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Suggest Treatment For Optic Neuritis
Question: Hi Dr. Saghafi,
As it turns out you were CORRECT in your suspicion for optic neuritis. I had recently contacted you about the eye movement pain and headaches I was having. Subsequently, I had two MRIs and some bloodwork through a neurologist I am seeing locally. I still have some visual issues, but they are slowly resolving - I think. I opted not to do 3 day IV steroids as I am managing and I do not wish to have the other side effects. The first MRI indicated optic neuritis.
My reason for contacting you again is that a second MRI I had completed of my C-spine indicated some mild to moderate uncovertebral joint degenerative changes in the C4-C5, and milder in the C3-C4 region. The most changes were noted in the C5-C6 region, with mild to moderate stenosis of both neural foramina? I don't quite understand this. The other concerning result was "bone marrow signal in the cervical spine is relatively and diffusely hypointense on T1-weighted imaging but likely within normal limits" and "Low T1 signal in the superior endplate of C5 may represent modic type 3 change." The radiologist's impression was that the bone marrow T1 signal in the cervical spine is at the lower limits or normal and that this may be seen in the setting of anemia or infiltrative processes. Don't quite understand?
I will not see my neurologist for a couple of weeks, so I am wondering what questions I should be asking and if any of this is of real concern? I did have tons of blood taken recently to check for everything - only some results back, but notably all normal so far with respect to my proteins, albumin, globulins, IGG, IGA, IGM, Kappa, Lambda, Lyme, ANA, IFA, T4, Erythro sed rate, TSH, C-Reactive Protein...
Would really like to get your opinion!
Thanks!
XXXXXXX
As it turns out you were CORRECT in your suspicion for optic neuritis. I had recently contacted you about the eye movement pain and headaches I was having. Subsequently, I had two MRIs and some bloodwork through a neurologist I am seeing locally. I still have some visual issues, but they are slowly resolving - I think. I opted not to do 3 day IV steroids as I am managing and I do not wish to have the other side effects. The first MRI indicated optic neuritis.
My reason for contacting you again is that a second MRI I had completed of my C-spine indicated some mild to moderate uncovertebral joint degenerative changes in the C4-C5, and milder in the C3-C4 region. The most changes were noted in the C5-C6 region, with mild to moderate stenosis of both neural foramina? I don't quite understand this. The other concerning result was "bone marrow signal in the cervical spine is relatively and diffusely hypointense on T1-weighted imaging but likely within normal limits" and "Low T1 signal in the superior endplate of C5 may represent modic type 3 change." The radiologist's impression was that the bone marrow T1 signal in the cervical spine is at the lower limits or normal and that this may be seen in the setting of anemia or infiltrative processes. Don't quite understand?
I will not see my neurologist for a couple of weeks, so I am wondering what questions I should be asking and if any of this is of real concern? I did have tons of blood taken recently to check for everything - only some results back, but notably all normal so far with respect to my proteins, albumin, globulins, IGG, IGA, IGM, Kappa, Lambda, Lyme, ANA, IFA, T4, Erythro sed rate, TSH, C-Reactive Protein...
Would really like to get your opinion!
Thanks!
XXXXXXX
Brief Answer:
Ok...clinical medicine is NOT DEAD...
Detailed Answer:
Although I'm not necessarily that happy to hear you have confirmed ON...
But I am happy to hear that The sounds of horses hooves still equates to probable horses as the cause of the noise...and not zebras pretending to be horses! LOL
I hope the ophthalmologist will file this case and not depend entirely on what they SEE as much as the clinical picture related by patients who generally want to get better and not just spin yarns to doctors trying to throw them off the track! At any rate, we've got a diagnosis and now you've got some more questions on the MRI so let's have at it......first, if you could upload the MRI images of both your head and c-spine that would be GRAND. The imaging facilities here in XXXXXXX (and many places) will give you CD's of the images which you could transfer digitally to this platform. Or perahps, you have the copies of the reports that you could upload. Even though you've copied out the interpretations....I'd also like to see the exact verbiage in the body of the report from where the conclusions have been drawn. You'd be surprised how many people FORGET what they dictated in the body of the report when it comes to drawing their final conclusions! LOL....
But based upon what you've written and not knowing much more than that I'll do my best and say the following:
Remember, these are reads of your cervical spine which were obtained by the neurologist in all probability for the purpose of making sure you didn't have any MS lesions in the neck. That's a good thing to do since many people only get MRI's of the brain and if we find a lesion or 2 they stop and never end up finding out that lesions can also be present in other parts of the spinal cord such as cervical (most often), lumbar at times, and thoracic (rarely).
Therefore, the reads by the radiologist are going to include all sorts of things which likely are of little interest to the neurologist who sent the scan. They are simply reading things that are there that have to do mainly with the arthritic changes in the spinal column (most of which are normal for age)....the vast majority of the radiographic findings in otherwise, normal and healthy subjects are meaningless clinically speaking. In other words, if you get an MRI of the spine in 100 normal, healthy, individuals who are not complaining of any pain in the back, no weakness, no sensory problems, and those individuals were all above say, age 35-40 then, statistics show that over 40% would have bulging discs, over 15% would have herniated disks, at least 10% would have some reading of possible bone marrow signal intensity changes or lucencies, and another 5-10% may have incidental findings consistent with congenital malformations such as angiomas, cavernomas, and Schmorl nodes, 60% would have some degree of facet joint arthropathy, and over 90% would have some radiographic evidence of degenerative changes at some level of the spinal column or within the discs, and so forth.
Remember, we started with a group of 100 healthy subjects without any complaints or limitations....the only thing was there were above the ages of 35-40 years.
So that's the preface to the interpretations of these readings.
"indicated some some mild to moderate uncovertebral joint degenerative changes in the C4-C5, and milder in the C3-C4 region."
Translation: Mild to moderate arthritis seen in the midregion of the neck. If you have any neck pain, soreness, or stiffness which has been bothering you for any time this may be the reason...If not, then, we're back to what I originally said which was that you can frequently see radiographic changes in the skeleton due to arthritis before anybody ever complains about it.
"The most changes were noted in the C5-C6 region, with mild to moderate stenosis of both neural foramina"
Translation: Mild to moderate arthritis found in the mid to lower neck region where nerves exit from the spinal cord....(i.e. possible squeezing of the these nerves by calcified deposits within their exit portals). Again, if there are any symptoms to go with this your doctor can interpret them.....sometimes people refer pain, shocklike sensations, numbness, tingling, etc. It wouldn't XXXXXXX me if you complained of NONE of those symptoms or some of them.
"bone marrow signal in the cervical spine is relatively and diffusely hypointense on T1-weighted imaging but likely within normal limits" and "Low T1 signal in the superior endplate of C5 may represent modic type 3 change."
Translation: The radiologist is waffling in the 1st statement because he doesn't want to quite call the whole thing NORMAL so he says it's "likely" normal which means that if the clinician has information that could support a further study or workup of any sort that he/she should feel free to do so.....therefore, since I don't have any other information on you than the report I would probably pass this off as a clinically insignificant finding and defer to your own physician who should have more information from labs, etc. to decide what if anything should be done. Modic refers to skeletal changes seen in radiographic images of which I'm not expert enough to comment on.....you'd have to ask your physician to give you the specifics on that information.
As far as the comments on the bone marrow....again, I would defer to your physician's discretion as to whether you have other supportive laboratory data that should indicate that further workup is necessary. My impression is that NO ADDITIONAL EFFORT having to do with bone marrow be looked at right now. The primary purpose of this C-spine film was to rule out demyelinating lesions....and it would appear that has been adequately accomplished. All the rest of the stuff they're talking about helps justify the radiologist's job at the hospital and often serves to confuse and worry unsuspecting patients that there are all sorts of bad things going on. The rule of thumb is that if a radiologist sees something that he/she thinks is potentially or absolutely BAD NEWS that a phone call goes to the ordering physician. In that phone call the radiologist will recommend the patient be sent back for further studies and they will typically tell the physician exactly what to order and when.
Then, patients get phone calls to tell them they need to return for additional views, etc. etc. If that hasn't happened then, the radiologist is simply doing his/her job in reading whatever they see which usually entails all sorts of minutia that are of no clinical value.
Ergo and thusly, I think your c-spine (for the purpose of evaluating the ON) passed with flying colors....but you do not have the skeletal constitution anymore of a 15 year old.....SURPRISE- SURPRISE! LOL.....Having said that, I believe that you are quite fine in the neck in terms of your bony structure, your bone marrow, and even your Uncle Vertebral Joint (which is that cool uncle you had who used to slip away while you were on the playground to his Rust colored Fleetwood to grab a toke or two before taking you out for ice cream....Uncle Vertebral Joint) ROFL!
All the best to you and I hope to still share my adventures at XXXXXXX College one day back in the summer of 1977!
If this information has been helpful and I've answered your questions would you do me the favor of some written feedback and a STAR RATING of the answer as you so generously did on your first round of questions. So many people on this network who are given answers to questions do not take the time to leave useful feedback and ratings and we're always left wondering why that might be the case....were they offended, did they not understand the answer sufficiently, did something else happen? Not only that but the STAR RATINGS are very helpful to the doctors because patients actually pay a lot of attention to a doctor's rating by his patients when deciding to ask him a specific question or to return to him for service.
Should you have no further questions or comments to place- CLOSING THE QUERY would be greatly appreciated as well.
And of course, in the future I'm happy to answer more concerns personally if you'd allow me this privilege by going to the following website and sending me your questions:
bit.ly/drdariushsaghafi
This query has required 60 minutes of physician specific review, research, and final draft documentation for envoy to this patient.
Ok...clinical medicine is NOT DEAD...
Detailed Answer:
Although I'm not necessarily that happy to hear you have confirmed ON...
But I am happy to hear that The sounds of horses hooves still equates to probable horses as the cause of the noise...and not zebras pretending to be horses! LOL
I hope the ophthalmologist will file this case and not depend entirely on what they SEE as much as the clinical picture related by patients who generally want to get better and not just spin yarns to doctors trying to throw them off the track! At any rate, we've got a diagnosis and now you've got some more questions on the MRI so let's have at it......first, if you could upload the MRI images of both your head and c-spine that would be GRAND. The imaging facilities here in XXXXXXX (and many places) will give you CD's of the images which you could transfer digitally to this platform. Or perahps, you have the copies of the reports that you could upload. Even though you've copied out the interpretations....I'd also like to see the exact verbiage in the body of the report from where the conclusions have been drawn. You'd be surprised how many people FORGET what they dictated in the body of the report when it comes to drawing their final conclusions! LOL....
But based upon what you've written and not knowing much more than that I'll do my best and say the following:
Remember, these are reads of your cervical spine which were obtained by the neurologist in all probability for the purpose of making sure you didn't have any MS lesions in the neck. That's a good thing to do since many people only get MRI's of the brain and if we find a lesion or 2 they stop and never end up finding out that lesions can also be present in other parts of the spinal cord such as cervical (most often), lumbar at times, and thoracic (rarely).
Therefore, the reads by the radiologist are going to include all sorts of things which likely are of little interest to the neurologist who sent the scan. They are simply reading things that are there that have to do mainly with the arthritic changes in the spinal column (most of which are normal for age)....the vast majority of the radiographic findings in otherwise, normal and healthy subjects are meaningless clinically speaking. In other words, if you get an MRI of the spine in 100 normal, healthy, individuals who are not complaining of any pain in the back, no weakness, no sensory problems, and those individuals were all above say, age 35-40 then, statistics show that over 40% would have bulging discs, over 15% would have herniated disks, at least 10% would have some reading of possible bone marrow signal intensity changes or lucencies, and another 5-10% may have incidental findings consistent with congenital malformations such as angiomas, cavernomas, and Schmorl nodes, 60% would have some degree of facet joint arthropathy, and over 90% would have some radiographic evidence of degenerative changes at some level of the spinal column or within the discs, and so forth.
Remember, we started with a group of 100 healthy subjects without any complaints or limitations....the only thing was there were above the ages of 35-40 years.
So that's the preface to the interpretations of these readings.
"indicated some some mild to moderate uncovertebral joint degenerative changes in the C4-C5, and milder in the C3-C4 region."
Translation: Mild to moderate arthritis seen in the midregion of the neck. If you have any neck pain, soreness, or stiffness which has been bothering you for any time this may be the reason...If not, then, we're back to what I originally said which was that you can frequently see radiographic changes in the skeleton due to arthritis before anybody ever complains about it.
"The most changes were noted in the C5-C6 region, with mild to moderate stenosis of both neural foramina"
Translation: Mild to moderate arthritis found in the mid to lower neck region where nerves exit from the spinal cord....(i.e. possible squeezing of the these nerves by calcified deposits within their exit portals). Again, if there are any symptoms to go with this your doctor can interpret them.....sometimes people refer pain, shocklike sensations, numbness, tingling, etc. It wouldn't XXXXXXX me if you complained of NONE of those symptoms or some of them.
"bone marrow signal in the cervical spine is relatively and diffusely hypointense on T1-weighted imaging but likely within normal limits" and "Low T1 signal in the superior endplate of C5 may represent modic type 3 change."
Translation: The radiologist is waffling in the 1st statement because he doesn't want to quite call the whole thing NORMAL so he says it's "likely" normal which means that if the clinician has information that could support a further study or workup of any sort that he/she should feel free to do so.....therefore, since I don't have any other information on you than the report I would probably pass this off as a clinically insignificant finding and defer to your own physician who should have more information from labs, etc. to decide what if anything should be done. Modic refers to skeletal changes seen in radiographic images of which I'm not expert enough to comment on.....you'd have to ask your physician to give you the specifics on that information.
As far as the comments on the bone marrow....again, I would defer to your physician's discretion as to whether you have other supportive laboratory data that should indicate that further workup is necessary. My impression is that NO ADDITIONAL EFFORT having to do with bone marrow be looked at right now. The primary purpose of this C-spine film was to rule out demyelinating lesions....and it would appear that has been adequately accomplished. All the rest of the stuff they're talking about helps justify the radiologist's job at the hospital and often serves to confuse and worry unsuspecting patients that there are all sorts of bad things going on. The rule of thumb is that if a radiologist sees something that he/she thinks is potentially or absolutely BAD NEWS that a phone call goes to the ordering physician. In that phone call the radiologist will recommend the patient be sent back for further studies and they will typically tell the physician exactly what to order and when.
Then, patients get phone calls to tell them they need to return for additional views, etc. etc. If that hasn't happened then, the radiologist is simply doing his/her job in reading whatever they see which usually entails all sorts of minutia that are of no clinical value.
Ergo and thusly, I think your c-spine (for the purpose of evaluating the ON) passed with flying colors....but you do not have the skeletal constitution anymore of a 15 year old.....SURPRISE- SURPRISE! LOL.....Having said that, I believe that you are quite fine in the neck in terms of your bony structure, your bone marrow, and even your Uncle Vertebral Joint (which is that cool uncle you had who used to slip away while you were on the playground to his Rust colored Fleetwood to grab a toke or two before taking you out for ice cream....Uncle Vertebral Joint) ROFL!
All the best to you and I hope to still share my adventures at XXXXXXX College one day back in the summer of 1977!
If this information has been helpful and I've answered your questions would you do me the favor of some written feedback and a STAR RATING of the answer as you so generously did on your first round of questions. So many people on this network who are given answers to questions do not take the time to leave useful feedback and ratings and we're always left wondering why that might be the case....were they offended, did they not understand the answer sufficiently, did something else happen? Not only that but the STAR RATINGS are very helpful to the doctors because patients actually pay a lot of attention to a doctor's rating by his patients when deciding to ask him a specific question or to return to him for service.
Should you have no further questions or comments to place- CLOSING THE QUERY would be greatly appreciated as well.
And of course, in the future I'm happy to answer more concerns personally if you'd allow me this privilege by going to the following website and sending me your questions:
bit.ly/drdariushsaghafi
This query has required 60 minutes of physician specific review, research, and final draft documentation for envoy to this patient.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Ok - thank you for your reply once again, and for the translations and intermixed lighthearted humor as well! I do have scans and reports; however, I cannot open the scans on my pc and there doesn't seem to be a way to link up attachments in this venue.
I did speak with my neurologist who said that he doesn't suspect MS given the feedback from the scans; however, he is still waiting on some bloodwork which ad to be sent out to see whether I have Devic's (NMO)? I am hoping not as I do not like what I am reading about that. Otherwise, maybe this is just an ideopathic event passing through my optical area? I also had sinus pressure and pain....so maybe a virus? This is still somewhat of a mystery which is now resolving on its own after three weeks of what I would characterize as intense pain and pressure around my eye & eye movements/ethmoid sinus area.
My family physician sees no reason to follow up on the bone marrow issue, as well, so that is good news - though, he will check for anemia (which he doesn't believe I have).
I will take my arthritic neck to the chiropractor!
Best, XXXXXXX
I did speak with my neurologist who said that he doesn't suspect MS given the feedback from the scans; however, he is still waiting on some bloodwork which ad to be sent out to see whether I have Devic's (NMO)? I am hoping not as I do not like what I am reading about that. Otherwise, maybe this is just an ideopathic event passing through my optical area? I also had sinus pressure and pain....so maybe a virus? This is still somewhat of a mystery which is now resolving on its own after three weeks of what I would characterize as intense pain and pressure around my eye & eye movements/ethmoid sinus area.
My family physician sees no reason to follow up on the bone marrow issue, as well, so that is good news - though, he will check for anemia (which he doesn't believe I have).
I will take my arthritic neck to the chiropractor!
Best, XXXXXXX
Brief Answer:
I wish you only the best
Detailed Answer:
Thanks for those updates....very helpful.....can't open the files on your computer? Really? Most places have switched over to software packages that make it easy for most PC home users to pop the disk in and open things up....not that they can necessarily manipulate files around with the tools or anything....heck, I have a tough time knowing how to play with those things....but just for straight viewing purposes. I'm crossing my fingers for you on the blood work and glad to hear that the neurologist is not highly suspicious of MS.
Sinus pressure or congestion does not cause an MR to show evidence of an optic neuritis which is inflammation. It would've shown ACUTE SINUS CONGESTION....did it? My impression is that there was really no sinus involvement that could be radiographically documented. Remember, chronic sinusitis is never considered a good neurological source of problems for headaches, optic neuritis, color desaturation, etc.
Please don't misunderstand my comments....I'm not trying to be negative for any reason...but just want YOU to keep your eye on the ball (no pun intended! HA)....the facts are what they are....so we're cool with that....what you don't want to do or let anyone else really do is try to explain them with things that are simply not true by either scientific literature or general consensus.
Perfectly fine to say that optic neuritis could be an isolated and transitory finding....in fact, most of the time...it is. But I wouldn't agree with any physician who would try and say, "well, maybe it was just a nasty virus...you know the flu season is upon us?".....or stuff like that.
Again, many thanks in allowing me to be part of your care and please keep me in the loop....maybe even in your travel plans if you happen by this way in the future... XXXXXXX is going to be beautiful this spring with all the new construction that she's doing! Now, if we could only have San Diego's climate....if only for 3 months! LOL...
Be well, safe, and stay positive!
Should you have no further questions or comments to place- CLOSING THE QUERY would be greatly appreciated as well along with your generous grading of our interaction with those all important and delicious STARS! LOL
And of course, in the future I'm happy to answer more questions personally if you'd allow me this privilege by going to the following website and sending me your questions:
bit.ly/drdariushsaghafi
This query has required 77 TOTAL minutes of physician specific review, research, and final draft documentation for envoy to this patient.
I wish you only the best
Detailed Answer:
Thanks for those updates....very helpful.....can't open the files on your computer? Really? Most places have switched over to software packages that make it easy for most PC home users to pop the disk in and open things up....not that they can necessarily manipulate files around with the tools or anything....heck, I have a tough time knowing how to play with those things....but just for straight viewing purposes. I'm crossing my fingers for you on the blood work and glad to hear that the neurologist is not highly suspicious of MS.
Sinus pressure or congestion does not cause an MR to show evidence of an optic neuritis which is inflammation. It would've shown ACUTE SINUS CONGESTION....did it? My impression is that there was really no sinus involvement that could be radiographically documented. Remember, chronic sinusitis is never considered a good neurological source of problems for headaches, optic neuritis, color desaturation, etc.
Please don't misunderstand my comments....I'm not trying to be negative for any reason...but just want YOU to keep your eye on the ball (no pun intended! HA)....the facts are what they are....so we're cool with that....what you don't want to do or let anyone else really do is try to explain them with things that are simply not true by either scientific literature or general consensus.
Perfectly fine to say that optic neuritis could be an isolated and transitory finding....in fact, most of the time...it is. But I wouldn't agree with any physician who would try and say, "well, maybe it was just a nasty virus...you know the flu season is upon us?".....or stuff like that.
Again, many thanks in allowing me to be part of your care and please keep me in the loop....maybe even in your travel plans if you happen by this way in the future... XXXXXXX is going to be beautiful this spring with all the new construction that she's doing! Now, if we could only have San Diego's climate....if only for 3 months! LOL...
Be well, safe, and stay positive!
Should you have no further questions or comments to place- CLOSING THE QUERY would be greatly appreciated as well along with your generous grading of our interaction with those all important and delicious STARS! LOL
And of course, in the future I'm happy to answer more questions personally if you'd allow me this privilege by going to the following website and sending me your questions:
bit.ly/drdariushsaghafi
This query has required 77 TOTAL minutes of physician specific review, research, and final draft documentation for envoy to this patient.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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