contrast. In this case, it's a little challenging because you have contrast allergy, but you want to highlight the synovial cyst on intra-articular contrast, and then you can access it with your trocar and remove it. So a third option, because these are very frustrating. They keep coming back, and in the third case, in the third time around, you now have a herniated on top of it, which would complicate more. But the very first chance or two, you may have been able to do that. So would you do it with the contrast allergy or would you retreat? Yes, so you're incising the patient. You're putting thicker instruments into the canal. You want to highlight that cyst so you can have a better access to it because you can see as much as you want on CAT scan, but on the person, you need some sort of highlighting of the synovial cyst so you can access it. I think that's a great point. Thank you for sharing that with us, and I look forward to your publication. I think with the mild procedure, especially given that these cysts have ligamentum flavum characteristics to it, histologically, sort of intuitively, it makes sense that debulking some of the ligamentum flavum could be helpful. So that's very interesting. Thank you. Just a question online. A patient in her 60s had repetitive relief for six to 12 months after steroid injections of a transitional segment pseudoarticulation for about five years. Then insurance dropped coverage for the procedure and refused coverage on multiple appeals. Patient has not responded as well to a radiofrequency neurotomy of the pertinent levels, recommendations. So unfortunately, these are not paravertebral joints, and the facet injection code is not an appropriate code. As far as I know, the best code is 64999, which is an unlisted code. So I don't know, Dr. Bakshi, how you coded that. Yeah, I mean, I don't remember exactly how I coded that one, but it certainly is a challenge. I guess it's hard to justify using a facet code if it's really not considered a facet. Insurance companies are tough, and so I think a lot of times, I don't know what the solution is. Sometimes billing it as a deep trigger point, having that discussion with the patient, a lot of times considering just having some sort of fee schedule that might help kind of be able to do these procedures without potentially going through insurance. Thanks so much. Unfortunately, we're out of time, but we're happy to answer questions after outside. So thank you so much for your participation. We appreciate it. Thank you.

bracing for spondylolysis treatment

evidence from different studies

advanced imaging

injury understanding

PARS defects severity

treatment decisions

spinal conditions in young athletes

spondylolisthesis

transitional anatomy

synovial cysts

individualized treatment plans

comprehensive approach