Sunday, April 23, 2017

Nerve Root(s)

In season 3, episode 18 of Star Trek: Deep Space Nine Dr. Bashir has to deal with some deep-seated personal issues. One of these is the fact that he graduated second in his medical school class because he mistook a "pre-ganglionic fiber for a post-ganglionic nerve." Spoiler alert: He did it on purpose because he didn't want to deal with the pressure of being first.

Dr. Bashir is not alone. I see this lead to 2 errors every day in our trainees. The clinical implication is zero, because the referring physicians also don't make this distinction (two wrongs do make a right, apparently).

First, take a look at the image below:

Note that there are 2 nerve roots (dorsal and ventral) on each side (left and right). When you say a lumbar disc compresses a nerve root in the central spinal canal, you need to add an "s," because these dorsal and ventral nerve roots travels down together in the cauda equina. Next time you look at an axial T2-WI of the lumbar spine, see if you can see two distinct nerve roots on either side.

Second, note that once we're post-ganglionic, we're dealing with a nerve, not a root. So, if you're talking about a nerve root outside the foramen, you're about as anatomically correct as a Ken doll.

The same goes for the "nerve roots" of the brachial plexus and the famous Randy Travis Drinks Cold Beer mnemonic for the brachial plexus anatomy (sorry, Randy). All is not lost. Just replace Randy Travis with Nikola Tesla.


  • Basic anatomy that everyone ignores.

Sunday, April 16, 2017

Ventriculus Terminalis

The ventriculus terminalis (also known as the terminal ventricle and the fifth ventricle) is a rarely identified cerebrospinal fluid cavity within the conus medullaris. The ventriculus terminalis does not communicate with the subarachnoid space or the central canal of the spinal cord, and may actually be an embryonal remnant of the primitive central canal, leading some to refer to it a sinus terminalis instead.

They are occasionally associated with caudal regression of the spinal cord, Chiari type I malformation, lipomyelomeningoceles, and lumbosacral "lipomas." Some authors believe that all of us have some sort of cystic CSF space at the conus medullaris, but that it's simply larger [and detectable on imaging] in some people and tends to regress (but not completely resolve) over time.

The characteristic imaging features are more commonly seen in children: Cystic lesion of the conus medullaris without spinal cord signal abnormality. In adults, ventriculus terminalis is more likely to have septations and be associated with spinal cord edema, kyphotic deformity and spinal arteriovenous malformations.

Rarely, ventriculus terminalis can enlarge in the presence of meningeal hemorrhage or deformities of the vertebral canal. An enlarged or symptomatic ventriculus terminalis can be treated by cyst fenestration with or without shunting to the subarachnoid space, pleural cavity, or peritoneal cavity.


Monday, April 10, 2017

False Perpetuations: Main Portal Vein Size and Portal Hypertension

Perpetuation: A main portal vein (MPV) diameter >13 mm is "consistent with portal hypertension" (pHTN)

This cutoff of 13 mm is based on weak literature (mainly from the 1980's), some of which did not include comparison values of normal patients

  • One comparative study using ultrasound found (Radiology 1982; 142: 167-172):
    • In 79 patients with pHTN
      • 36 had a MPV diameter of <13 mm 
      • 33 had a MPV diameter >/= 13 mm
      • The MPV was not visualized in 10 patients
    • In the 45 control patients
      • The MPV diameter was < 13 mm in 41 cases
      • The MPV was not visualized in 4 patients. 

More recent studies have found that there is no significant difference in MPV diameters when comparing patients without cirrhosis to patients with cirrhosis, and the normal MPV diameter is significantly larger than the 13 mm cutoff

  • A study (Eur J Gastroenterol Hepatol 2004; 16:147-155) from King's College using ultrasound (49 controls and 14 cirrhotics) found: 
    • the average MPV diameters were 9.6 cm and 10.8 cm in patients without and with cirrhosis, respectively.
  • A second study (JCAT 2008; 32: 198-203) from UCSF using CT (59 controls and 67 cirrhotics) found:
    • The average MPV diameters were 14.5 cm and 14.8 cm in patients without and with cirrhosis, respectively.
  • Using CT, the MPVs in healthy renal donor patients were measured before and after the administration of intravenous contrast, and in the axial and coronal planes (Abdom Radiol 2016; 41:1931-1936). This study found:
    • The average MPV diameter was 15.5 +/- 1.9 mm
      • This value was significantly different than 13 mm
    • Post-contrast MPVs were 0.56 mm larger compared to non-contrast
    • A positive correlation between BMI and height versus MPV diameter
In fact, the MPV size can be reduced in portal hypertension and has been described as a sign of hepatofugal MPV flow (AJR 2003; 181: 1629-1633). This study found:
  • A MPV diameter of less than 1 cm is a highly sensitive (but not very specific) for MPV flow reversal in patients with cirrhosis