Recovery Related to Vocalization and Swallowing After Tracheostomy

Tracheostomy refers to a surgical incision created in the neck to allow direct air entry into the trachea bypassing the upper respiratory tract including the oral and nasal cavities. Normal vocalization and swallowing are limited immediately postoperatively; however, gradual recovery of vocalization and swallowing function can be initiated, following improvement in the causative condition that necessitated the tracheostomy. Duration of the tracheostomy depends upon the patient’s condition, and the degree of vocalization and swallowing function recovery after tracheostomy tube removal varies widely across patients. In this review, we investigated the changes associated with vocalization and swallowing function in patients who underwent tracheostomy and have discussed the various approaches and voice rehabilitation treatments to aid with normal recovery.

Gene Expression Analyses of Mutant Flammulina velutipes (Enokitake Mushroom) with Clogging Phenomenon

Regulation of proper gene expression is important for cellular and organismal survival, maintenance, and growth. Abnormal gene expression, even for a single critical gene, can thwart cellular integrity and normal physiology to cause diseases, aging, and death. Therefore, gene expression profiling serves as a powerful tool to understand the pathology of diseases and to cure them. In this study, the difference in gene expression in Flammulina velutipes was compared between the wild type (WT) mushroom and the mutant one with clogging phenomenon. Differentially expressed transcripts were screened to identify the candidate genes responsible for the mutant phenotype using the DNA microarray analysis. A total of 88 genes including 60 upregulated and 28 downregulated genes were validated using the realtime quantitative PCR analysis. In addition, proteomic differences between the WT and mutant mushroom were analyzed using two–dimensional gel electrophoresis and matrixassisted laser desorption/ionization-time of flight (MALDI-TOF). Interestingly, the genes identified by these genomic and proteomic analyses were involved in stress response, translation, and energy/sugar metabolism, including HSP70, elongation factor 2, and pyruvate kinase. Together, our data suggest that the aberrant expression of these genes attributes to the mutant clogging phenotype. We propose that these genes can be targeted to foster normal growth in F. velutipes.

2021 Korean Thyroid Imaging Reporting and Data System and Imaging-Based Management of Thyroid Nodules: Korean Society of Thyroid Radiology Consensus Statement and Recommendations

Incidental thyroid nodules are commonly detected on ultrasonography (US). This has contributed to the rapidly rising incidence of low-risk papillary thyroid carcinoma over the last 20 years. The appropriate diagnosis and management of these patients is based on the risk factors related to the patients as well as the thyroid nodules. The Korean Society of Thyroid Radiology (KSThR) published consensus recommendations for US-based management of thyroid nodules in 2011 and revised them in 2016. These guidelines have been used as the standard guidelines in Korea. However, recent advances in the diagnosis and management of thyroid nodules have necessitated the revision of the original recommendations. The task force of the KSThR has revised the Korean Thyroid Imaging Reporting and Data System and recommendations for US lexicon, biopsy criteria, US criteria of extrathyroidal extension, optimal thyroid computed tomography protocol, and US follow-up of thyroid nodules before and after biopsy. The biopsy criteria were revised to reduce unnecessary biopsies for benign nodules while maintaining an appropriate sensitivity for the detection of malignant tumors in small (1–2 cm) thyroid nodules. The goal of these recommendations is to provide the optimal scientific evidence and expert opinion consensus regarding US-based diagnosis and management of thyroid nodules.

Protocol for a Korean Multicenter Prospective Cohort Study of Active Surveillance or Surgery (KoMPASS) in Papillary Thyroid Microcarcinoma

Background@#A Korean Multicenter Prospective cohort study of Active Surveillance or Surgery (KoMPASS) for papillary thyroid microcarcinomas (PTMCs) has been initiated. The aim is to compare clinical outcomes between active surveillance (AS) and an immediate lobectomy for low-risk PTMCs. We here outline the detailed protocol for this study. @*Methods@#Adult patients with a cytopathologically confirmed PTMC sized 6.0 to 10.0 mm by ultrasound (US) will be included. Patients will be excluded if they have a suspicious extra-thyroidal extension or metastasis of a PTMC or multiple thyroid nodules or other thyroid diseases which require a total thyroidectomy. Printed material describing the prognosis of PTMCs, and the pros and cons of each management option, will be provided to eligible patients to select their preferred intervention. For the AS group, thyroid US, thyroid function, and quality of life (QoL) parameters will be monitored every 6 months during the first year, and then annually thereafter. Disease progression will be defined as a ≥3 mm increase in maximal diameter of a PTMC, or the development of new thyroid cancers or metastases. If progression is detected, patients should undergo appropriate surgery. For the lobectomy group, a lobectomy with prophylactic central neck dissection will be done within 6 months. After initial surgery, thyroid US, thyroid function, serum thyroglobulin (Tg), anti-Tg antibody, and QoL parameters will be monitored every 6 months during the first year and annually thereafter. Disease progression will be defined in these cases as the development of new thyroid cancers or metastases. @*Conclusion@#KoMPASS findings will help to confirm the role of AS, and develop individualized management strategies, for low-risk PTMCs.

Protocol for a Korean Multicenter Prospective Cohort Study of Active Surveillance or Surgery (KoMPASS) in Papillary Thyroid Microcarcinoma

Background@#A Korean Multicenter Prospective cohort study of Active Surveillance or Surgery (KoMPASS) for papillary thyroid microcarcinomas (PTMCs) has been initiated. The aim is to compare clinical outcomes between active surveillance (AS) and an immediate lobectomy for low-risk PTMCs. We here outline the detailed protocol for this study. @*Methods@#Adult patients with a cytopathologically confirmed PTMC sized 6.0 to 10.0 mm by ultrasound (US) will be included. Patients will be excluded if they have a suspicious extra-thyroidal extension or metastasis of a PTMC or multiple thyroid nodules or other thyroid diseases which require a total thyroidectomy. Printed material describing the prognosis of PTMCs, and the pros and cons of each management option, will be provided to eligible patients to select their preferred intervention. For the AS group, thyroid US, thyroid function, and quality of life (QoL) parameters will be monitored every 6 months during the first year, and then annually thereafter. Disease progression will be defined as a ≥3 mm increase in maximal diameter of a PTMC, or the development of new thyroid cancers or metastases. If progression is detected, patients should undergo appropriate surgery. For the lobectomy group, a lobectomy with prophylactic central neck dissection will be done within 6 months. After initial surgery, thyroid US, thyroid function, serum thyroglobulin (Tg), anti-Tg antibody, and QoL parameters will be monitored every 6 months during the first year and annually thereafter. Disease progression will be defined in these cases as the development of new thyroid cancers or metastases. @*Conclusion@#KoMPASS findings will help to confirm the role of AS, and develop individualized management strategies, for low-risk PTMCs.

Comparison of the diagnostic performance of the modified Korean Thyroid Imaging Reporting and Data System for thyroid malignancy with three international guidelines

Purpose@#This study compared the diagnostic performance of the modified Korean Thyroid Imaging Reporting and Data System (K-TIRADS) for thyroid malignancy with three international guidelines. @*Methods@#From June to September 2015, 5,708 thyroid nodules (≥1.0 cm) in 5,081 consecutive patients who underwent thyroid ultrasound (US) at 26 institutions were evaluated. The US features of the thyroid nodules were retrospectively reviewed and classified according to all four guidelines. In the modified K-TIRADS, the biopsy size threshold was changed to 2.0 cm for K-TIRADS 3 and 1.0 or 1.5 cm for K-TIRADS 4 (K-TIRADS1.0cm and K-TIRADS1.5cm, respectively). We compared the diagnostic performance and unnecessary fine-needle aspiration biopsy (FNAB) rates for thyroid malignancy between the modified K-TIRADS and three international guidelines. @*Results@#Of the 5,708 thyroid nodules, 4,597 (80.5%) were benign and 1,111 (19.5%) were malignant. The overall sensitivity was highest for the modified K-TIRADS1.0cm (91.0%), followed by the European (EU)-TIRADS (84.6%), American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi (AACE/ACE/AME) (80.5%), American College of Radiology (ACR)-TIRADS (76.1%), and modified K-TIRADS1.5cm (76.1%). For large nodules (>2.0 cm), the sensitivity increased to 98.0% in both the modified K-TIRADS1.0cm and K-TIRADS1.5cm. For small nodules (≤2.0 cm), the unnecessary FNAB rate was lowest with the modified K-TIRADS1.5cm (17.6%), followed by the ACR-TIRADS (18.6%), AACE/ACE/AME (19.3%), EU-TIRADS (28.1%), and modified K-TIRADS1.0cm (31.2%). @*Conclusion@#The modified K-TIRADS1.5cm can reduce the unnecessary FNAB rate for small nodules (1.0-2.0 cm), while maintaining high sensitivity for detecting malignancies >2.0 cm.

The Effect of Voice Therapy Applying Self-Regulation Concepts on Dysphonia Patients

BACKGROUND AND OBJECTIVES: The goal of this study is to present a strategy for improving the self-regulation (SR) ability and facilitating the change of vocal behavior by applying voice therapy using the SR concept to the patients with vocal cord nodule and muscle tension dysphonia. MATERIALS AND METHOD: The subjects were 80 patients and 80 patients who were diagnosed with muscle tension dysphonia and vocal nodules. As a control group, the results were compared among patients with the same dysphonia without using SR strategies. The concept of SR before voice therapy was explained to the patients, and the treatment was divided into three stages according to the goal of voice therapy. The treatment stages consist of 1) skill acquisition, 2) habit formation, and 3) habit changes. voice therapy was performed by applying SR strategies such as goal implementation intentions and a less routine behavior. Patient's dropout rates were measured to compare the adherence of voice therapy. RESULTS: Significant improvement was seen in all groups receiving voice therapy. However, in the group using the SR strategy, the voice analysis results showed a relatively low dropout rate of voice therapy. In the generalization confirmation stage, patients who applied SR concept showed better results. SR strategy did no longer be necessary to maintain newly adopted vocal behavior. CONCLUSION: The results of this study show that SR is one of the cognitive factors that can have a significant impact on the outcome of voice therapy, and also has a positive impact on the acquisition and generalization of new skills. A better understanding of SR and the development of therapeutic strategies using it will play an important role in solving voice problems in clinical settings.

2017 Thyroid Radiofrequency Ablation Guideline: Korean Society of Thyroid Radiology

Thermal ablation using radiofrequency is a new, minimally invasive modality employed as an alternative to surgery in patients with benign thyroid nodules and recurrent thyroid cancers. The Task Force Committee of the Korean Society of Thyroid Radiology (KSThR) developed recommendations for the optimal use of radiofrequency ablation for thyroid tumors in 2012. As new meaningful evidences have accumulated, KSThR decided to revise the guidelines. The revised guideline is based on a comprehensive analysis of the current literature and expert consensus.

Study Protocol of Multicenter Prospective Cohort Study of Active Surveillance on Papillary Thyroid Microcarcinoma (MAeSTro)

BACKGROUND: The ongoing Multicenter Prospective Cohort Study of Active Surveillance on Papillary Thyroid Microcarcinoma (MAeSTro) aims to observe the natural course of papillary thyroid microcarcinoma (PTMC), develop a protocol for active surveillance (AS), and compare the long-term prognosis, quality of life, and medical costs between the AS and immediate surgery groups. METHODS: This multicenter prospective cohort study of PTMC started in June 2016. The inclusion criteria were suspicious of malignancy or malignancy based on fine needle aspiration or core needle biopsy, age of ≥18 years, and a maximum diameter of ≤1 cm. If there was no major organ involvement, no lymph node/distant metastasis, and no variants with poor prognosis, the patients were explained of the pros and cons of immediate surgery and AS before selecting AS or immediate surgery. Follow-up visits (physical examination, ultrasonography, thyroid function, and questionnaires) are scheduled every 6 months during the first 2 years, and then every 1 year thereafter. Progression was defined as a maximum diameter increase of ≥3, ≥2 mm in two dimensions, suspected organ involvement, or lymph node/distant metastasis. RESULTS: Among 439 enrolled patients, 290 patients (66.1%) chose AS and 149 patients (33.9%) chose immediate surgery. The median follow-up was 6.7 months (range, 0.2 to 11.9). The immediate surgery group had a larger maximum tumor diameter, compared to the AS group (7.1±1.9 mm vs. 6.6±2.0 mm, respectively; P=0.014). CONCLUSION: The results will be useful for developing an appropriate PTMC treatment policy based on its natural course and risk factors for progression.

Aerodynamic Evaluation of Voice Changes in Thyroid Surgery Extent

BACKGROUND AND OBJECTIVES: The purpose of this study was to evaluate the impact of surgical extent on voice using acoustic and aerodynamic measurements in a serially followed thyroidectomy patients. MATERIALS AND METHOD: From October 2015 to January 2017, 108 patients who had undergone thyroid surgery and voice test for preoperative, 2, 3, and 6 months postoperatively were classified into five operative types. The radiological stage preoperatively and histopathological stage postoperatively were classified according to the invasion of thyroid capsule and surrounding tissue. For each classification, the results of the voice analysis according to the period were compared and analyzed. RESULTS: The difference of voice according to surgical extent, radiological stage, and histopathologic stage showed significant difference only with Maximal phonation time (MPT) over time. However, in the analysis of interaction between each classification and period, Phonation threshold pressure (PTP) only showed significant results. CONCLUSION: Differences in imaging and histopathologic stages have no significant effect on recovery of voice symptoms after thyroid surgery. As the extent of operation increases, the pressure to start vocalization is relatively higher, which also varies with time after surgery.

Corrigendum: Study Protocol of Multicenter Prospective Cohort Study of Active Surveillance on Papillary Thyroid Microcarcinoma (MAeSTro)

No abstract available.

Effects of Injection Laryngoplasty with Hyaluronic Acid in Patients with Vocal Fold Paralysis

OBJECTIVES: The purpose of this study was to explore the effects of injection laryngoplasty (IL) with hyaluronic acid in patients with vocal fold paralysis (VFP). METHODS: A total of 50 patients with VFP participated in this study. Pre- and post-IL assessments were performed, which included analyzing the sustained vowel /a/ phonation, and the patient reading 1 Korean sentence from the “Walk” passage that comprised 25 syllables in 10 words. To investigate the effect of IL on vocal fold function, acoustic analysis (acoustic voice quality index, cepstral peak prominence, maximum phonation time, speaking fundamental frequency) was conducted and auditory-perceptual (grade and overall severity), visual judgment (gap), and self-questionnaire (voice handicap index-10) assessments were performed. RESULTS: The patients with VFP showed statistically significant differences between pre-and post-IL assessments for acoustic and auditory-perception, visual judgment, and self-questionnaire assessments. CONCLUSION: The patients with VFP showed positive change in vocal fold function between pre- and post-IL measurements. The findings showed that IL with hyaluronic acid is an effective method to improve vocal fold function in patients with VFP.

Usefulness of Cepstral Peak Prominence (CPP) in Unilateral Vocal Fold Paralysis Dysphonia Evaluation

BACKGROUND AND OBJECTIVES: The purpose of this study was to compare the usefulness of Cepstral peak prominence (CPP) with parameter of Multiple Dimensional Voice Program (MDVP) in evaluating unilateral vocal fold paraylsis patients with subjective voice impairment. MATERIALS AND METHODS: From July 2014 to August 2016, 37 patients with unilateral vocal fold paralysis who had been diagnosed with unilateral vocal fold paralysis and had received two or more voice tests before and after the diagnosis were evaluated for maximum phonation time (MPT), MDVP and CPP. Respectively. Voice tests were performed with short vowel /a/ and paragraph reading. RESULTS: The CPP-a (CPP with vowel /a/) and CPP-s (CPP with paragraph reading) of the Cepstrum were statistically negatively correlated with G, R, B, and A before the voice therapy. Jitter, Shimmer, and NHR of MDVP were positively correlated with G, R, B. Jitter, Shimmer, and NHR of the MDVP were significantly correlated with the Cepstrum index. G, B, A and CPP-a and CPP-s showed a statistically significant negative correlation and a somewhat higher correlation coefficient between 0.5 and 0.78. On the other hand, in MDVP index, there was a positive correlation with G and B only with Jitter of 0.4. CONCLUSION: CPP can be an important evaluation tool in the evaluation of speech in the unilateral vocal cord paralysis when speech energy changes or the cycle is not constant during speech.

Comparison of Initial Therapeutic Effects of Voice Therapy and Injection Laryngoplasty for Unilateral Vocal Cord Paralysis Patients

BACKGROUND AND OBJECTIVES: The purpose of this study was to classify patients with unilateral vocal fold paralysis according to their fixed location and to analysis the effects of two treatment methods by early voice therapy and injection laryngoplasty. MATERIALS AND METHODS: Twenty patients who were classified as full abduction and slight abduction according to the position of paralysis were treated injection laryngoplasy, and 23 patients were treated by voice therapy. Twenty patients were treated injection laryngoplasy and 23 patients were treated voice therapy. Results were evaluated by acoustic analysis, electroglottography, cepstrum analysis before and after therapy. The voice therapy was conducted by improving the larynx movement and glottal contact, whilst removing hypertension of the supraglottic and use the breathing. RESULTS: Significant improvement was found in the acoustic parameter, cepstrum parameter, and EGG before and after treatment in both groups. There was no significant difference between the two groups when compared before and after treatment to compare the effects of injection laryngoplasty and voice therapy. CONCLUSION: The initial treatments for unilateral vocal cord paralysis are injection laryngoplasty and voice therapy. however, there is no precise standard about which method should be applied first. Therefore, in this study, we tried to classify patients according to their paralysis position and then apply two methods. The results of this study suggest that voice therapy and Injection laryngoplasty at the initial stage is a very useful method to improve voice quality of vocal fold paralysis and improve laryngeal function.

The Effect of Voice Therapy in Unilateral Vocal Fold Paralysis

BACKGROUND AND OBJECTIVES: This study aims to conduct post-voice therapy to patients with unilateral vocal fold paralysis for vocal improvement, motility recovery and analyze the results. MATERIALS AND METHODS: Voice therapy was conducted to 13 patients who had shown response to voice therapy amongst 98 patients diagnosed with unilateral vocal fold paralysis. In order to be able compare before and after perceptual, acoustic and aerodynamic evaluations were conducted after voice therapy. Also, by using dysphagia checklist, we have verified whether if the patient had dysphagia prior to voice therapy. The therapy was conducted by improving the larynx movement and glottal contact, whilst removing hypertension of the supraglottic. RESULTS: All 13 patients who underwent voice therapy had shown improvements that are statistically significant from 4 scales excluding the S scale from auditory perception evaluation (p<0.05), with enhanced glottal contact. In acoustic evaluation, Jitter, Shimmer and NHR had shown significant improvement after voice therapy. MPT was also notably improved among aerodynamical evaluation (p<0.001). All 11 patients had with dysphagia prior to voice therapy reported to have improved swallowing functions. CONCLUSION: Application of adequate voice therapy to patients with unilateral vocal fold paralysis, is an effective method that might be employed in the initial phase. Especially, the voice therapy proposed in this study is expected to be useful for patients in hypertension status due to secondary compensation after initial paralysis, since it focuses on improving vocal symptoms in a calm state with the supraglottis sufficiently relaxed. Also, the therapy is expected to be effective for improving swallowing functions.

Ultrasonography Diagnosis and Imaging-Based Management of Thyroid Nodules: Revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations

The rate of detection of thyroid nodules and carcinomas has increased with the widespread use of ultrasonography (US), which is the mainstay for the detection and risk stratification of thyroid nodules as well as for providing guidance for their biopsy and nonsurgical treatment. The Korean Society of Thyroid Radiology (KSThR) published their first recommendations for the US-based diagnosis and management of thyroid nodules in 2011. These recommendations have been used as the standard guidelines for the past several years in Korea. Lately, the application of US has been further emphasized for the personalized management of patients with thyroid nodules. The Task Force on Thyroid Nodules of the KSThR has revised the recommendations for the ultrasound diagnosis and imaging-based management of thyroid nodules. The review and recommendations in this report have been based on a comprehensive analysis of the current literature and the consensus of experts.

Reproductive and Hormonal Factors Associated with Fatty or Dense Breast Patterns among Korean Women / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Dense breasts have been suggested as a risk factor for breast cancer, but controversy still remains. This study evaluates the association of reproductive and hormonal factors with dense breasts among Korean women. MATERIALS AND METHODS: Using a cross-sectional design, 516 women were recruited and classified for breast density patterns as being either fatty or dense, using the Breast Imaging Reporting and Data System (BI-RADS) of the American College of Radiology. Univariate and multivariate logistic regression models were used for statistical analysis. RESULTS: In univariate logistic regression, older age, higher body mass index, older age at menarche, and oral contraceptive use were associated with more fatty breasts. On the contrary, longer duration of education, alcohol consumption, lower parity, menopause and use of hormone replacement therapy were associated with dense breasts. After adjustment, age and body mass index were inversely associated with breast density (p-value for trend or =2 children, nulliparous women had an 11.8-fold increase of dense breasts (p-value for trend <0.01). Compared to postmenopausal women, premenopausal women had 2.4-fold increase of dense breasts (odds ratio, 2.42; 95% confidence interval, 1.36 to 4.32). CONCLUSION: Young age, lower body mass index, lower parity, and premenopausal status were significantly associated with dense breasts in Korea.

Added Value of Screening Low Dose Computed Tomography of the Chest for the Evaluation of Abdominal Solid Organs by Ultrasound in Physical Check-up Patients

PURPOSE: The purpose of this study was to assess the added value of screening low-dose computed tomography of the chest (LDCT) covering the abdomen in evaluating abdominal solid organs to the screening abdominal ultrasonography (US). MATERIALS AND METHODS: We prospectively enrolled a consecutive series of 393 physical check-up patients, who underwent screening abdominal US and LDCT of the chest from January to February, 2008. LDCT covered the lungs, liver, pancreas, gallbladder, spleen, and both kidneys. The 1st screening abdominal US were performed without information from the LDCT, and then abdominal images covered by LDCT were immediately evaluated. Then a 2nd US session was done with additional information from LDCT and US examination was focused to the findings of LDCT. Perpatient and per-lesion analyses were performed. RESULTS: In per-patient analysis, additional focal lesions were found in 20 patients (5.1%) for liver and 9 patients (2.3%) for kidneys in the 2nd US sessions. In per-lesion analysis, 154 and 73 focal lesions were found in liver and kidneys, respectively, in the 1st US sessions. On the 2nd US session, 186 and 86 lesions were found in liver and kidneys, respectively. 20.8% and 17.8% of focal lesions were additionally found on 2nd US session in liver and kidneys, respectively. Most (62.5%) of the additional lesions detected in liver were located in segment 7 and 8, the hepatic dome. CONCLUSION: Previewing LDCT of the chest and abdominal solid organs before performing screening abdominal US can enhance the diagnostic performance of US in physical check-up patients.

US Diagnosis of Sparganosis Within the Thigh: Case Report

Sparganosis is an uncommon infection caused by sparganum, a migrating plerocercoid larva. Currently, various imaging modalities have been actively used for the diagnosis of sparganosis before surgery. We present a case of sparganosis arising in the subcutaneous layer of the thigh that was diagnosed only by an ultrasound examination.

Tuberculous Spondylitis vs Pyogenic Spondylitis: Focusing on the Discriminative MR Findings for Differentiation

PURPOSE: The purpose of this study is to analyze the most discriminative MR findings for making the differential diagnosis of tuberculous and pyogenic spondylitis. MATERIALS AND METHODS: Sixty MR scans of 18 pyogenic spondylitis patients and 42 tuberculous spondylitis patients were retrospectively reviewed. The statistical analysis was performed using stepwise discriminant analysis and Student's T-test. RESULTS: The patients with tuberculous spondylitis had a significantly higher incidence of MRI findings as follows (p <0.05): smooth margin of a paraspinal mass/abscess in 67% [28/42] of the tuberculous spondylitis patients vs 6% [1/18] in the pyogenic spondylitis patients, mild endplate erosion in 52% [22/42] vs 38% [7/18], respectively, the presence of paraspinal mass/abscess in 100% [42/42] vs 6% [1/18], respectively, central dark signal intensity of the abscess in 86% [36/42] vs 39% [7/18]), respectively, subligamentous spread in 81% [34/42] vs 50% [9/18]), respectively, severe vertebral collapse in 20% [8/42] vs 11% [2/18]), respectively, and posterior extension in 62% [26/42] vs 33% [6/18]), respectively. Among of them, the significant discriminative MR findings were the margin of a paraspinal mass, the grade of endplate erosion and the presence or absence of a paraspinal mass in that order. CONCLUSION: In the differentiation of tuberculous and pyogenic spondylitis, the margin of the paraspinal mass, the grade of endplate erosion and the presence or absence of a paraspinal mass are the most three discriminating MR findings in that order.