Avicenna Society

04/09/2026

A challenging mismatch between imaging and clinical presentation.

This patient has had complete left tibialis anterior weakness with foot drop for 5 years, hamstring weakness for 3 years, pain centered in the low back with L4 to S1 distribution, and L4 to L5 radicular symptoms. No proprioception loss pattern suggesting upper cord involvement, no myelopathy, and no convincing L1 to L3 radiculopathy.

The MRI draws attention to T11-12 and upper lumbar spondylolisthesis, but the clinical story points elsewhere. When the pictures and the patient tell two different stories, which do you trust more, and which level would you address first?

My bias is always to treat the patient, not the most dramatic image.

04/09/2026

A challenging mismatch between imaging and clinical presentation.

This patient has had complete left tibialis anterior weakness with foot drop for 5 years, hamstring weakness for 3 years, pain centered in the low back with L4 to S1 distribution, and L4 to L5 radicular symptoms. No proprioception loss pattern suggesting upper cord involvement, no myelopathy, and no convincing L1 to L3 radiculopathy.

The MRI draws attention to T11-12 and upper lumbar spondylolisthesis, but the clinical story points elsewhere. When the pictures and the patient tell two different stories, which do you trust more, and which level would you address first?

My bias is always to treat the patient, not the most dramatic image.

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04/05/2026

03/25/2026

I am a strong believer in treating symptoms, not pictures. Still, every so often, our own protocols deserve to be challenged.

This patient is now 1.5 years after surgery. After multiple falls, the L5-S1 cage is about 60% extruded. The surprising part is that the patient has remained practically completely asymptomatic since surgery.

The main new variable here is the repeated trauma from the falls. Even so, I do not feel comfortable leaving the cage in this position, and I am leaning toward revision despite the absence of symptoms over the last year and a half.

Cases like this force us to ask a difficult question, when imaging looks unacceptable but the patient is doing well, how much weight should we give the picture alone?

I would genuinely appreciate the opinion of colleagues on this. Would you observe, or would you revise?