Correlation of Clinical Findings in Acute Spinal Injury Patients with Magnetic Resonance Including Diffusion Tensor Imaging and Fiber Tractography.

INTRODUCTION: Many types of research are being carried out in the fields of understanding of the pathogenesis, early recognition, and improving the outcomes after spinal cord injury (SCI). Diffusion tensor imaging (DTI) is one of the modalities used in vivo microstructural assessment of SCI. The aim of the present study is to evaluate the role of DTI imaging and fiber tractography in acute spinal injury with clinical profile and neurological outcome. METHODS: The study was carried out on twenty-five patients of acute spinal cord injury who presented within 48 hours of injury and completed minimum of six months follow-up. RESULTS: The mean age of patients was 37.32±13.31 years and male & female ratio of 18:7. Total MIS score was 91.64±6.0 initially which improved to 96.92±3.68 after 3 months and 99.4±1.35 after 6 months. Total SIS score was similar at all the time intervals i.e. 224±0. Maximum subjects 14(56%) were classified into AIS C and 5(20%) into AIS D whereas only 6(24%) subjects were having no deficit (AIS E). At the end of 6 months, 13(52%) subjects had no deficit (AIS E). Mean fractional anisotropy (FA) initially was 0.451 (± 0.120) but after 6 months, it increased to 0.482 (± 0.097) (p<0.001). The mean apparent diffusion coefficient (ADC) initially was 3.13 (± 2.68) but after 6 months, it decreased to 3.06 (± 2.68) and this change was found to be statistically highly significant (p<0.001). Mean anisotropy index (AI) initially was 0.420 (± 0.245) but after 6 months, it increased to 0.430 (± 3.41) and this change was found to be statistically significant (p<0.01). CONCLUSIONS: DTI is a sensitive tool to detect neurological damage in SCI and subsequent neurological recovery. FA correlated with ASIA impairment scale. It can be useful as an adjunct to conventional MRI for better evaluation and predicting prognosis in SCI patients.

Computed tomographic-based morphometric study of thoracic spine and its relevance to anaesthetic and spinal surgical procedures.

BACKGROUND: To collect a baseline computer software aided normative morphometric data of thoracic spine in the Indian population and analyze it to give pre-procedural guidelines to clinicians for safe surgical and anaesthetic procedures in the thoracic spine. METHODS: CT scans of thoracic spine of patients free from spinal disorders were reviewed in a total of 600 vertebrae in 50 patients. Parameters recorded with the help of computer software were pedicle width, length and height, transverse pedicle angles, chord length, canal dimensions, body width and height, spinous process angle and transverse process length. RESULTS: Pedicle width decreased from T1 (9.27 ± 1.01) to T4 (4.5 ± 0.93) and increased to T12 (8.31 ± 1.83). At T4 76% and at T5 62% of the pedicles were smaller than 5 mm and would not accept 4 mm screw with 1.0-mm clearance. However, at T1 2%, at T11 7% and at T12 8% would not accept a 4 mm screw. Chord length gradually increased in upper thoracic vertebrae and was relatively constant in middle and decreased in lower thoracic vertebrae. Shortest estimated chord length was at T1 (30.30 ± 2.11). On an average, from T1 to T6 and at T11 and T12, a screw length of 25-30 mm could be accommodated and from T7 to T10, 30-35 mm screw length could be accommodated. Transverse pedicle angle decreased from T1 (35.4 ± 2.21) to T12 (-9.8 ± 2.39). Canal dimensions were narrowest at T4/T5 (20.02 ± 1.23) in anteroposterior and 21.12 ± 1.23 in interpedicular diameters. Spinous process angle increased from T1 (30.11 ± 6.74) to T6 (57.89 ± 9.31) and decreased to 16.21 ± 7.38 at T12. Transverse process length increased from T1 to T7 (23.54 + 2.12 to 31.21 + 1.91) and then decreased to 12.11 + 2.3 at T12. Vertebral body dimensions showed increasing trends from T1 to T12. CONCLUSIONS: A thorough knowledge of anatomical and radiological characteristics of the spine and their variations is essential for the clinicians. Data collected in the present study provides baseline normative values in Indian population and will help in guiding safe and effective completion of both surgical and anaesthetic procedures in the thoracic spine. Computer software aided morphometric data can help in selecting appropriate size and optimal placement of the implant with minimal procedural difficulties and complications during spine surgery.

Evaluation of Traumatic Spine by Magnetic Resonance Imaging and Correlation with Neurological Recovery.

STUDY DESIGN: Prospective study. PURPOSE: To compare magnetic resonance imaging (MRI) findings with clinical profile and neurological status of the patient and to correlate the MRI findings with neurological recovery of the patients and predict the outcome. OVERVIEW OF LITERATURE: Previous studies have reported poor neurological recovery in patients with cord hemorrhage, as compared to cord edema in spine injury patients. High canal compromise, cord compression along with higher extent of cord injury also carries poor prognostic value. METHODS: Neurological status of patients was assessed at the time of admission and discharge in as accordance with the American Spine Injury Association (ASIA) impairment scale. Mean stay in hospital was 14.11±5.74 days. Neurological status at admission and neurological recovery at discharge was compared with various qualitative cord findings and quantitative parameters on MRI. In 27 patients, long-term follow-up was done at mean time of 285.9±43.94 days comparing same parameters. RESULTS: Cord edema and normal cord was associated with favorable neurological outcome. Cord contusion showed lesser neurological recovery, as compared to cord edema. Cord hemorrhage was associated with worst neurological status at admission and poor neurological recovery. Mean canal compromise (MCC), mean spinal cord compression (MSCC) and lesion length values were higher in patients presenting with ASIA A impairment scale injury and showed decreasing trends towards ASIA E impairment scale injury. Patients showing neurological recovery had lower mean MCC, MSCC, and lesion length, as compared to patients showing no neurological recovery (p<0.05). CONCLUSIONS: Cord hemorrhage, higher MCC, MSCC, and lesion length values have poor prognostic value in spine injury patients.

A prospective study of neurological outcome in relation to findings of imaging modalities in acute spinal cord injury.

AIM: The aim was to correlate the clinical profile and neurological outcome with findings of imaging modalities in acute spinal cord injury (SCI) patients. SUBJECTS AND METHODS: Imaging (radiographs, computed tomography [CT], and magnetic resonance imaging [MRI]) features of 25 patients of acute SCI were analyzed prospectively and correlated with clinical and neurology outcome at presentation, 3, 6 and 12 months. RESULTS: Average initial sagittal index, Gardner's index, and regional kyphosis were 8.12 ± 3.90, 15.68 ± 4.09, 16.44 ± 2.53, respectively; and at 1-year were 4.8 ± 3.03, 12.24 ± 4.36, 12.44 ± 2.26, respectively. At presentation patients with complete SCI had significantly more compression percentage (CP) (P < 0.001), maximum canal compromise (P < 0.001), maximum spinal cord compression (P < 0.001), in comparison to incomplete SCI patients. Qualitative MRI findings; hemorrhage, cord swelling, stenosis showed a predilection toward complete SCI. Improvement in canal dimensions (P = 0.001), beck index (P = 0.008), spinal cord edema (P = 0.010) and stenosis (P = 0.001) was more significant in patients managed operatively; but it was not associated with improved neurological outcome. Cord edema was found more in incomplete SCI patients. Patients presenting with complete SCI improved neurologically to a lesser extent. CONCLUSIONS: The present study concludes that imaging modalities in spinal cord injuries have a major role in diagnosis, directing management and predicting prognosis. Imaging findings of severe kyphotic deformities, higher canal and cord compression, lesion length, hemorrhage, and cord swelling are associated with poor initial neurological status and recovery. Quantitative and qualitative parameters measured on MRI have a significant role in predicting initial severity of neurological status and outcome. Operative intervention helps in improving few of these imaging parameters, but not ultimate neurological outcome. MRI is an excellent modality to evaluate acute SCI, and MR images obtained in the acute period significantly and usefully predict neurological outcome.

External iliac artery thrombus masquerading as sciatic nerve palsy in anterior column fracture of the acetabulum.

We report a case of ischemic neuropathy of the sciatic nerve in a patient with an anterior column fracture of the acetabulum operated by ilioinguinal approach. It resulted from occlusion of the blood supply to the sciatic nerve. There were no signs of a vascular insult until ischemic changes ensued on the 6(th) postoperative day on the lateral part of great toe. The patient underwent crossover femoro-femoral bypass grafting and there was a complete reversal of the ischemic changes at 6 months. The sciatic nerve palsy continued to recover until the end of 1 year; by which time the only deficit was a Grade 4 power in the extensor hallucis longus (EHL) and the extensor digitorum longus (EDL). There was no further recovery at 2 years followup.

Computed tomographic evaluation of the proximal femur: A predictive classification in displaced femoral neck fracture management.

BACKGROUND: Femoral neck fracture is truly an enigma due to the high incidence of avascular necrosis and nonunion. Different methods have been described to determine the size of the femoral head fragment, as a small head has been said to be associated with poor outcome and nonunion due to inadequate implant purchase in the proximal fragment. These methods were two dimensional and were affected by radiography techniques, therefore did not determine true head size. Computed tomography (CT) is an important option to measure true head size as images can be obtained in three dimensions. Henceforth, we subjected patients to CT scan of hip in cases with displaced fracture neck of femur. The study aims to define the term small head or inadequate size femoral head" objectively for its prognostic significance. MATERIALS AND METHODS: 70 cases of displaced femoral neck fractures underwent CT scan preoperatively for proximal femoral geometric measurements of both hips. Dual energy X-ray absorptiometry scan was done in all cases. Patients were treated with either intertrochanteric osteotomy or lag screw osteosynthesis based on the size of the head fragment on plain radiographs. RESULTS: The average femoral head fragment volume was 57 cu cm (range 28.3-84.91 cu cm; standard deviation 14 cu cm). Proximal fragment volume of >43 cu cm was termed adequate size (type I) and of ≤43 cu cm as small femoral head (type II). Fractures which united (n = 54) had a relatively large average head size (59 cu cm) when compared to fractures that did not (n = 16), which had a small average head size (49 cu cm) and this difference was statistically significant. In type I fractures union rate was comparable in both osteotomy and lag screw groups (P > 0.05). Lag screw fixation failed invariably, while osteotomy showed good results in type II fractures (P < 0.05). CONCLUSION: Computed tomography scan of the proximal femur is advisable for measuring true size of head fragment. An objective classification based on the femoral head size (type I and type II) is proposed. Osteosynthesis should be the preferred method of treatment in type I and osteotomy or prosthetic replacement is the method of choice for type II femoral neck fractures.

Diaphragmatic hernia mimicking hydropneumothorax: common error in emergency department.

Detection of diaphragmatic hernia in the acute setting is problematic and diagnosing diaphragmatic hernia as hydropneumothorax is not an uncommon mistake. We present a series of four such cases diagnosed over a 7-year period, from December 2004 to January 2011 and analyse them for how this mistake can be avoided. In case of all the patients reported by us the initial radiographs were technically compromised because the patient could not be positioned properly. Also they were examined by non-radiologists. We feel that treating surgeons in emergency department tend to overdiagnose pneumothorax as it is a life-threatening condition. We feel that in the appropriate setting suspicion of diaphragmatic hernia should be raised in patients having fractured ribs associated with homogenous opacity, which cannot be differentiated from the diaphragm. Evidence of loculation of hydropneumothorax in the appropriate setting should also raise the possibility of diaphragmatic hernia.

Sonographic measurement of thymic size in preterm infants: prediction model for thymic size in the Indian subcontinent.

OBJECTIVE: To study the relationship of thymic size in vivo in preterm infants with gestational age (GA), birth-weight (BW) and length of the baby. METHODS: Two hundred consecutive preterm, appropriate for GA, asymptomatic neonates with GA between 26 and 36 wk and BW between 1000 and 2700 g were examined during the first week following delivery. Neonates of mothers with medical complications were excluded from the study. Thymic size was assessed sonographically and thymic index (Ti) was calculated. RESULTS: The mean gestational age was 32.62 ± 2.32 wk, the mean birth weight was 1850 ± 41 g and the mean length was 42.93 ± 3.09 cm. The number of boys were 109 (54.5%) and the number of girls were 91 (45.5%). The mean Ti in boys (4.11 ± 2.10) was similar to that in girls (4.36 ± 2.05). Thymic index was positively correlated with GA and length and the correlation was not significant with BW and sex of the infant. CONCLUSIONS: The sonographic method is a safe and effective technique for measuring the size of the thymus in preterm infants. A normal range of Ti has been established and correlates positively with GA and length and negatively with BW and sex of the preterm infants of the Indian subcontinent.

Multi detector computed tomography in the diagnosis of bowel injury.

Bowel Injuries are uncommonly associated with traumatic abdominal injuries. However, they are associated with significant morbidity and mortality and require operative intervention unlike solid organ injuries. Hence, early diagnosis is of paramount importance. Computed tomographic (CT) scan is a well-established and highly accurate imaging modality for the detection of solid organ injury after blunt abdominal trauma. However, its role in diagnosing hollow viscus injury remains controversial. The aim of our study was to analyze the accuracy of multidetector CT (MDCT) in the diagnosis of bowel injury. Imaging features of surgically proven cases of bowel injury were identified over 8-year period (i.e., from January 2003 to December 2010) and were retrospectively analyzed. There were 32 patients with age range of 3-90 years. There was only one female. Sensitivity of various CT signs specific to bowel injury (i.e., extravasation of contrast and discontinuity of bowel wall) was 15.62, and 28.12%, respectively. While that of signs suggestive of bowel injury were pneumoperitoneum, 62.5%; gas in the vicinity, 40.62%; bowel wall hematoma, 21.87%; bowel wall thickening, 75%; ascites, 78.12%; mesenteric hematoma, 46.87%; and mesenteric stranding, 40.62%. Based on the major and minor signs, a diagnosis of bowel injury could be made in all patients except one. The minor signs showed a higher sensitivity than the major signs. Hence, we recommend that multidetector CT should be used as the modality of choice in case of patients with suspected bowel injury. We also suggest that the minor signs should be given as much importance as the major signs.

Computed Tomography in the Evaluation of Diaphragmatic Hernia following Blunt Trauma.

Diagnosis of traumatic diaphragmatic hernia due to blunt abdominal trauma requires a high index of suspicion. This study was conducted to assess the accuracy of multidetector computed tomogram (MDCT) in the diagnosis of traumatic diaphragmatic hernia. All patients with thoracoabdominal blunt trauma with diaphragmatic hernia diagnosed on radiologic evaluation during a 3-year period (i.e., from June 2004 to June 2007) were analyzed. Nineteen patients with diaphragmatic injuries in 117 patients with blunt thoracoabdominal injury (16.23%) were studied. Age range was 8-60 years (mean 34 years). Male-female ratio was 18:1. Various features seen on CT scan were diaphragmatic discontinuity in 13 (68.42%), thickened diaphragm in 10 (52.63%), "collar sign" in 8 (42.10%), visceral herniation in 12 (63.15%), dependent viscera sign in 8 (42.10%), and segmental nonrecognition of the diaphragm in 1 patient (5.88%). Two patients presented with delayed rupture. In the rest mean duration between time of injury and performance of CT scan was 44.35 h (range 3-288 h). Fourteen patients underwent operative management. Sensitivity, specificity, and accuracy of MDCT scan were 100, 93, and 95%, respectively. Three patients (15.78%) expired. MDCT is a highly accurate modality for detecting traumatic diaphragmatic hernia.

Computed tomography in blunt chest trauma.

OBJECTIVE: To assess the role of multidetector spiral CT in patients with blunt chest trauma. METHODS: Forty-two patients (38 males and four females), age range from 6 to 80 years, of blunt chest trauma were evaluated with multidetector computed tomogram (MDCT) after initial radiographs and the results were tabulated. RESULTS: The most common mode of injury was motor vehicle accidents (64%). On computed tomography (CT), major injuries were haemothorax (83.33%), consolidation (66.6%), rib fractures (61.90%), pneumothorax (54.76%), diaphragmatic injury (30.95%), lung contusions (28.57%), spinal injury (16.66%), lacerations (9.52%), tracheo-bronchial injury (4.76%), mediastinal haematoma (4.76%), thoracic-aortic injury (4.76%) and oesophageal injury (2.38%). Operative intervention was performed in 11 (26.19%) patients. Of these, diaphragmatic rent repair was done in seven patients (63.63%), exploratory laparotomy alone was done in two (18.18%) and resection and anastomosis and polytetrafluoroethylene graft in one patient each. Three patients each with chest wall injury, thoracic vascular injury and diaphragmatic injury died; while only one patient with lung injury died. CONCLUSION: Multidetector computed tomogram is the modality of choice for rapid assessment of emergency chest trauma patients.

Unusual cause of haemorrhage from surgical wound in a child.

Haemorrhage from a surgical wound can be from many potential sources such as injury to vessel, muscle and bone; bleeding disorders; incomplete haemostasis; pseudoaneurysm; and neovascularisation. We report an unusual cause of haemorrhage from the surgical incision in a 9-year-old child. We emphasize that a high index of suspicion is required for early diagnosis, and pseudoaneurysm and neoangiogenesis should be considered in the differential diagnosis of soft tissue masses resulting from direct, blunt trauma even in children.

Thoracopagus parasites in two sets of twins: evidence for the fusion theory.

We report two sets of parasitic twins attached in the thoracic region. Exomphalos major in the autosite was present in both cases. While in case 1, the autosite could be salvaged after easier dissection, in case 2, the autosite could not be salvaged due to the presence of the life-threatening anomalies. The presence of a right-angled communication between the gastrointestinal tracts of the autosite and the independent tactile responses of the parasite from that in the autosite supports the 'fusion theory' to explain the fusion of the embryos that could have led to this defect. The presence of the ano-rectal malformation and common bile duct dilatation exclusively in the parasite appears to be the result of the abnormalities in the endodermal-mesodermal interactions, probably due to the relative positioning of the parasite with respect to the autosite.

Pneumothorax: a rare presentation of pulmonary mycetoma.

Pneumothorax due to mycetoma is extremely rare and has been described only in patients undergoing intensive cytotoxic therapy for hematologic malignancies. A non-immunocompromised subject presenting with pneumothorax due to rupture of the mycetoma into the pleural cavity is being described here.

Cystogastrostomy: a valid option for treating pancreatic pseudocysts of children in developing countries.

Twelve children with pancreatic pseudocysts were managed for over 10 years at our institute that is a tertiary referral center of our country. A majority of them had posttraumatic pancreatic pseudocysts. Six of them were early referrals and presented within 1-2 weeks of pancreatic injury while the remaining six were referred later than 6 weeks with thick cyst walls. An initial conservative management and observation (with serial ultrasounds) led to a resolution of the pseudocysts in three patients (25% resolution rate). All the remaining subjects were treated using surgical modality (cystogastrostomy). In all the subjects where cystogastrostomy was done, the pseudocysts resolved completely, except in one child, who required the procedure to be repeated. The authors encountered no complications of the pancreatic pseudocyst disease in children i.e. infection, rupture, etc, that have been frequently described for adults. The authors conclude that pancreatic pseudocyst is a comparatively benign entity in children with a better outcome than in adults. Though various sophisticated treatment modalities are in vogue in the developed countries for managing pancreatic pseudocysts in children, cystogastrostomy is still a valid option for this purpose in the developing countries with suboptimal infrastructure and gives good results.