foreign if you look at this everything's messed up right you have all of these hyper intense bony changes that's arthritis that's basically spondylosis you have discs that are collapsing on onto themselves you have end plates that are collapsing and you have you can see the canal is pinched in at the disc basis because of herniated discs foreign so this is a patient that has probably very severe back pain they probably have significant pain in their legs from nerve compression and you could look at this MRI and you say well what the heck am I supposed to do and if you get 10 spine surgeons some orthopedic surgeons some neurosurgeons you're going to get 10 different ideas for what to do for a spine that looks like this and unfortunately with the Obesity epidemic in this country this is what most spines look like one option if it's a fairly healthy patient is you can do a huge operation and realign and fuse and decompress everything that's the most definitive treatment sometimes that's the right way to go other times the best thing to do for the patient is the smallest least invasive footprint so what's tricky for this multi-level disease these patients are like I said they're going to have the back pain radicular pain claudication which we're going to talk about in a second and you really need to rely on your exam and your history now figure out out of all of these problems in the spine which one is the actual trigger for their pain or their deficit and if you can just fix that you can make the patient pretty happy without giving them an enormous operation so again for this problem you want to look at the nerves look at the MRI get a myelogram if they can't get the MRI and the X-ray helps to tell you what's unstable here are the bones moving on top of each other because if they are then you really need a fusion you can't do a decompression at an unstable level because you take instability and you're just making it worse by drilling off bone but if you can get a pain management doctor to put a needle around a specific nerve numb it up and the patient says they're happy then you decompress one nerve and that just means drilling the bone and taking the disc material around the one nerve and that may give you a good result so here we're talking about claudication so you guys probably covered this a few times in different med school uh modules claudication there's two kinds neurogenic and vascular and unfortunately they have very very similar symptoms and that can be a non-dermatomal non-specific burning in the legs can be unilateral or bilateral that is accompanied by weakness and these symptoms these problems get worse with walking and exertion so it's kind of a busy slide here but just to give you a little bit of clarity for neurogenic claudication sometimes it's positional if you lean forward the neurofaramina actually open up a little bit more and if you stretch backward they tighten up and the symptoms get worse so one classic example is if somebody has neurogenic claudication they can bike very well if it's a stationary bike they can exert themselves and do well no problem if it's vascular that's a blood supply issue it doesn't matter what position you're in as long as you're exerting yourself you're going to have the symptoms and that's aside from all of these other different characteristics to try to memorize for for standardized tests which one causes which what matters the most when you're examining a real patient is do they get positional relief if the answer is yes you're thinking neurogenic and if it's no you're thinking vascular and as a as future neurosurgeons your ability in the clinic to determine if a patient has normal or diminished pulses in their lower extremities you're going to have to rely on someone else for that because that's not something that's going to be in your skill set but again there will be pulse and blood supply and blood flow issues in the lower extremities but that's not going to be your responsibility to figure that out as a neurosurgeon hey everyone Ryan rad here from neurosurgerytraining.org if you like that video subscribe and donate to keep our content available for medical students across the world