ISSLS PRIZE in Clinical Science 2023: comparison of degenerative MRI features of the intervertebral disc between those with and without chronic low back pain. An exploratory study of two large female populations using automated annotation.

OBJECTIVES: The relationship of degeneration to symptoms has been questioned. MRI detects apparently similar disc degeneration and degenerative changes in subjects both with and without back pain. We aimed to overcome these problems by re-annotating MRIs from asymptomatic and symptomatics groups onto the same grading system. METHODS: We analysed disc degeneration in pre-existing large MRI datasets. Their MRIs were all originally annotated on different scales. We re-annotated all MRIs independent of their initial grading system, using a verified, rapid automated MRI annotation system (SpineNet) which reported degeneration on the Pfirrmann (1-5) scale, and other degenerative features (herniation, endplate defects, marrow signs, spinal stenosis) as binary present/absent. We compared prevalence of degenerative features between symptomatics and asymptomatics. RESULTS: Pfirrmann degeneration grades in relation to age and spinal level were very similar for the two independent groups of symptomatics over all ages and spinal levels. Severe degenerative changes were significantly more prevalent in discs of symptomatics than asymptomatics in the caudal but not the rostral lumbar discs in subjects < 60 years. We found high co-existence of degenerative features in both populations. Degeneration was minimal in around 30% of symptomatics < 50 years. CONCLUSIONS: We confirmed age and disc level are significant in determining imaging differences between asymptomatic and symptomatic populations and should not be ignored. Automated analysis, by rapidly combining and comparing data from existing groups with MRIs and information on LBP, provides a way in which epidemiological and 'big data' analysis could be advanced without the expense of collecting new groups. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Neutrophil-derived JAML inhibits repair of intestinal epithelial injury during acute inflammation.

Neutrophil transepithelial migration (TEM) during acute inflammation is associated with mucosal injury. Using models of acute mucosal injury in vitro and in vivo, we describe a new mechanism by which neutrophils infiltrating the intestinal mucosa disrupt epithelial homeostasis. We report that junctional adhesion molecule-like protein (JAML) is cleaved from neutrophil surface by zinc metalloproteases during TEM. Neutrophil-derived soluble JAML binds to the epithelial tight junction protein coxsackie-adenovirus receptor (CAR) resulting in compromised barrier and inhibition of wound repair, through decreased epithelial proliferation. The deleterious effects of JAML on barrier and wound repair are reversed with an anti-JAML monoclonal antibody that inhibits JAML-CAR binding. JAML released from transmigrating neutrophils across inflamed epithelia may thus promote recruitment of leukocytes and aid in clearance of invading microorganisms. However, sustained release of JAML under pathologic conditions associated with persistence of large numbers of infiltrated neutrophils would compromise intestinal barrier and inhibit mucosal healing. Thus, targeting JAML-CAR interactions may improve mucosal healing responses under conditions of dysregulated neutrophil recruitment.

Incidence of serious side effects with intravenous bisphosphonate: a clinical audit.

BACKGROUND: Bisphosphonates (BP) have been associated with osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFF). The prevalence of these side effects in intravenous (IV) BP-treated subjects is not well understood. AIM: This audit aimed to delineate the prevalence of ONJ, thigh pain and AFF in patients having regular IV BP and its effect on bone mineral density (BMD). Design and METHODS: Patients attending for IV BP over a 3-month period completed a questionnaire about thigh pain and dental health. Data concerning BMD, treatment indication and treatment history were obtained from medical records. RESULTS: There were 201 patients between 28 and 94 years (74.1% female) mostly on zoledronate (ZOL) (102) or pamidronate (PAM) (97). Osteoporosis (75.6%) and Paget's disease (16.5%) were the main indications for treatment; median length of IV BP was 4 years (range 0.25-25). One patient had ONJ (0.5%) while oral pain was reported by 6.5% and 12.7% noted tooth loosening. Twenty-seven subjects (13.4%) complained of current thigh pain. AFF occurred in four patients (2%), none of whom had idiopathic osteoporosis. At time of AFF, only one patient had a femoral neck T-score less than -2.5. All four had received pamidronate treatment; median 12.5 years (range 7-22). IV BP treatment significantly increased lumbar spine BMD but not femoral neck BMD. CONCLUSION: Classical ONJ was rare (0.5%), although tooth loss was more frequent. Thigh pain was frequent while AFF occurred in 2.0% of subjects and was associated with long treatment periods and non-osteoporotic bone.

Slipped upper femoral epiphysis: imaging of complications after treatment.

Slipped upper femoral epiphysis (SUFE) is a multifactorial condition usually affecting adolescents. Obesity is one risk factor, and as this is increasing the incidence of SUFE is likely to rise. Diagnosis and treatment are usually straightforward and carried out by orthopaedic surgeons. However, the recognition of post-treatment complications poses a much greater challenge. This article focuses on possible complications of surgical treatment of SUFE particularly. Chondrolysis, avascular necrosis, as well as other complications of treatment and conditions leading to premature osteoarthritis are discussed. Checklists for a systematic approach to post-treatment imaging are provided.

Combined autologous chondrocyte implantation and allogenic meniscus transplantation: a biological knee replacement.

Meniscus deficient knees develop early osteoarthritis in the knee. Autologous Chondrocyte Implantation has provided a new dimension to the treatment of chondral defects in the knee, with 85% good to excellent results and a long-term durable outcome of up-to 11 years. However, it is contraindicated in meniscus deficient knees. Allogenic Meniscus Transplantation gives good symptomatic relief in meniscus deficient knees, with a success rate of 89%. However, it is contraindicated in advanced cartilage degeneration. We hypothesized that combination of these two might be a solution for bone-on-bone arthritis in young individuals. We studied a consecutive series of eight patients, with mean age of 43 years, presenting with large kissing chondral defects, secondary to the previous meniscectomy. All the patients were treated with a combination of Autologous Chondrocyte Implantation and Allogenic Meniscus Transplantation. Mean pre-operative Lysholm score was 49, which rose to mean of 66 at 1 year, an average increase by 16.4 points. Six patients showed significant improvement at one year. MRI scans showed good integration of the menisci with the capsule, without any rejection. Histology confirmed the integration. All the patients could lead an active life-style. Five patients maintained the improvement at a mean follow-up of 3.2 years. We could not find any deleterious effects of the combination of these two techniques. So we conclude that the combination of these two techniques together may act a one step towards a true biological knee replacement.

Effect of age and gender on the number and distribution of sites in Paget's disease of bone.

Paget's disease of bone (PDB) is reportedly declining in prevalence and severity, with increasing numbers of monostotic cases. Some accounts suggest that these findings are more evident in women, and that monostotic disease is unexpectedly frequent at certain sites. We have studied whether birth date or gender is associated with the number of sites affected and with the distribution of sites in monostotic disease and, by reviewing 100 follow-up 99Tc(m) methylene diphosphonate (MDP) scans, whether additional sites appear after initial diagnosis. Scintigraphic scans from 171 male (age 40-91 years) and 179 female (44-88 years) consecutive referrals with PDB were reviewed. Patients were analysed by referral date (1982-1992 and 1993-2001), and by their median date of birth (before (PRE21) and after (POST21) 1921). Mean age of pre-1993 patients was 69 years and 75 years for referrals after 1993. Younger patients had more monostotic disease (POST21 vs PRE21 subjects (47% vs 28%)), with a more marked trend in females (52% vs 25%), and POST21 females had fewer polyostotic sites than males (p<0.05), whereas the number in PRE21 males and females was similar. Monostotic females, but not males, showed an excess of tibial involvement. The spine was less involved in monostotic disease. Follow-up scans in 100 patients revealed no new sites. The incidence of monostotic disease has doubled over the last 30 years, but diminishing site involvement appears to be more marked in females. The lesser involvement at the axial sites in monostotic disease may lead to overestimation of the decline in PDB based on abdominal radiographs.

Quantitative 3D MR evaluation of autologous chondrocyte implantation in the knee: feasibility and initial results.

OBJECTIVE: To evaluate the feasibility of quantitative magnetic resonance imaging (MRI) based follow-up of cartilage volumetric data in patients after autologous chondrocyte implantation (ACI). To provide results from a 1-year follow-up study. METHODS: From 21 ACI patients sagittal FS 3D FLASH (50/11/30; 0.6x0.6x1.5mm(3)) MRI knee data sets were obtained pre and 1-year post-ACI surgery in the femoral condyles. After semi-automated segmentation and 3D reconstruction of the cartilage plates, cartilage volume, mean thickness and size of the cartilage-bone interface were calculated. Susceptibility artifacts were evaluated in all, intra-observer reproducibility was evaluated in six of the patients. Volumetric parameters were compared during follow-up and sensitivity to change was assessed for the total femur vs the separately evaluated medial/lateral portions of the femur. RESULTS: Reproducibility error (coefficient of variation %) was 3.9%/4.4% for the med./lat. tibial and 5.1% for the femoral cartilage volume. Susceptibility artifacts led to the exclusion of three out of the 21 patients, but were moderate in the remaining 18 patients, not preventing reproducible segmentation. In contrast to lack of significant change in the (non-operated) tibiae, a mean 6% increase of volume and thickness in the treated femora (P<0.001 Wilcoxon) relative to the pre-OP data was observed. Sensitivity to change for the femur ranged from 0.74 to 2.60 for cartilage volume and thickness and was improved when evaluating only the treated portion of the femur in contrast to the total femur. CONCLUSION: Our data indicate that despite postoperative susceptibility artifacts quantitative evaluation of cartilage volumetric parameters can be performed in ACI patients. The technique is able to describe changes of these parameters over 1 year. Volumetric follow-up may help to identify altered disease progression.

Symptoms and radiographic osteoarthritis: not as discordant as they are made out to be?

OBJECTIVES: Joint pain and radiographic osteoarthritis are often discordant. AIM: To investigate this issue more closely by studying the detailed nature of pain and disability, and how this relates to radiographic osteoarthritis. METHODS: Population-based study of 819 adults aged >or=50 years with knee pain. The severity of knee pain, stiffness and disability was measured using a validated scale (the Western Ontario and McMaster Universities (WOMAC) Score) and pain persistence was recorded. Global severity was measured by the graded chronic pain scale. Three radiographic views of the knees were obtained-weight-bearing posteroanterior metatarsophalangeal, supine skyline and supine lateral. RESULTS: 745 participants with knee pain in the past 6 months were eligible (mean age 65 years, 338 men). Radiographic osteoarthritis was more common in those with a longer history and more persistent symptoms. A strong trend was found of radiographic osteoarthritis being more strongly associated with higher WOMAC scores for pain severity, stiffness and disability (adjusted odds ratio (95% confidence interval (CI)) for highest v lowest WOMAC category: 3.7 (2.0 to 6.7), 3.0 (2.0 to 4.6) and 2.8 (1.6 to 5.0), respectively). Those individual WOMAC items for pain and disability pertaining to weight-bearing mobility were the most strongly associated with radiographic osteoarthritis. Combining pain persistence and global severity, persistent severe pain was associated with a significant increase in the occurrence of radiographic osteoarthritis (2.6 (95% CI 1.5 to 4.7)). CONCLUSIONS: A consistent association was found between severity of pain, stiffness and physical function and the presence of radiographic osteoarthritis. This study highlights the potential contribution of underlying joint disease to the degree of pain and disability.

Cauda equina syndrome presentation of sacral insufficiency fractures.

INTRODUCTION: Sacral insufficiency fractures are a well recognised cause for low back, buttock and groin pain in the elderly. However, over a 4 year period, four patients have presented with symptoms of cauda equina syndrome, who were found on investigation to have acute sacral insufficiency fracture without any other aetiological spinal abnormality. PATIENTS AND METHOD: Four patients who presented to the spinal surgeons of our institution with symptoms of cauda equina syndrome were referred for spinal MR. Sagittal and axial T1 and T2 weighted turbo spin echo sequences of the lower thoracic and lumbar spine were performed on all patients. Subsequent studies included MR of the sacrum supplemented where appropriate by CT and technetium MDP bone scintigraphy. RESULTS: No evidence of a compressive lesion of the lower thoracic or lumbar spine was present in any of the four patients. Dedicated MR examination of the sacrum in these patients revealed unilateral acute insufficiency fractures involving zone 1 from S1 to S3 extending from the sacro-iliac joint to the lateral margin of the sacral foramen. There was no evidence of compression of the sacral nerve roots. The possible mechanism for the symptomatic presentation is discussed. CONCLUSION: Sacral insufficiency fractures should be excluded in elderly or osteoporotic patients presenting with cauda equina syndrome who have no evidence of compression in the thoraco-lumbar MR studies.

Longitudinal study of high intensity zones on MR of lumbar intervertebral discs.

AIM: To study the temporal evolution of high intensity zones (HIZ) on MRI in patients with degenerative disease of the lumbar spine, and to evaluate whether any correlation exist between such evolution and in patient's symptoms. MATERIALS AND METHODS: HIZs in the MRI of 56 patients were included in the study. Each Patient had an initial and a follow-up scan performed at various time intervals. Scans were assessed for any change in HIZs by two observers (D. M. and I. W. M.). Patients' symptoms were assessed for by visual analogue score (VAS), the Oswestry Questionnaire Score (OQS) and patients' subjective assessment of change in symptoms. Any MRI feature, apart from HIZs, which could independently explain a patient's change in symptoms, was considered to be a confounding factor. Data were analysed separately in the whole group as well as in the group without confounding factors. RESULTS: On follow-up MRI, HIZs were found to have resolved in 17 lumbar disc levels (26.6%), improved in 9 (14%), worsened in 12 (18.8%) and remained unchanged in 26 (40.6%) at lumbar disc levels. Chi-square testing did not demonstrate any correlation between HIZ changes and evolution of patients' subjective symptoms (p = 0.26 for the whole group; p = 0.07 for the group without confounding factors). Similar lack of meaningful relationship was noted between HIZ changes and the VAS and OQS scores. CONCLUSION: We conclude that HIZs either do not change or improve spontaneously in a large proportion of cases over a period of time. Furthermore, there is no statistical correlation between HIZ changes and change in a patient's symptoms.

Ultrasound measured renal length versus low dose CT volume in predicting single kidney glomerular filtration rate.

Ultrasound measured renal length and CT measured renal volume are potential surrogate markers for single kidney glomerular filtration rate (SKGFR). The aims of this study are to determine: (1) the repeatability of ultrasound measured length and low radiation dose spiral CT measured volume; (2) the relationship between renal length and volume; and (3) whether length and/or volume is a predictor of SKGFR. 69 patients with suspected renal artery stenosis underwent ultrasound renal length measurement, CT evaluation of renal volume and assessment of SKGFR. 40 patients had ultrasound measurement of length and CT evaluation of volume performed twice on two separate visits. 25 patients also had ultrasound measured renal parenchymal thickness and area. The region of interest was drawn around the kidneys and a threshold set to subtract renal peripelvic fat and renal pelvis. The volume from each slice was summed to obtain the total volume for each kidney. The limits of agreement for ultrasound measured renal length were -1.6 cm to 1.52 cm and that for CT renal volume were -33 ml to 32 ml. There was significant correlation between ultrasound measured length and CT volume (r=0.74, p<0.01). Volume was a better predictor of SKGFR (r(2)=0.57) than length (r(2)=0.48). The combined parameters of ultrasound measured length, area and parenchymal thickness were a better predictor of volume (r(2)=0.81) and SKGFR (r(2)=0.58) than ultrasound measured length on its own. The low dose CT technique was reasonably reproducible and renal volume measurements correlate better with SKGFR than length. Ultrasound predictions of renal volume and SKGFR can be improved by incorporating cross-sectional area and parenchymal thickness. Further investigation is required to refine our low dose CT technique.

Longitudinal study of vertebral type-1 end-plate changes on MR of the lumbar spine.

The purpose of this study was to investigate the temporal evolution of type-1 end-plate changes on MRI in patients with degenerative disease of the lumbar spine and to evaluate whether any correlation exists between such evolution and the change in patients' symptoms. Forty-four patients with 48 Modic type-1 end-plate changes (low TI signal and high T2 signal) were studied. All patients had an initial and a follow-up non-contrast lumbar MRI with variable intervals between the studies (12-72 months). Severity of the end-plate changes was assessed by eyeball estimation. Correlation with patients' symptoms was studied with the help of the Visual Analogue Score (VAS), Oswestry Questionnaire Score (OQS) and patients' subjective assessment. Of the 48 disc levels with type-1 changes, 18 (37.5%) converted fully to type 2 (high T1 signal and intermediate to high T2 signal), 7 (14.6%) partially converted to type 2, 19 (39.6%) became worse (i.e. type 1 changes became more extensive) and 4 (8.3%) showed no change. Higher average VAS (5.7) and OQS (42.3) scores were noted in patients where there was worsening type-1 change and lower scores (3.8 and 27, respectively) were seen in those where there was conversion to type-2 change. These trends, however, did not reach statistical significance (P values 0.16 and 0.09 for VAS and OQS, respectively). The statistical relationship was stronger after exclusion of patients with confounding factors (i.e. changes in lumbar MRI other than end-plate changes that could independently explain the evolution of patients' symptoms) with P-values of 0.08 and 0.07 for VAS and OQS, respectively. Type-1 end-plate change represents a dynamic process and in a large majority of cases either converts to type-2 change or becomes more extensive. The evolution of type-1 change relates to change in patient's symptoms, but not to a statistically significant level.

The emergency department: an appropriate referral rate for radiography.

AIM: To evaluate the hypothesis that where there is good clinical practice in an emergency department (ED), there is a low uptake of plain radiography. MATERIALS AND METHODS: Emergency notes and radiography records were reviewed over one week in January 1999, to determine the rate of radiography of first time attenders at the North Staffordshire NHS Trust. The clinical appropriateness of the imaging was assessed by pairs of radiology specialist registrars and casualty physicians. They judged the appropriateness of the imaging by the 1998 Royal College of Radiologists (RCR) guidelines and/or their clinical judgement, by consensus. Where there was no consensus or the data appeared incomplete, the radiology and ED consultant reviewed the notes. RESULTS: A total of 1615 notes were found out of 1643 (98%). Of these, 147 (9%) return attenders were excluded and 32 patients left without being seen. The number of first time attenders was 1436 (87%), of whom 637 (44%) were radiographed; 95% of these radiography examinations were appropriate and 5% were inappropriate. Of the first time attenders who were not radiographed the decision was appropriate in 95% of cases, and inappropriate for 5%, i.e. 5% of those who had no radiography, should have been X-rayed. There were no disagreements between RCR guidelines and the clinical judgements, but in 16% there were no suitable RCR guidelines. Junior doctors were not always able to find the relevant RCR guideline (relevant clinical guideline found in 73% of cases) in the guideline book, compared to the consultants (relevant clinical guideline found in 84% of cases). CONCLUSION: The application of the RCR guidelines is taken as representing good clinical practice in determining when to refer a patient for radiography. Based on this assumption, a referral rate for radiography of 44% of first time attenders was found to be appropriate. This referral rate can be taken as a benchmark. A benchmark is necessary in order to allow departments to make a local assessment as to whether their local referral rate is likely to be too high or too low.

MRI detection of unsuspected vertebral injury in acute spinal trauma: incidence and significance.

OBJECTIVE: Multilevel spinal injury is well recognised. Previous studies reviewing the radiographs of spinal injury patients have shown an incidence of 15.2% of unsuspected spinal injury. It is recognised that magnetic resonance imaging (MRI) can identify injuries that are not demonstrated on radiographs. The objective of this study was to determine the incidence and significance of spinal injuries using MRI in comparison with radiographs. DESIGN AND PATIENTS: The radiographs and MR images of 110 acute spinal injury patients were reviewed independently of each other and the findings were then correlated to determine any unsuspected injury. RESULTS: MRI detected vertebral body bone bruises (microtrabecular bone injury) in 41.8% of spinal injury patients which were not seen on radiographs. These bone bruises were best appreciated on sagittal short tau inversion recovery MR sequences and seen at contiguous and non-contiguous levels in relation to the primary injury. CONCLUSION: This level of incidence of bone bruises has not previously been appreciated. We recommend that patients undergoing MRI for an injured segment of the spine are better assessed by MRI of the entire spine at the same time to exclude further injury.

Achilles tendon (TA) size and power Doppler ultrasound (PD) changes compared to MRI: a preliminary observational study.

AIM: To assess whether abnormal Achilles tendon (TA) magnetic resonance imaging (MRI) and spectral ultrasound (US) features have associated development of microvascular power Doppler (PD) flow. MATERIALS AND METHODS: In a prospective, controlled and blinded study six patients with TA symptoms were compared to five with other ankle abnormalities. Two radiologists independently measured the mean maximal anteroposterior diameter on MRI and conventional US (categorized as normal <6 mm, mild 6.1-10 mm, moderate 1.1-1.5 cm and severely enlarged > 1.6 cm), assessed morphology and studied the vessels using power Doppler. They formed a consensus over discrepancies. Sonography of the contralateral side within 24 h was used as a control. RESULTS: Twenty-one tendons in six women and five men, aged 45-77 years (mean 57.6 years), were examined, 12 tendons were of normal US morphology and size (< 6 mm), and did not exhibit PD's flow (interobserver agreement K > 0.74). Of the 12 tendons studied by MRI five were normal, seven tendons were enlarged, five of which had a proportionate increase in PD flow at the margin on the deep surface and four also had vessels in the centre of the tendon. All five of these tendons had high signal on T2-weighting (T2W). Of the two mildly enlarged tendons of intermediate signal on T1 and T2W, one showed PD flow and the other did not. CONCLUSIONS: In patients with TA disease power Doppler ultrasound shows proliferation of vessels in enlarged, abnormal tendons demonstrated on MRI and standard ultrasound, in the absence of definite tears.

Lumbar herniated disks.

Patients with low back and leg pain require careful evaluation and it is essential that there is correlation between the symptoms and signs of sciatica and the imaging demonstration of nerve root compression or displacement by a disk herniation before invasive therapy is undertaken. The natural history of herniations of the nucleus pulposus is complex and the relationship between the appearances on imaging and low back and radicular pain still has to be completely resolved. Considerable experimental work has been undertaken on the relationship between nerve compression, inflammation, and pain and recent studies on cytokines may lead to more precise pharmacologic therapies. The prime value of MR imaging may be in monitoring disk and nerve root changes in longitudinal studies of patients randomized to different therapeutic programs.

Effect of Paget's disease of bone on areal lumbar spine bone mineral density measured by DXA, and density of cortical and trabecular bone measured by quantitative CT.

Although bone density may be increased in bone that is affected by Paget's disease, density changes in cortical and trabecular bone and the effect on bone that is apparently unaffected by Paget's disease are relatively unexplored. We have investigated 81 vertebrae (28 affected, 53 unaffected) in 27 patients with Paget's disease, by dual X-ray absorptiometry (DXA) and by quantitative CT (QCT) bone density measurements of trabecular and cortical bone. DXA bone density was high (mean z-score = 1.62, p < 0.001) in vertebrae affected by Paget's disease, but not significantly different from normal in unaffected vertebrae (mean z-score = 0.07, ns). Mean QCT z-score in Paget's vertebrae was 2.07 (p = 0.009) for cortical bone and 1.37 (p = 0.008) for trabecular bone. DXA correlated with QCT cortical values in affected and unaffected bone (r = 0.8 and 0.56, respectively), and with QCT trabecular values (r = 0.72 and 0.48, respectively). There was no significant difference in the slopes for the correlations in affected or unaffected bone. Cortical QCT values are underestimated in Paget's disease compared with physical measurements of density, owing to the computer algorithm used. High DXA values may alert to the possibility of Paget's disease, especially if the value deviates from the expected normal sequence in lumbar vertebrae. Osteoporotic vertebrae may be overlooked if the average value of bone mineral density is taken in the lumbar spine without reviewing each vertebra.

Intra-articular ganglion cysts of the cruciate ligaments.

Intra-articular ganglion cysts of the cruciate ligaments are associated with non-specific clinical signs and symptoms. Familiarity with the MR appearances in particular is important to make an accurate diagnosis, exclude associated abnormalities, and avoid misdiagnosis.

Marginal erosive discovertebral "Romanus" lesions in ankylosing spondylitis demonstrated by contrast enhanced Gd-DTPA magnetic resonance imaging.

OBJECTIVE: To assess the value of Gd-DTPA magnetic resonance (MR) imaging in the demonstration of marginal destructive discovertebral Romanus lesions in ankylosing spondylitis. DESIGN AND PATIENTS: A prospective study of Gd-DTPA MR imaging was performed in 39 patients with a clinical diagnosis of ankylosing spondylitis and typical Romanus lesions seen on radiographs of the thoracolumbar spine. MR morphological appearances and signal intensity changes at the discovertebral junctions were analysed and compared with the radiographic findings. RESULTS: Ninety-nine discovertebral junctions with Romanus lesions showed low signal intensity on T1-weighted and high signal on T2-weighted and T1-weighted postcontrast images at the vertebral corners consistent with oedematous hyperaemic inflammatory tissue. There were nine discovertebral junctions with similar MR findings but normal radiographs. Fifty-three discovertebral junctions showed syndesmophyte formation with increased signal intensity on both T1- and T2-weighted images with no contrast enhancement. Sixty-five discovertebral junctions showed a mixture of radiographic features and varied high and low signal changes at the vertebral rim on MR imaging with rims of enhancement in the vertebral body following contrast administration. CONCLUSION: Gd-DTPA MR imaging demonstrates a variable signal pattern and degree of contrast enhancement which may reflect the evolutionary stages of discovertebral enthesitis in ankylosing spondylitis. MR imaging may identify early erosive changes in radiographically normal vertebra. The role of MR imaging needs further investigation.

Emergency pre-hospital management of patients admitted with acute asthma.

BACKGROUND: Little is known about the management of acute asthma prior to hospital admission. Pre-hospital treatment of patients referred to hospital with acute asthma was therefore studied in 150 patients divided into three groups: those in the Edinburgh Emergency Asthma Admission Service (EEAAS) who can contact an ambulance and present directly to respiratory services when symptoms arise (n = 38), those under continuing supervision at a hospital respiratory outpatient clinic (n = 54), and those managed solely in primary care (n = 58). METHODS: Standardised admission forms detailing aspects of pre-hospital management, case records, GP referral letters, and ambulance patient transport forms were analysed. RESULTS: In each group airflow obstruction had improved upon arrival at hospital, the effect being most marked in patients transported by ambulance (p<0. 001) and in those receiving nebulised beta(2) agonists prior to admission (p<0.005). However, 25% of patients arrived without having nebulised beta(2) agonists and 37% without having glucocorticoids. EEAAS patients were least likely to receive nebulised beta(2) agonists before arrival at hospital (p<0.05). This observation was attributable to a tendency for these patients to travel to hospital by car rather than by ambulance. CONCLUSIONS: There is an important shortfall in administration of bronchodilators and glucocorticoids for acute asthma before arrival at hospital. Ambulances equipped with nebulised bronchodilators provide the optimal mode of transport to hospital for patients with acute asthma. In Edinburgh ambulances are not being used by a significant proportion of the population with asthma, possibly because of the mistaken belief that personal transport arrangements reduce journey time to hospital.