The fifth cranial nerve in headaches.

The fifth cranial nerve is the common denominator for many headaches and facial pain pathologies currently known. Projecting from the trigeminal ganglion, in a bipolar manner, it connects to the brainstem and supplies various parts of the head and face with sensory innervation. In this review, we describe the neuroanatomical structures and pathways implicated in the sensation of the trigeminal system. Furthermore, we present the current understanding of several primary headaches, painful neuropathies and their pharmacological treatments. We hope that this overview can elucidate the complex field of headache pathologies, and their link to the trigeminal nerve, to a broader field of young scientists.

Post-traumatic osteoid osteoma in an 18-year-old adolescent.

Osteoid osteoma (OO) is a painful, benign bone-forming lesion, which often poses a diagnostic challenge. The aetiology of OO is still poorly understood. Although not generally accepted, an association with previous trauma or infection has occasionally been suggested. We present a case of an OO 12 years following an ulnar fracture. Radiologists should consider OO as a potential delayed "complication" of a previous fracture. Persistent pain at a previous fracture site should alert the clinician to request cross-sectional imaging. CT scanning plays a pivotal role in the correct diagnosis of OO.

Two-year clinical and radiologic follow-up of early RA patients treated with initial step up monotherapy or initial step down therapy with glucocorticoids, followed by a tight control approach: lessons from a cohort study in daily practice.

The objective of the study was to evaluate the effect of initial disease-modifying antirheumatic drug (DMARD) combination therapy with steroids (ICTS) and DMARD monotherapy (IMT) on the clinical and radiologic evolution of patients with early rheumatoid arthritis (RA) over a 2-year treatment period, applying tight control (TC) in daily practice. Seventy-four DMARD-naive early RA patients received ICTS or IMT in a TC setting. Baseline and year 1 and year 2 X-rays of hands and feet were scored according to Sharp/van der Heijde. Rapid radiographic progression (RRP) was defined as total Sharp score (TSS) of >5 units/year. At year 1, both treatment groups achieved 50 % remission. At year 2, 37 % of IMT and 60 % of ICTS patients were in remission, despite ICTS patients having initially a more severe RA profile. RRP was found in 4/74 patients at year 1: 3 IMT and 1 ICTS patients. Remarkably, three of these four patients had no radiographic progression in the second year. Five other patients had RRP in the second year: four IMT and one ICTS patients. In a TC setting, ICTS and IMT can prevent radiographic progression in the majority of patients in the daily practice of a Belgian academic hospital over 2 years. ICTS seems to be more effective than IMT in achieving higher remission rates and less radiographic progression.

The performance of matrices in daily clinical practice to predict rapid radiologic progression in patients with early RA.

OBJECTIVE: To compare in daily clinical practice the reliability of matrices that forecast rapid radiologic progression (RRP) at year one, at year two, and over 2 years in patients with early rheumatoid arthritis (RA). METHODS: Overall, 74 early RA patients with X-rays of hands and feet at baseline, year one, and year two were included. Initial DMARD combination therapy with steroids (ICTS) or DMARD monotherapy (IMT) was initiated according to patients' RA severity, based on rheumatologist opinion. The images were scored via the modified Sharp/van der Heijde (SvH) method. A total Sharp score progression of equal or higher than five per year was considered RRP. Six matrices were tested: ASPIRE CRP/ESR matrices, the BEST matrix, two SWEFOT matrices, and the ESPOIR matrix. Patients were placed in each of them yielding a RRP probability. The performance was tested by Area Under the Curve analysis reflecting the predictive value. RESULTS: Four patients developed RRP in year one, five in year two, and four over 2 years. With regard to face validity, the predicted probability did not correspond to the risk in reality: the one ICTS patient who developed RRP over 2 years was always found in the lowest RRP categories of all matrices. The ASPIRE CRP matrix yielded at least a moderate predicting value for the three time points. The other matrices showed moderate to no predicting value. CONCLUSION: The performance of all matrices was disappointing and it is impossible to fully rely on the existing matrices in daily clinical practice.

Magnetic resonance imaging of cartilage and cartilage repair.

Magnetic resonance (MR) imaging of articular cartilage has assumed increased importance because of the prevalence of cartilage injury and degeneration, as well as the development of new surgical and pharmacological techniques to treat damaged cartilage. This article will review relevant aspects of the structure and biochemistry of cartilage that are important for understanding MR imaging of cartilage, describe optimal MR pulse sequences for its evaluation, and review the role of experimental quantitative MR techniques. These MR aspects are applied to clinical scenarios, including traumatic chondral injury, osteoarthritis, inflammatory arthritis, and cartilage repair procedures.

Osteoid osteoma of the spine treated with percutaneous computed tomography-guided thermocoagulation.

STUDY DESIGN: Two cases are reported in which an osteoid osteoma of the lumbar spine was treated with CT-guided thermocoagulation. OBJECTIVES: To review an alternative and minimally invasive treatment for spinal osteoid osteomas. SUMMARY OF BACKGROUND DATA: Surgical resection of a spinal osteoid osteoma can, depending on the location, be a formidable undertaking. Bone scintigraphy can be helpful in intraoperative identification. More recently, resection through a computed tomography-guided drill hole was found to minimize exposure. Using a thermocoagulation probe, as has been used in osteoid osteoma of the extremities, may be technically easier and cause less morbidity. METHOD: With the patient under general anesthesia, a bone biopsy cannula was introduced into the center of the osteoid osteoma. Material was subjected to histologic examination. A thermocoagulation probe was then inserted and heated to 90 C for 4 minutes. The two patients were kept overnight for observation. RESULTS: Both patients had complete pain relief and no evidence of recurrence after 2 years' follow-up. There were no complications. Scoliosis resolved in one patient and persisted in the other. CONCLUSION: Percutaneous computed tomography-guided thermocoagulation is a minimally invasive and technically straightforward method to achieve ablation of a spinal osteoid osteoma. No complications were encountered in these two patients. Future research should focus on the safety of thermocoagulation, especially cephalad to the level of the conus medullaris.

Ultrasound in musculoskeletal tumors with emphasis on its role in tumor follow-up.

Ultrasonography allows visualization of musculoskeletal masses that are not confined to the intraosseous compartment and assists in the determination of the consistency of such masses. Making a specific diagnosis using ultrasonography is hampered by the lack of specificity; however, it may be an indicator in guiding diagnostic needle biopsy, especially in large heterogeneous tumors. Color Doppler flow imaging allows visualization of blood flow within solid soft tissue masses. Probably, CDFI features do not assist in differentiation between malignant and benign tumors; however, it has proved to be a useful tool to monitor regression of tumor neovascularity induced by therapy in patients with musculoskeletal sarcoma. When recurrence of a soft tissue sarcoma is clinically suspected, ultrasonography can be used as the initial imaging technique for evaluation. Ultrasonography can also be used in addition to MR imaging when susceptibility artifacts secondary to orthopedic hardware (including prostheses) prevent evaluation of specific areas.

US of the ankle: technique, anatomy, and diagnosis of pathologic conditions.

For specific indications, ultrasound (US) is an efficient and inexpensive alternative to magnetic resonance (MR) imaging for evaluation of the ankle. In addition to the tendons and tendon sheaths, other ankle structures demonstrated with US include the anterior joint space, retrocalcaneal bursa, ligaments, and plantar fascia. Ankle US allows detection of tenosynovitis and tendinitis, as well as partial and complete tendon tears. Joint effusions, intraarticular bodies, ganglion cysts, ligamentous tears, and plantar fasciitis can also be diagnosed. As pressure for cost containment continues, demand for US of the ankle may increase given its lower cost compared with that of MR imaging. In most cases, a focused ankle US examination can be performed more rapidly and efficiently than MR imaging. Familiarity with the technique of ankle US, normal US anatomy, and the US appearances of pathologic conditions will establish the role of US as an effective method of imaging the ankle.

US depiction of partial-thickness tear of the rotator cuff.

PURPOSE: To test previously defined ultrasound (US) criteria for identification of partial-thickness tears of the rotator cuff. MATERIALS AND METHODS: Before shoulder arthroscopy, 52 patients with shoulder pain for more than 3 months were examined with a 7.5-MHz commercially available linear-array transducer and a standardized study protocol. The criteria used to detect partial-thickness tears were (a) a mixed hyper- and hypoechoic focus in the crucial zone of the supraspinatus tendon and (b) a hypoechoic lesion visualized in two orthogonal imaging planes with either articular or bursal extension. RESULTS: The US findings were reported as partial-thickness tears in 17 shoulders, of which three were false-positive findings. There was one false-negative finding. The sensitivity of US in depiction of partial-thickness tears was 93%, and specificity was 94%. The positive predictive value was 82%, and the negative predictive value was 98%. CONCLUSION: US can depict most partial-thickness tears with use of the criteria described.

CT and MR in infants with pericerebral collections and macrocephaly: benign enlargement of the subarachnoid spaces versus subdural collections.

PURPOSE: To compare CT and MR in the differentiation of benign enlargement of the subarachnoid spaces and subdural collections in infants with macrocephaly. METHODS: MR was performed in 19 infants with macrocephaly, showing bifrontal enlargement of the subarachnoid spaces on CT. RESULTS: In 11 patients, a single fluid layer could be distinguished on MR of the pericerebral collections, suggesting benign enlargement of the subarachnoid spaces. In eight patients, two separate layers were clearly differentiated, an outer layer that was hyperintense on all sequences and an inner layer with the same intensity as the cerebrospinal fluid. This indicated the presence of subdural collections. These collections were mainly frontal in six and extended over the entire hemisphere in two patients. On CT, these separate lesions were seen only in three patients and missed in three others. In two final patients, CT findings were equivocal with evidence of membrane formation within the hypodense collections. In seven patients with a subdural collection, subdural-external drainage was performed. In three patients, the collection was hemorrhagic. The protein content of the fluid showed a mean of 1381.7 +/- 785.6 mg/dL. The MR and surgical findings of a subdural collection correlated with the absence of a family history of macrocrania, an age under 5 months, and acute clinical signs of vomiting, somnolence, and hypotonia. CONCLUSION: MR appears essential in the differential diagnosis between benign enlargement of the subarachnoid spaces and subdural collections in infants.

[Prenatal bowing of the long bones]. / De prenatale buiging van lange beenderen.

A case of congenital angulation and bowing of the long bones is reported. The condition belongs to a group of bone pathologies which have as a common feature an abnormal bowing of the diaphysis. The cortex at the concave side shows a thickening while the convex side shows a cortical thinning, corresponding to a structural adaptation to external compressing forces at the site of the bowing of the bone. The angulation is a consequence of bowing of long bones over other foetal parts.