1. NOTE: To change the image on this slide, select the picture and delete it. Then click the Pictures icon in the placeholder to insert your own image. UNUSUAL IMAGING FINDINGS To treat or not to treat? Venu Akuthota, MD University of Colorado

2. Three Cases  Case 1  Case 2  Case 3

3. CASE 1: HISTORY 55 y.o. diabetic male who presents with a six-month history of right shoulder and arm pain. He states there is no particular inciting event. He noted initially pain around his right shoulder. MRI shoulder showed rotator cuff tendinopathy. Underwent a right subacromial injection- no relief Over time pain radiated down his right arm. He feels numbness/tingling throughout his right arm esp. lateral aspect of his upper arm into the extensor forearm and into all 5 digits. He perhaps has more pain sensation into the right thumb region. He denies significant weakness. Not much neck pain ROS negative except peripheral neuropathy in LE

4. CASE 1: PHYSICAL EXAM Neurologic: Sensation: deficit noted - decreased sensation in his toes. Normal sensation noted to light touch in his upper extremities. Upper and lower extremities strength exam is 5/5 bilaterally except mild weakness of his right external rotators. UE Reflexes are difficult to elicit particularly with biceps. Able to elicit brachioradialis reflexes. LE reflexes are present at knees but diminished at ankles. MSK: Cervical range of motion is full and pain-free. Spurling's maneuvers negative bilaterally. Shoulder range of motion is normal. Mildly positive right impingement maneuver.

5. MRI of cervical spine- uniform nerve root swelling Caption

6. ASK THE AUDIENCE: What does this represent?  A: Perineural cysts  B: CIDP  C: Neurofibromatosis

9. WHAT DID I DO… TEACHING POINTS:  CIDP can show as uniform nerve root swelling but this is a red herring in this case  Spurling’s maneuver modifications can be made to increase sensitivity (however remember confirmation biases)  EMG can still be helpful

10. CASE 2: HISTORY 70 year old female with RA and bladder stimulator presents with multiple joint pain with particular disability from right hip pain Denies constitutional symptoms Failed PT

11. CASE 2: PHYSICAL EXAM Neurologic: Sensation: deficit noted UE and LE distally. Strength 4/5 bilateral HF. Reflexes 1+ throughout except absent bilateral ankle jerks. MSK: Thoracolumbar ROM severely limited. Swelling of multiple joints including bilateral knees, right shoulder. Right shoulder noted to have large mass at right armpit. Ulnar deviation of hands. Hip Xrays- mild symmetric OA

13. ASK THE AUDIENCE: What would you do next?  A: MRI  B: Right L1 TFESI  C: IR-guided biopsy  D: Surgical decompression  E: Medication management

14. WHAT DID I DO… TEACHING POINTS:  CPPD (pseudogout) should be in our differential of calcified lesions  Evaluate epidural steroid risk for fracture (Schlomo Mandel study)

15. CASE 3: HISTORY 52 year old female with history of breast cancer Axial low back pain Pain with transitions

16. CASE 3: PHYSICAL EXAM Neurologic: Normal MSK: Pain worse with end range flexion and extension. Positive prone instability test.

17. Lumbar flexion/extension films

18. Picture with Caption Layout Caption

19. ASK THE AUDIENCE: What would you do next?  A: L4-5 facet intra-articular injections  B: Interspinous injection  C: PT for core strengthening  D: Surgical referral

20. WHAT DID I DO… TEACHING POINTS:  Facet synovitis (facet distension sign) often represents instability  Bastruup’s (Kissing Spine) may not be a “kissing” problem as much as AP instability problem  Retrodural space of Okada

23. THANK YOU  Case 1: CIDP  Case 2: Pseudogout  Case 3: Retrodural Space of Okada