Selective cervical nerve root blockade: experience with a safe and reliable technique using an anterolateral approach for needle placement.

BACKGROUND AND PURPOSE: [corrected] Our aim was to evaluate the safety and clinical utility of a fluoroscopically guided anterolateral oblique approach technique for outpatient diagnostic and therapeutic selective cervical nerve root blockade (SCNRB). MATERIALS AND METHODS: During a 13-year period (1994 through February 2007), 4612 patients underwent fluoroscopically guided diagnostic and/or therapeutic extraforaminal SCNRB by using an anterior oblique approach at affiliated outpatient imaging centers. Each procedure was performed by 1 of 6 procedural radiologists, all highly experienced in and actively performing spinal injections on a full-time basis in clinical practice. All of the proceduralists were thoroughly experienced with lumbar injections before endeavoring to perform SCNRBs. Nonionic contrast was injected in nearly all patients (except isolated patients with contrast allergy), and a minimum of 2 projection filming procedures were performed to document the accuracy of needle placement and contrast dispersal before the injection of therapeutic substances. All clinically significant complications beyond skin discoloration and temporary exacerbation of symptoms were recorded. RESULTS: There were no serious neurologic complications, such as stroke, spinal cord insult, or permanent nerve root deficit. One life-threatening anaphylactic reaction occurred and was attributed to the injected materials and not the specific procedure itself. Another patient had a 3- to 4-minute grand mal seizure, from which he fully recovered within 30 minutes. There were no infections. CONCLUSION: The technique we describe for fluoroscopically guided SCNRB is a useful and safe outpatient procedure when performed by skilled and experienced proceduralists.

Diskography: infectious complications from a series of 12,634 cases.

BACKGROUND AND PURPOSE: Diskography is commonly performed to investigate pain of suspected diskogenic origin. Although uncommon, diskitis is a feared complication of this procedure. We reviewed the incidence of diskitis and other infectious complications following diskography in a large busy outpatient practice and discuss technical aspects that may contribute to infection prevention. METHODS: We reviewed the electronic records of all diskograms obtained at our institution during a 12.25-year period, looking for all cases of procedure-related infection. All diskograms had been obtained by skilled and experienced procedural radiologists in dedicated spine-injection suites with specialized technical staff. RESULTS: There were 12,634 examinations performed on 10,663 patients for a total of 37,135 disk levels. Of the disk levels, 5981 were cervical; 3083, thoracic; and 28,071, lumbar. Two cases of confirmed lumbar diskitis and no cases of either cervical or thoracic diskitis were seen in our series. No other infectious complications were found. The incidence of diskitis was 0.016% per examination and 0.0054% per disk level. CONCLUSION: In skilled and experienced hands using proper technique, diskography is a safe outpatient procedure with an extremely low incidence of diskitis and other procedure-related infections.

Cervical diskography: analysis of provoked responses at C2-C3, C3-C4, and C4-C5.

BACKGROUND AND PURPOSE: Previous authors have described the locations of provoked responses to cervical diskography from C3-C4 to C6-C7, but we have found no description of the findings at C2-C3. This study was undertaken to analyze the sensations provoked during cervical diskography at C2-C3 and to compare the results with those provoked at C3-C4 and C4-C5. METHODS: The locations of diskographically provoked responses from 40 consecutive patients who had undergone C2-C3, C3-C4, and C4-C5 diskography were analyzed. Only intensely painful (> or = 7/10) and concordant responses were considered. Disk morphology on MR images and diskograms was also compared with the provoked responses. RESULTS: Eighteen subjects described either unilateral (n = 10) or bilateral (usually asymmetric) (n = 8) concordant pain at the craniovertebral junction in response to C2-C3 diskography. Nine subjects described either unilateral (n = 5) or bilateral (n = 4) neck pain during injection. Cephalalgia or head pain was provoked in 19 subjects, seven bilaterally. Four subjects described either unilateral (n = 3) or bilateral (n = 1) trapezius muscle and/or shoulder pain. Preliminary MR studies were not helpful, as most C2-C3 disks either appeared normal or exhibited nonspecific signs of degeneration. All disks exhibited either fissuring or extradiskal leakage of contrast material at diskography, regardless of the response provoked. CONCLUSION: Diskography at C2-C3 and C3-C4 frequently produces pain sensations in the head, craniovertebral junction, and neck. There is no correlation between C2-C3 disk morphology and the diskographically provoked response.

Epidurography and therapeutic epidural injections: technical considerations and experience with 5334 cases.

BACKGROUND AND PURPOSE: Even in experienced hands, blind epidural steroid injections result in inaccurate needle placement in up to 30% of cases. The use of fluoroscopy and radiologic contrast material provides confirmation of accurate needle placement within the epidural space. We describe our technique and experience with contrast epidurography and therapeutic epidural steroid injections, and review the frequency of systemic and neurologic complications. METHODS: Epidural steroid injections were performed in 5489 consecutive outpatients over a period of 5 1/2 years by three procedural neuroradiologists. In 155 cases (2.8%), the injections were done without contrast material owing to either confirmed or suspected allergy. The remaining 5334 injections were performed after epidurography through the same needle. Patients and referring clinicians were instructed to contact us first regarding complications or any problem potentially related to the injection. In addition, the referring clinicians' offices were instructed to contact us regarding any conceivable procedure-related complications. RESULTS: Only 10 patients in the entire series required either oral (n = 5) or intravenous (n = 5) sedation. Four complications (0.07%) required either transport to an emergency room (n = 2) or hospitalization (n = 2). None of the complications required surgical intervention, and all were self-limited with regard to symptoms and imaging manifestations. Fluoroscopic needle placement and epidurography provided visual confirmation of accurate needle placement, distribution of the injectate, and depiction of epidural space disease. CONCLUSION: Epidurography in conjunction with epidural steroid injections provides for safe and accurate therapeutic injection and is associated with an exceedingly low frequency of untoward sequelae. It can be performed safely on an outpatient basis and does not require sedation or special monitoring.

Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers.

STUDY DESIGN: Asymptomatic subjects and chronic head/neck pain sufferers were studied with high-field magnetic resonance imaging and cervical discography to compare and correlate both tests. OBJECTIVES: To assess the accuracy of magnetic resonance imaging and discography in identifying the source(s) of cervical discogenic pain. SUMMARY OF BACKGROUND DATA: Previous retrospective studies describe a generally poor correlation between magnetic resonance imaging and provocative discography in the cervical spine. METHODS: Ten lifelong asymptomatic subjects and 10 nonlitigious chronic neck/head pain patients underwent discography at C3-C4 through C6-C7 after magnetic resonance imaging. Disc morphology and provoked responses were recorded at each level studied. RESULTS: Of 20 normal discs by magnetic resonance from the asymptomatic volunteers, 17 proved to have painless anular tears discographically. The average response per disc (N = 40) for this group was 2.42, compared to 5.2 (N = 40) for the neck pain group. In the pain patients, 11 discs appeared normal at magnetic resonance imaging, whereas 10 of these proved to have anular tears discographically. Two of these 10 proved concordantly painful with intensity ratings of at least 7/10. Discographically normal discs (N = 8) were never painful (both groups), whereas intensely painful discs all exhibited tears of both the inner and outer aspects of the anulus. CONCLUSIONS: Significant cervical disc anular tears often escape magnetic resonance imaging detection, and magnetic resonance imaging cannot reliably identify the source(s) of cervical discogenic pain.

Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography.

STUDY DESIGN: This study correlated a specific lumbar disc abnormality described as the high-intensity zone observed on high-field magnetic resonance imaging with discography. OBJECTIVES: To analyze the significance of high-intensity zones in lumbar discs of symptomatic patients with low back/radicular pain. SUMMARY OF BACKGROUND DATA: Aprill and Bogduk described an 86% incidence of concordantly painful discography in lumbar discs exhibiting a posterior high-intensity zone on T2-weighted magnetic resonance imaging studies performed on back pain sufferers. They assert that the high-intensity zone is a reliable marker of discogenic pain in symptomatic subjects. METHODS: Consecutive cases of lumbar spine high-field magnetic resonance imaging using T2-weighted images on symptomatic patients followed by discography at all high-intensity zone levels and at non-high-intensity zone control levels were reviewed until 100 high-intensity zone discs in 63 patients were found. Seventeen lifelong asymptomatic (for low back/radicular pain) adults were also scanned as magnetic resonance imaging controls. All magnetic resonance scans and discograms were agreed on by at least two of the radiologist authors. RESULTS: Eighty-seven of 100 of the high-intensity zone discs proved concordantly painful at discography. All 87 painful and concordant discs exhibited abnormal morphology with anular tears extending either well into or through the outer third of the anulus fibrosus. Sixty-five of 67 non-high-intensity zone control discs were nonconcordant and of lower sensation intensity than the high-intensity zone discs. Only one high-intensity zone was found in the control subjects. CONCLUSIONS: In patients with symptomatic low back pain, the high-intensity zone is a reliable marker of painful outer anular disruption.

Thoracic discography. A safe and reliable technique.

OBJECTIVES: To evaluate the safety and reliability of discography used to investigate thoracic disc degeneration observed on magnetic resonance (MR) imaging studies in patients with clinical pain, we analyzed retrospectively the results of thoracic discograms performed on 100 outpatients. METHODS: After MR imaging, clinically suspect, morphologically abnormal thoracic discs and at least one, nearby, control level were injected with either nonionic contrast or saline, filmed, and individually described by the patient as concordant versus nonconcordant relative to clinical pain and rated in intensity on a scale of 0-10. RESULTS: There were no serious complications in the series, and the authors resolved whether the injected discs related to pain in each case. They found discs with anular tears, intrinsic degeneration, and/or associated vertebral body endplate infractions to be painful approximately 75% of the time. Clinical concordance was approximately 50%. Control levels were usually painless. CONCLUSIONS: They conclude that thoracic discography can be performed safely by experienced individuals as a reliable tertiary diagnostic procedure to determine if degenerated discs on MR studies are related to clinical complaints.

Delineation of gliomas with various doses of MR contrast material.

PURPOSE: To examine the effects of different gadolinium doses on the delineation of gliomas, particularly the demonstration of abnormal enhancement on T1-weighted images extending beyond the zone of apparent signal abnormality on corresponding T2-weighted images. METHODS: During phase II clinical trials of gadoteridol, 23 patients with pathologically proved gliomas were studied by MR with various doses of gadoteridol, ranging from 0.05 to 0.3 mmol/kg. RESULTS: All of the gliomas were readily detected by T2-weighted images. Twelve of 23 patients demonstrated enhancement on T1-weighted images extending beyond the zone of apparent signal abnormality demonstrated on T2-weighted images. These findings were seen in none of the six patients (0%) studied at 0.05 mmol/kg, one of five patients (20%) studied at 0.1 mmol/kg, four of five patients (80%) studied at 0.2 mmol/kg, and seven of seven patients (100%) studied at 0.3 mmol/kg. CONCLUSIONS: The detection of symptomatic gliomas does not require a contrast agent because they are generally large and readily demonstrated on T2-weighted images. However, the area of postcontrast enhancement of gliomas seems to be greater with higher doses of contrast agent. The cause of the abnormal enhancement extending beyond the zone of apparent signal abnormality on T2-weighted images seen in this limited study is unknown and probably represents tumor infiltration. The frequency of detection of such findings appears to be proportional to the dose of contrast material used.

The role of discography in the evaluation of patients with spinal deformity.

The indications, applications, and technique of lumbar, thoracic, and cervical discography in patients with spine deformity are presented. Details of technique for each anatomic region are provided, along with representative case presentations. The role of discography in the assessment of juvenile discogenic disease in association with spinal deformity (Scheuermann's disease) in the thoracic and lumbar regions also is discussed.

Pediatric internal derangements of the temporomandibular joint: effect on facial development.

To evaluate the relationship between internal derangement(s) of the temporomandibular joint(s) (TMJ) and disturbed facial skeleton growth (dysmorphogenesis), 128 consecutive children (103 girls, 25 boys), who were 14 years of age or younger and had undergone combined radiographic and magnetic resonance (MR) imaging studies of both TMJs, were retrospectively analyzed. Imaging studies had been performed to investigate suspected TMJ derangement because of symptoms that included, either individually or in various combinations, pain, mechanical TMJ dysfunction, and facial skeleton abnormalities, such as mandibular deficiency (particularly retrognathia) and lower facial (mandibular) asymmetry, manifested by chin deviation from the midline. Of these patients, 112 were found to have at least one internally deranged TMJ on imaging studies; in 85 patients, both TMJs were abnormal. Of the 60 retrognathic patients 56 were found to have TMJ derangement, generally bilateral and often of advanced stage. In cases of lower facial asymmetry, the chin was uniformly deviated toward the smaller or more degenerated TMJ. Both TMJs were normal in 16 patients, most of whom had normal facial structure. We conclude that TMJ derangements are both common in children and may contribute to the development of retrognathia, with or without asymmetry, in many cases.

Efficacy, safety, and tolerability of ioversol in intra-arterial digital subtraction angiography.

Twenty-two women and 18 men undergoing intra-arterial digital subtraction angiography were enrolled in an open-label, noncomparative study to assess the efficacy, safety, and patient tolerance of the contrast medium ioversol. The quality of radiographs generated was excellent in 60.0% of the studies, diagnostic in 37.5%, and nondiagnostic in 2.5%. There were no clinically significant drug-related changes in vital signs or laboratory tests among the patients, and no drug-related adverse effects were reported. Heat and pain related to injection of ioversol were graded on a four-point scale, with 0 indicating none and 3 indicating severe. The average scores were 1.3 for heat and 0.1 for pain. In this study, ioversol was a safe and effective contrast medium for angiography and was associated with a low incidence of patient discomfort.

Disorders of histogenesis: the neurocutaneous syndromes.

MRI is uniquely suited to demonstration of the wide array of brain abnormalities in the neurocutaneous syndromes, due to its ability to provide previously unattainable neuroanatomic information on T1-weighted images and its extreme sensitivity to changes in water content of brain structures on T2-weighted images. It therefore is assisting physicians in better understanding the full expression of these heritable disorders, such as the extent of optic pathway involvement in optic nerve glioma, the presence of hamartomas in TS, and abnormal myelination in Sturge-Weber syndrome. It may in the future have a role in genetic counseling in TS. CT provides complimentary information to MRI in the evaluation of intracranial pathology in the neurocutaneous syndromes. Bone abnormalities and abnormal states of calcification may at times still be better evaluated by CT. Additionally, CT is a less expensive means of following existent abnormalities over time.

Occult breast cancer: prevalence and radiographic detectability.

The radiographic detectability of occult breast cancer has been difficult to determine. A prospective study of breast disease was carried out that involved the performance of subcutaneous mastectomies in 519 consecutive cases of traumatic or initially unexplained death in New Mexico. Routine mammograms and radiographs of 1-cm specimens were obtained. At least 18 biopsies were performed in each subject. Carcinoma was identified in ten subjects; one subject had metastatic carcinoma from the lung, and two subjects had bilateral breast cancer, for a total of 11 breast cancers identified with microscopic examination. Two of the cancers were seen on whole-breast mammograms, and six were seen on radiographs of thin-section specimens. Four of the 11 breast cancers were apparent only on histologic study of breast tissue that was not suggestive of malignancy. No cancer was found in subjects under the age of 39 years. Five carcinomas were found in the 40-69-year age group; six were found in the 70-year and over age group. No correlation was noted between the radiographic Wolfe parenchymal patterns and the prevalence of breast cancer.