Paravertebral venous plexus distention (Batson's): an inciting etiologic agent in lumbar radiculopathy as observed by venous angiography.

Can the paravertebral plexus of veins adjacent to the spinal nerve root within the narrow confines of the lateral neural canal be a collateral generator of radicular pain when no other evidence of spinal pathology is evident? A patient with complaints of intractable lumbar radiculopathy and an otherwise unremarkable clinical neuromusculoskeletal examination, as well as normal imaging and electrodiagnostic studies, is reviewed with special reference to symptomatic and paravertebral venous responses to both a Valsalva maneuver and dipyridamole infusion as imaged by magnetic venous angiography.

Paravertebral muscle metastases as imaged by magnetic resonance venography: a brief report.

Paraspinal muscle metastasis as initially suggested by an electromyographic pattern of isolated posterior primary ramus denervation and subsequently confirmed by magnetic resonance imaging has been reported. However, despite widespread systemic tumor dissemination, metastases to other skeletal muscle occurs infrequently. Uniquely, the paraspinal muscles are drained by the paravertebral plexus of veins. Valveless and at very low pressures, they communicate directly by collaterals with the portal system. Valsalva maneuvers with sudden increases of pressure within the intra-abdominal and intrathoracic cavities can force venous blood from the systemic circulation into the paravertebral plexus of veins. These same venous surges potentially carry tumor emboli to the vertebrae and/or from the vertebral medulla to the adjacent paravertebral muscle by the venous communicators. The inherent increased vascularity of metastatic tumor relative to the surrounding paraspinal muscle as demonstrated by magnetic venous angiography for the first time now permits earlier confirmation and biopsy of the electromyographic-suspected metastatic lesion. In this reported instance of a magnetic resonance imaging-recognized primary lung metastasis confirmed by magnetic resonance venography, there is the future promise of identifying earlier and smaller lesions by this technique.

Physical and occupational therapy in the treatment of patients with multiple sclerosis.

The interdisciplinary approach to the management of MS patients includes the services of both physical and occupational therapy. These professions complement one another in their concerted effort to mobilize the patient, thereby minimizing the symptoms of progressive weakness, fatigue, and spasticity. The ambulant patient is far less likely to develop complications of inactivity such as contractures, decubitus ulcers, venous thrombosis, or osteoporosis (with its associated fatigue fractures), as well as bowel or bladder complications.

Physical medicine and rehabilitation workforce study: the supply of and demand for physiatrists.

OBJECTIVE: Analysis, results, and implications of a supply and demand workforce model for physical medicine and rehabilitation. Explicit issues addressed include: (1) the supply implications of maintaining current (1994-1995) output of physiatrists from residency programs; (2) the implications of continued growth in managed care on the demand for the services of physiatrists; (3) likely future supply and demand conditions; and (4) strategies to adapt to future conditions. DESIGN: A workforce model of the supply and demand for physiatrists was developed. Parameters of the model are estimated using econometric models and by applying the judgments of a consensus panel. The model evaluated several different scenarios regarding managed care growth, competition from other providers and other factors. RESULTS: Based on the analysis, physiatrists will continue to be in excess demand through the year 2000. More aggressive growth in managed care can affect this result. CONCLUSIONS: Based on an overall assessment of supply and demand conditions, and under the assumption that the supply of new entrants each year remains in the range of 1994-1995 levels, demand for physiatrists will continue to exceed supply, on average, through the year 2000. Excess supply has, and will, emerge in selected geographic areas. If the profession is successful in informing the market regarding the advantages of physiatry, the profession can continue to grow without experiencing excess supply, in the aggregate, for the foreseeable future.

Slip of the lip--tears of the superior glenoid labrum-anterior to posterior (SLAP) syndrome. A report of four cases.

The shoulder's unique wide range of motion is largely restrained by the articular capsule and the external ligaments of the glenohumeral joint. Internally, the long head of the biceps tendon passes within the capsule and inserts on the superior lip of the glenoid labrum. Trauma distracting this tendon can tear the superior glenoid labrum, producing the superior labrum anterior to posterior (SLAP) syndrome. Four patients, two of whom were female, presented with complaints of acute shoulder pain associated with weakness in abduction and forward flexion. Routine shoulder roentgenograms were normal. Magnetic resonance imaging (MRI) studies revealed a superior glenoid labral tear consistent with a SLAP syndrome. The superior labrum, unlike the firmly bound inferior portion, is loosely attached to the glenoid fossa. This inherent mobility predisposes it to disruption. To routine ultrasonography and arthrogram, the superior labrum may be obscured by superimposed structures. Shoulder arthroscopy, computed tomography, arthrography, and MRI have relatively equal sensitivity in visualizing these labral tears. The SLAP lesion accompanies 16% of all rotator cuff tears, occurring more often than heretofore recognized. When clinically suspected, they can be readily visualized by a noninvasive MRI examination.

Osteoporotic stress fractures in anorexia nervosa: etiology, diagnosis, and review of four cases.

Anorexia nervosa (AN) is a chronic eating disorder characterized by self-imposed semi-starvation that affects 1% of adolescent females. AN predisposes to osteoporosis through hypothalamic dysfunction, which may lead to elevated cortisol as well as diminished estrogen and progesterone. The osteoporosis associated with AN affects both trabecular and cortical bone and increases the risk of osseous fracture. Fractures in this population may go unrecognized, because planar X-rays may be nondiagnostic for 6 weeks or more. Four women with AN ranging in ages from 22 to 34 with skeletal pain and nondiagnostic roentgenographs are described. Stress fractures in these patients were subsequently identified by bone scan. Although moderate exercise in patients with AN-associated osteoporosis may be beneficial, strenuous exercise can be detrimental, with its potential risk of stress fractures and exacerbation of the underlying neurohormonal abnormalities. This risk for fracture may persist well after improvement in the patient's AN.

The lumbar herniated disk of pregnancy: a report of six cases identified by magnetic resonance imaging.

Although the mechanical and positional stresses of pregnancy are the primary inciting factors contributing to lumbosacral pain accompanying gestation, in approximately 1:10,000 cases a herniated disk (HNP) can be identified as the proximal cause of pain. Six patients are described, all of whom without antecedent history of pain presented with acute, disabling, gestational lumbosacral, and sciatic radiculopathy. Their ages ranged from 29 to 36, their parity from 0 to 1, and their gestational age at onset of symptoms from 6 weeks to 32 weeks. Each by magnetic resonance imaging (MRI) was identified as having an HNP, 2 at the L4-5 level and 4 at the L5-S1 level. During pregnancy, an MRI evaluation permits a detailed spinal examination without the ionizing effects of x-ray and its acknowledged biological risk to the developing fetus. This potential for an immediate and accurate diagnosis has significant implications for the management and subsequent planning of delivery.