Computed Tomography Fluoroscopy-Guided Selective Nerve Root Block for Acute Cervical Disc Herniation

OBJECTIVE: To analyze the clinical outcomes of computed tomography (CT) fluoroscopy-guided selective nerve root block (SNRB) for severe arm pain caused by acute cervical disc herniation. METHODS: The authors analyzed the data obtained from 25 consecutive patients who underwent CT fluoroscopy-guided SNRB for severe arm pain, i.e., a visual analogue scale (VAS) score of 8 points or more, caused by acute soft cervical disc herniation. Patients with chronic arm pain, motor weakness, and/or hard disc herniation were excluded. RESULTS: The series comprised 19 men and 6 women whose mean age was 48.1 years (range 35-72 years). The mean symptom duration was 17.5 days (range 4-56 days) and the treated level was at C5-6 in 13 patients, C6-7 in 9, and both C5-6 and C6-7 in 3. Twenty-three patients underwent SNRB in 1 session and 2 underwent the procedure in 2 sessions. No complications related to the procedures occurred. At a mean follow-up duration of 11.5 months (range 6-22 months), the mean VAS score and NDI significantly improved from 9 and 58.2 to 3.4 and 28.1, respectively. Eighteen out of 25 patients (72%) showed successful clinical results. Seven patients (28%) did not improve after the procedure, and 5 of these 7 underwent subsequent anterior cervical discectomy and fusion. CONCLUSION: CT fluoroscopy-guided SNRB may play a role as a primary conservative treatment for severe arm pain caused by acute cervical disc herniation.

CT Findings of Swyer-James-MacLeod Syndrome in Adults: Are There Any Different Findings with Aging?

PURPOSE: We wanted to evaluate whether there is any different finding on CT with aging for the patients suffering with adult Swyer-James-MacLeod Syndrome (SJMS). MATERIALS AND METHODS: We included 11 patients (7 males and 4 females) who underwent chest CT scan among 18 patients who were suspected of suffering with SJMS on chest radiographs. The range of age was from 28 to 85 years (mean: 58.5). We evaluated the diameter of both the main pulmonary artery (MPA) with its ratio, and the diameter of the pulmonary trunk (PT) to evaluate the possibility of pulmonary arterial hypertension, and the presence or absence of bronchiectasis. We also evaluated the relationships between these findings and aging. RESULTS: SJMS affected the left lung in 10 of 11 patients. The mean diameter of the main pulmonary artery of the normal lung was 2.5 cm and it was 1.6 cm in the involved site. The mean ratio of the normal MPA diameter to the involved one was 1.6 and this did not correlate with age (p>0.1). The mean diameter of the pulmonary trunk was 2.8 cm and this increased with age (p0.5). CONCLUSION: SJMS absolutely affected the left lung much more than the right lung. All the patients demonstrated about 1.6 times the compensatory hypertrophy of MPA of the normal lung compared with that of the affected lung on chest CT, which was irrespective of age. The presence or absence of bronchiectasis has no correlation with age.

Naviculo-Medial Cuneiform Coalition: Radiological Features

PURPOSE: To define the radiological features of the naviculo-medial cuneiform coalition. MATERIALS AND METHODS: This study examined 35 feet from 25 patients (mean age 26 years) with a naviculo-medial cuneiform coalition. The images were analyzed retrospectively with regard to irregular articular surface, subchondral sclerosis, subchondral cyst, beak-like spur, the change in joint space, bony fusion seen on plain radiographs (n=35) and CT (n=14), and the histological type of coalition on MRI (n=3). The extent of joint involvement was also evaluated. RESULTS: Of the 35 feet, plain radiographs and/or CT showed an irregular articular surface in 34 (97.1%), subchondral sclerosis in 30 (85.7%), a subchondral cyst in 29 (82.9%), a beak-like spur in 23 (65.7%), a narrowing of the joint space in 24 (68.6%) and no bony fusions (0%). The T1-weighted images revealed low signal intensity, and the T2-weighted fast spin-echo and gradient images revealed high signal intensity in the three feet with a cartilaginous coalition. The coalition involved the plantar part of the joint in all 35 feet. CONCLUSION: The characteristic radiological features of a naviculo-medial cuneiform coalition include an irregular articular surface with possible secondary degenerative changes in the plantar margin of the joint, non-osseous type.

Non-Contiguous Spinal Injury in Cervical Spinal Trauma: Evaluation with Cervical Spine MRI

OBJECTIVE: We wished to evaluate the incidence of non-contiguous spinal injury in the cervicothoracic junction (CTJ) or the upper thoracic spines on cervical spinal MR images in the patients with cervical spinal injuries. MATER AND METHODS: Seventy-five cervical spine MR imagings for acute cervical spinal injury were retrospectively reviewed (58 men and 17 women, mean age: 35.3, range: 18-81 years). They were divided into three groups based on the mechanism of injury; axial compression, hyperflexion or hyperextension injury, according to the findings on the MR and CT images. On cervical spine MR images, we evaluated the presence of non-contiguous spinal injury in the CTJ or upper thoracic spine with regard to the presence of marrow contusion or fracture, ligament injury, traumatic disc herniation and spinal cord injury. RESULTS: Twenty-one cases (28%) showed CTJ or upper thoracic spinal injuries (C7-T5) on cervical spinal MR images that were separated from the cervical spinal injuries. Seven of 21 cases revealed overt fractures in the CTJs or upper thoracic spines. Ligament injury in these regions was found in three cases. Traumatic disc herniation and spinal cord injury in these regions were shown in one and two cases, respectively. The incidence of the non-contiguous spinal injuries in CTJ or upper thoracic spines was higher in the axial compression injury group (35.3%) than in the hyperflexion injury group (26.9%) or the hyperextension (25%) injury group. However, there was no statistical significance (p > 0.05). CONCLUSION: Cervical spinal MR revealed non-contiguous CTJ or upper thoracic spinal injuries in 28% of the patients with cervical spinal injury. The mechanism of cervical spinal injury did not significantly affect the incidence of the non-contiguous CTJ or upper thoracic spinal injury.

The Diagnostic Usefulness of CT-guided Needle Biopsy or Aspiration in Infectious Spondylitis

PURPOSE: To determine the diagnostic value of CT-guided biopsy or aspiration of the spine and paraspinal soft tissue in infectious spondylitis. MATERIALS AND METHODS: Between January 2000 and June 2002, 58 patients underwent 67 biopsies and/or aspirations under CT guidance to identify the organism causing infectious spondylitis, and were included in this study. Nine underwent rebiopsy. In all patients, MR images were available before biopsy and/or aspiration. In 63 of 67 procedures, the specimens or aspirates obtained were prepared for culture and smear, and for histological examination, four procedures involved aspiration only. In ten patients with suspected tuberculosis, a polymerase chain reaction test was performed. For all procedures, the transpedicular, transcostovertebral or paravertebral route was involved, according to the level and shape of the lesions, and 14-, 16-, or 18-gauge core biopsy needles and/or 20-gauge aspiration needles were employed. Lesions invloved a paravertebral (n=17), psoas (n=8) or epidural (n=1) abscess; an intervertebral disc (n=20); or a vertebral body (n=21). The levels at the mid-thoracic spine were T4-T10 (n=11); at the thoracolumbar junction, T11-L1 (n=14); at the lumbar spine, L1-L4 (n=25); and at the lumbo-sacral junction, L5-S1 (n=17). In nine of 58 patients, rebiopsy was performed. RESULTS: Diagnosis was confirmed in 22 of 58 patients (38%), and was as follows: tuberculous spondylitis (n=17), pyogenic spondylitis (n=4), and fungal spondylitis (n=1). Thirty-six unconfirmed cases were diagnosed as nonspecific inflammation (n=21), fibrosis involving cortical bone (n=1), necrotic material (n=5) and inadequate specimen without evidence of malignancy (n=9). Only one of the nine cases in which biopsy was repeated was confirmed as tuberculous spondylitis. Diagnosis was confirmed in 7 of 17 paravertebral abscesses (41%), 8 of 21 vertebral bodies (38%), 6 of 20 intervertebral discs (30%) and 1 of 8 psoas abscesses (13%). CONCLUSION: In infectious spondylitis, the overall diagnostic yield of CT-guided needle biopsy and/or aspiration is relatively low, but the procedure seems to be effective for excluding malignancy. In identifying the organisms involved in infectious spondylitis, a paravertebral lesion is in a more favoured location than a psoas lesion.

Ultrasonographic Classification of Atypical Hepatic Hemangiomas

Cavernous hemangioma is the most common benign hepatic tumor. Typically, the most common features revealed by ultrasound(US) include its small size(4cm or less in diameter), uniform hyperechogenicity, welldefined margins, position in the subcapsular region of the right lobe of the liver, and some posterior echo enhancement. In addition, follow-up scanning may reveal changes in size, though this is rare. The US findings of hepatic hemangiomas may vary, however, especially when lesions are large and/or multiple. For that reason, differential diagnosis between this condition and hepatocellular carcinomas, metastatic lesions, lymphomas and other tumors is difficult. An understanding of the various sonographic findings of hepatic hemangioma can facilitate the early detection of the condition.

A Retrievable Nitinol Endobronchial Stent: An Experimental Study in Dog

PURPOSE: The purpose of this study was to evaluate the safety and the retrievability of a new coveredretrievable nitinol tracheobronchial stent. MATERIALS AND METHODS: Stents were knitted from 0.2mm nitinol wire,covered with polyurethane, and were 20 -22mm in diameter and 2cm in length. Under fluoroscopic guidance, a stentwas placed in the normal right bronchus intermedius of ten dogs. Using a retrieval hook, stent retrieval wasattempted after 1 month(N=5) or 2 months(N=5). After removal, the dogs were sacrificed and their tracheobronchialtrees were examined grossly and histologically. RESULTS: Eleven stents were successfully placed in ten dogs.Migration and expectoration occurred in four of ten stents in nine dogs(40%). Five stents were successfullyremoved from six dogs(83%). Without significant difference between the two groups, mild to moderate mucosalhyperplasia was noted at the sites of stents as well as above and below them. On microscopy, three of five dogsshowed pneumonia in the right middle lobes, but none of the stents was covered with epithelium. CONCLUSION:Temporary placement of a covered expandable nitinol stent in the tracheobronchial tree is feasible, but toestablish its efficacy, further experimental studies are needed.

Two Cases of Citrullinemia Presented with Strokes

Urea cycle disorders are characterized by encephalopathy, respiratory alkalosis, and hyperammonemia. A urea cycle disorder should be considered a diagnostic possibility in any patient regardless of age with occult encephalopathy. The most common central nervous system pathology of urea cycle disorder is cerebral edema. The cerebral edema is caused by astrocyte swelling secondary to hyperammonemia and intracellular glutamine accumulation. Strokes in children occur in conjunction with cardiac disease, hematologic disorders, mitochondrial encephalopathy, trauma, intracranial infections and migraines. Recently, several inborn errors in metabolism have been recognized as possible causes of stroke. To our knowledge, there have been several reports on ornithine transcarbamylase deficiency with stroke. However, the case of citrullinemia presenting with a stroke-like episode has not been described previously. We report two infantile cases of citrullinemia with initial presentation of stroke. The differential diagnosis of unexplained strokes should include inborn errors of urea cycle metabolism during childhood.

Usefulness of Additional Prone pad compression Study in Upper Gastrointestinal Series for Detecting EarlyGastric Cancer

PURPOSE: To evaluate the usefulness of prone pad study in upper gastrointestinal series(UGIS) for thedetection of early gastric cancer(EGC). MATERIALS AND METHODS: During an eight-month period, 88 of 170 patientswho underwent gastrectomy due to EGC were also the subjects of prone pad study as well as double contrast(n=92),mucosal relief(n=76), or compression(n=91) studies. The EGCs were single in 84 patients and double in four. Wecompared prone pad study with the three other techniques for detecting a tumor and depicting the surroundingmucosal changes. Lesional conspicuity was rated 'complete', 'incomplete','suspicious'. or 'undetected'. Thedepiction of surrounding mucosal change was rated 'excellent', 'good', 'fair', or 'poor'. RESULTS: Mean tumorsize was 3.2cm, with a range of 0.3-9cm. Tumors were located in the antrum(n=55), angle(n=13), lower or midbody(n=16), or the sign body and cardia(n=5). Among the 92 EGCs evaluated, UGIS missed the lesion in threecases(sensitivity, 97%). The rates of 'complete' lesional conspicuity were 49% inn prone pad, 29% in compression,20% in double contrast, and 9% in mucosal relief. The rates of excellent' in depicting surrounding mucosal changewere 45% in prone pad, 11% in double contrast, 9% in mucosal relief, and 9% in compression. The tumor wasdemonstrated only in prone pad study in five(5%) of the 92 EGCs. CONCLUSION: prone pad study during UGIS improvesboth the detection rate of EGC and the depiction of mucosal change around the tumor.

Reaction Difference of Glue-Lipiodol Mixture According to the Different Lot Number

PURPOSE: We noted that in a catheter, glue-lipiodol mixtures (GLM) prematurely turned into a cast duringembolization of brain arteriovenous maliformation, and to avoid this problem, added tungsten to GLM. The reactiontime and hardness of GLM were then evaluated in vitro. MATERIALS AND METHODS: Six lots of Lipiodol (Nos.97LU009A, 96LU018A, 96LU017A, 96LUollA and 95Lu020A)(Laboratoire Guerbet, Cedex, France) and three lots HistoacrylBlue (2/7121, Ex. Date 03/99 (993);2/6263, 06/98 (986);2/6132 03/98 (983))(B. Brown, Melsungen, Germany) weremixed in a 5cc bottle at concentrations of 25-50%(glue:lipiodol=1:1 to 1:3) and observed for two weeks. Thehardness of polymerized GLM was classified as liquid, gel, semi-solid or solid. After the addition of tungsten ortantalum powder (0.2gm) and a drop of blood to GLM, different series of experiments were performed. pH wasmeasured in distilled water mixed with tungsten of tantalum(0.1 to 0.5 gm). RESULTS: At a concentration of 50%,most GLM turned into solid casts within 48 hours;at one of 25%, most GLM gelled within 24hrs. At concentrations of28 and 33%, hardness was between that of a solid and that of a gel. After the addition of tungsten to 50% and 25%GLM, this remained in a liquid state until two weeks later, regardless of lipiodol products. In 5cc distilledwater with 0.1 to 0.5 gm tungsten, pH changed from 3.5 to 2.6, and on the addition of tantalum from 6.4 to 5.7.The addition of blood to the mixture immediately turned the cast solid at a GLM concentration of 50%, andsemi-solid at one of 25%. CONCLUSION: The reaction time of GLM differed according to the lot number of lipiodol.The addition of tungsten seemed to prevent premature cast formation by decreasing pH;the mechanism was similar tothat observed when acetic acid was added.

CT and MR Findings of Meningioangiomatosis

PURPOSE: To characterize the CT and MR findings in patients with meningioangiomatosis(MA). MATERIALS AND METHODS: Four patients (18 to 53 years old, two females and two males) with MA were retrospectively reviewed. CTwas used in four cases and MR in three. Pathologic specimens were obtained from all four. RESULT: All lesions were located in the cortical and subcortical areas and showed spotty(n=1), popcornlike(n=2), or gyral(n=1) calcification. The mass were associated with surrounding edema and gliosis. In two patients, lesions were multiple and were accompanied by eccentric cysts. CONCLUSION: MA is a surgically correctable benign disease. Its radiologic characteristics are cortical or subcortical mass with various calcifications, associated peripheral edema and gliosis.