Comparison of MRI and Discography in Disc Extrusion: Low Signal Intensity Change in the Anterior Epidural Space at Sagittal T1-weighted Imaging

PURPOSE: To determine the significance of low signal intensity change in the anterior epidural space at sagittal T1-weighted (ST1WI) magnetic resonance imaging (MRI) of patients in whom discography revealed disc extrusion, and to correlate interruption of the solid dark line seen at sagittal T2-weighted imaging (ST2WI) with discographic findings of extrusion. MATERIALS AND METHODS: One hundred and forty-two patients (159 cases) with lumbar disc disease proven at MRI underwent discography. Disc extrusion was diagnosed in cases in which contrast media leaked into the anterior epidural space. The findings of ST1WI were used to determine whether low signal intensity change had occurred in the anterior epidural space between the posterior aspect of the vertebral body and the posterior longitudinal ligament, and whether ST2WI depicted interruption of the solid dark line at the posterior aspect of the disc was also assessed. RESULTS: At discography, disc extrusion was diagnosed in 134 of 159 cases. At ST1WI, low signal intensity change was noted in 75 (56%) of the 134 cases, and at ST2WI interruption of the solid dark line was observed in 63 (47%). In the remaining 25 cases, there was no evidence of disc extrusion, and at ST2WI the solid dark line was well-preserved. At ST1WI, 22 (88%) of 25 cases showed normal signal intensity in the anterior epidural space, but in the remaining three, low signal intensity change was evident. Correlation between the findings of MRI and discography was statistically significant. CONCLUSION: In disc disease, low signal intensity change at ST1WI, as well as interruption of the solid dark line seen at ST2WI, are useful indicators of disc extrusion.

Transcatheter Ovarian Vein Embolization for Pelvic Congestion Syndrome: Short-Term Outcome

PURPOSE: To evaluate the short-term therapeutic effectiveness of ovarian vein embolization using coils for pelvic congestion syndrome (PCS), a common cause of chronic pelvic pain, and to determine patient satisfaction. MATERIALS AND METHODS: Forty-four multiparous women aged 26-73 (mean, 39.9) years in whom chronic pelvic pain due to unknown causes had lasted for more than six months, and whose gynecologic findings and laboratory data suggested PCS, underwent transabdominal or transvaginal ultrasonography and selective ovarian venography. PSC was finally diagnosed in 21 of th 44, who underwent 22 ovarian vein embolizations (in one case, bilaterally). The simple pain rating system was used at admission, with a 'minimal' or 'moderate' grade representing discomfort in daily life, and 'severe' indicating the need for medication. Indications for coil embolization included dilatation of the ovarian vein to a diameter of more than 6 mm, reflux involving an incompetent valve, congestion of the pelvic venous plexus (involving the stasis of contrast media), and/or opacification of the ipsilateral internal iliac vein (or contralateral filling). Embolizations were undertaken using coils of optimal size and number, and the mean follow-up period was 217 (31-267) days. By means of a telephone questionnaire, the outcome was classified as a cure, pain reduction, or 'no change, or aggravation', and on the basis of whether or not they would opt for the same treatment, or recommend embolization to others, patient satisfaction was graded as 'substantial', 'moderate', or 'absent. RESULTS: Venous occlusion was confimed at postembolization venography in all 22 cases. Clinical treatment led to symptomatic relief in 76.2% of patients a cure in 33.3% (7/21), pain reduction in 42.9% (9/21) and no imchange, or aggravation, in 23.8% (5/21). Eighteen patients (85.8%) were very (9/21, 42.9%) or moderately (9/21, 42.9%) satisfied with coil embolization. In two, the coil migrated, and was successfully retrieved using a snare loop. CONCLUSION: In this study, ovarian vein embolization using coils for PCS appeared to be both safe and effective in controlling pain. If other causes of pelvic pain are absent, it is thought to be a valuable alternative to surgical procedures.

Laparoscopic Interbody Fusion in Degenerative Disc Disease of the Lumbosacral Spine

OBJECTIVE: The surgical treatment of symptomatic degenerative disc disease remains one of the most controversial topics among spine surgeons. Recently, advances in many endoscopic surgical techniques have resulted in lowered morbidity, expense, and suffering associated with their open surgery counterparts. The purpose of this study is to evaluate the efficacy of laparoscopic anterior lumbosacral interbody fusion in our patients with symptomatic degenerative disc disease. PATIENTS AND METHODS: We performed laparoscopic anterior interbody fusion for degenerative disc disease at L5-S1 in 26 patients who were unresponsive to conservative treatments for 1 year, from Oct. 1996 to Dec. 1997. This technique consists of a four-puncture laparoscopic approach with a 10mm trocar at the umbilicus for laparoscope, two 5mm trocars at left and right flanks for dissection, and a 15mm trocar at suprapubic area for working port. We performed complete discectomy and stabilized the spine with carbon interbody fusion cages filled with allograft bone. RESULTS: Laparoscopic fusion at L5-S1 was successful in 22 of 26 patients and the remaining four patients were successfully converted to minilaparotomy. The operation time averaged 150 minutes, hospitalization 4.1 days and average blood loss was 90cc. The mean follow-up period was 16.8 months. Radiographic fusion was achieved in 23 of 26 patients(88.5%) and clinical results showed excellent in 11/26, good in 11/26, fair in 3/26, poor in 1/26 according to Macnab's criteria. There were four complications; retroplacement of cages(1), transient dry ejaculation (1), transient urinary bladder dysfunction(1) and malposition of cages(1). CONCLUSION: Laparoscopic fusion at L5-S1 in degenerative disc disease seems to be safe, with satisfactory clinical results. Main advantage are early recovery and short hospitalization time compared with conventional technique.

Normal Apical Pleural Tenting: CT Findings

PURPOSE: To define the anatomy of apical pleural tenting commonly seen in computed tomography(CT) of the upper posterior thorax. MATERIALS & METHODS: Chest CTs of 393 patients with no pleural disease clinically and radiographically were analyzed. GE-9800 Quick and Toshiba-900S were used, employing the usual contrast enhanced CTtechnique. CT findings of focal pleural tenting on the inner side of the upper posterior thorax(apical pleural tenting) were evalvated and analysed in terms of location and shape. The CT findings were compared with the gross findings of the inner aspect of the posterior cadaveric thorax. RESULTS: Apical pleural tenting was formed by the upper border of the subcostal muscle. It's incidence was 44%(n=171), with bilaterality in 29%(n=49), and unilaterality in 71% of cases(n=122). This tenting was most frequently found between the third rib and the fourth intercostal space(81%), and seen in the outer third(42%) or central third(41%) part of the posterior costalpleura. In fifteen cases(7%), it was directed obliquely and had changed its location from the inner to the centralor the central to the outer part. The shapes of the tenting were classified as follows : type 1(convex innerborder with sharp apex, 62%) ; type 2(convex inner border with broad apex, 23%) ; type 3(undulated contour ofapex, 13%) ; and type 4(two-spike apices, 1%). CONCLUSION: Apical pleura tenting is a normal CT finding probably demonstrated by the upper border of the subcostal muscle. Misdiagnosis of pleural disease can be avoided by recognition of the location and type of this tenting.

CT Findings of Neck Lymphoma:Significance of Central Low Attenuation and Differentiation of Non-Hodgkin's Lymphoma from Hodgkin's Disease

PURPOSE: Lymphoma is considered when multiple, nonnecrotic lymph nodes are present in the superficial and deep lymphatic chains, especially if they are large and bilateral, on CT scan. It is reported that combined nodal and extranodal presentation of HD is uncommon. However, we found central low density in involved lymph node of NHL, and combined nodal and extranodal disease in HD, not infrequently. The purpose of this study is to ascertain whether our findings may be characteristics of NHL and HD. MATERIALS AND METHODS: CT findings with contrast enhancement were reviewed in 23 patients with untreated neck lymphoma:18 NHL and 5 HD. The followings were analyzed in each case: nodal or extranodal involvement; unilateral or bilateral involvement; presence or absence of central low density with peripheral enhancement in nodal lesion ;infiltration into adjacent structures. Nodal and extranodal lesions were confirmed by pathologic studies. RESULTS: Of 18 patients with NHL, nine cases had nodal disease and the rest had combined nodal and extranodal disease. Lymphadenopathy was bilateral in ten cases and unilateral in eight. Five cases with HD were composed of three combined nodal and extranodal diseases and two nodal diseases. Central low density of involved lymph node was shown in eight cases of 18 NHL and in one case of five HD. CONCLUSION: Central low density with peripheral enhancement was not uncommon in NHL, in contrast to HD. Hence, it is suggested that in case of nodal necrosis, NHL be also considered, besides tuberculous lymphadenitis and metastatic lymphadenopathy. It is not considered that nodal or extranodal disease, and unilateral or bilateral involvement are of high significance in differentiation of NHL from HD.

Sonographic-Pathologic Correlation of Gallbladder Adenoma: Adenoma versus Adenoma with Dysplasia

PURPOSE: To correlate SOhographic and pathologic findings of gallbladder adenoma, and to evaluate the clinical significance of sonographic findings. MATERIALS AND METHODS: Ultrasound findings of twenty gallbladder adenomas were retrospectively reviewed to evaluate the size, shape and echogenicity of the adenoma, and was correlated with the pathological finding. RESULTS: Among 14 patients, 11 patients had single lesion and 3 patients had multiple lesions. Three patients showed 2, 3 and 4 adenomas, respectively. Nine of 20 lesions showed focal dysplasia pathologically. Among the nine adenomas with dysplasia, two adenomas showed focal cancerous change. The nine adenomas showing focal dysplasia measured 25.6mm (14-35mm) in mean diameter, while the mean diameter of adenomas without dysplasia was 8.7 mm (3-13mm). The echogenicity of adenoma with focal dysplasia were hyperechoic in 8, isoechoic in 1. The echogenicity of adenomas without dysplasia were hyperechoic in 7, isoechoic in 4. Sessile(7/9) and papillary shape(6/9) were predominant in adenoma with dysplasia, but smooth shape(8/11) and stalked type(9/11) were predominant in adenoma without dysplasia. Two adenomas with focal cancerous change showed histological transition from cancer to dysplasia and to adenomatous tissue. In adenoma with dysplasia, the diameter more than 14 mm on sonography was statistically significant (p<0. 005). Also age of patient was significantly different between the two groups (p<0.01), while echogenicity and associated stone were not statistically significant. CONCLUSION: As gallbladder adenoma more than 14ram in diameter on US is suggestive of dysplasia on pathology, so, close follow up US or surgery is recommended.

Combined Effect of Angioinfarction with Immunotherapy in Patients with Stage IV Renal Cell Carcinoma

PURPOSE: To assess the combined effectiveness of angioinfarction and immunotherapy for improving survival in patients with stage IV renal cell carcinoma. MATERIALS AND METHODS:During the past 3 years, 13 patients of stage IV renal cell carcinoma were treated with angioinfarction and immunotherapy. Angioinfarction was performed on these 13 patients using absolute ethanol and occlusive baloon catheter. After angioinfarction, Interferon alpha was used for immunotherapy. For our analysis, 12 control patients of stage IV renal cell carcinoma without treatment were included in the study. Survival has been calculated according to the Kaplan and Meier method. RESULTS: The 1 year survival rate and median survival time in patients treated with angioinfarction and immunotherapy, were 46% and 13 months and in patients without treatment, 16% and 4 months, respectively. CONCLUSION:The combined treatment of angioinfarction and immunotherapy is of considerable value for improving survival in patients with stage IV renal cell carcinoma

Recurrent pyogenic cholangitis: The pattern of thickening of the extrahepatic bile duct on CT

The pattern of thickening of the extrahepatic bile duct on computed tomography was analysed in 30 cases with recurrent pyogenic cholangitis diagnosed by surgery (n=19) or clinical basis (n=11). The mean wall thickness of the extrahepatic bile duct was 3.3mm (range, 1-6.3mm). Diffuse thickening of the extrahepatic bile ductal wall was demonstrated in 26 of 30 cases. Diffuse thickening of the extrahepatic bile duct in recurrent pyogenic cholangitis may be differentiated from focal thickening of duct in a common duct cancer or pancreatic cancer.

Recurrent pyogenic cholangitis: The pattern of thickening of the extrahepatic bile duct on CT

The pattern of thickening of the extrahepatic bile duct on computed tomography was analysed in 30 cases with recurrent pyogenic cholangitis diagnosed by surgery (n=19) or clinical basis (n=11). The mean wall thickness of the extrahepatic bile duct was 3.3mm (range, 1-6.3mm). Diffuse thickening of the extrahepatic bile ductal wall was demonstrated in 26 of 30 cases. Diffuse thickening of the extrahepatic bile duct in recurrent pyogenic cholangitis may be differentiated from focal thickening of duct in a common duct cancer or pancreatic cancer.