High-resolution outpatient imaging of the wrist.

The authors describe their experience with magnetic resonance imaging (MRI) in the evaluation of pathologic conditions of the wrist in an outpatient setting. In that setting, because time and quality are both important factors, they have concentrated on developing protocols that will allow effective, time-efficient, high-resolution MRI of the wrist. With these wrist imaging protocols, they have evaluated the majority of commonly encountered pathologic conditions of the wrist. They have found that high-resolution images, which can be acquired in a very timely fashion when fast spin echo sequences are used in imaging protocols, will demonstrate the most common pathologic conditions, including triangular fibrocartilage and ligament tears in the wrist. They present the practical issues of patient position and imaging sequences as well as the imaging findings in those pathologic conditions.

Sonographic appearance of nonoperatively treated Achilles tendon ruptures.

OBJECTIVE: This report describes the gray-scale and color Doppler sonographic appearance of healed Achilles tendon ruptures that have been treated nonoperatively. DESIGN AND PATIENTS: Eleven patients with acute Achilles tendon ruptures were studied with sonography in the acute setting and following nonoperative management of their torn tendon. RESULTS: On sonographic examination, healed tendons treated nonoperatively are characterized by mild residual distortion of the normal fibrillar architecture of the tendon, anterior bulging or irregularity of the healed tendon, and a hypoechoic area about the site of rupture. Less frequent observations include mildly increased color flow and calcification at the rupture site. The previously described findings of acute tears, including hematomas, gaps at the rupture site, hyperemic torn tendon ends, and markedly distorted fibrillar architecture, were seen to have resolved in this series. CONCLUSION: The Achilles tendon tear treated nonoperatively has a different sonographic appearance from that of a normal or acutely ruptured tendon.

Associations between patient report of symptoms and anatomic impairment visible on lumbar magnetic resonance imaging.

STUDY DESIGN: A cross-sectional study comparing the relationship of symptoms with anatomic impairment visible on lumbar magnetic resonance imaging in 408 symptomatic subjects. OBJECTIVE: To determine how various anatomic impairments, including the magnitude and location of nerve compression visible on lumbar magnetic resonance imaging, are associated with patient reports of pain, weakness, and dysesthesia. SUMMARY AND BACKGROUND DATA: Anatomic impairments of the intervertebral disc, radicular canal, and associated soft tissues are prevalent in people with and those without low back pain or lower extremity radiculopathy. This has led to confusion in differentiating between symptom generators and benign variation visible on lumbar magnetic resonance imaging. Recent literature has suggested that the presence of nerve compression is an important finding in the prediction of symptoms. However, the threshold for meaningful nerve compression has not been described. METHODS: In this study, 408 participants undergoing a diagnostic workup for low back pain, radiculopathy, and/ or completed a survey and pain drawing. Participants underwent standardized lumbar magnetic resonance imaging using a 1.5-T scanner. Two classification systems describing the spatial distribution of symptoms were developed. An additional system to quantify the magnitude of nerve and thecal sac compression was created. All systems were assessed for reliability, after which comparisons among variables were performed using Chi2 as well as simple and multiple logistic regression analysis. RESULTS: The reliability coefficients for categorizing patients on the basis of pain drawing ranged from 0. 75 to 0.88. The S1-S2 segmental distribution was the most commonly reported location of symptoms, followed by L4-L5. The most common magnetic resonance imaging diagnosis was "unremarkable," followed by "disc impairment without nerve compression." Disc extrusion was present in 10.8% of participants. The reliability of classifying nerve compression visible on magnetic resonance imaging ranged from 0.27 to 1. Nerve compression was present in 37% of participants, and 18% had severe nerve compression. There were no significant associations between segmental distribution of symptoms and the presence of anatomic impairment. However, according to a collapsed classification scale, severe nerve compression and disc extrusion were predictive of pain distal to the knee (odds ratios, 2.72 and 3. 34). The self-report of weakness was associated mildly with severe nerve compression and disc extrusion, but not with other findings. Magnetic resonance imaging findings did not predict self-reports of dysesthesia. CONCLUSIONS: The presence of disc extrusion and/or ipsilateral, severe nerve compression at one or multiple sites is strongly associated with distal leg pain. Mild to moderate nerve compression, disc degeneration or bulging, and central spinal stenosis are not significantly associated with specific pain patterns. Although segmental distributions of pain can be determined reliably from pain drawings, this finding alone is of little use in predicting lumbar impairment. The self-report of lower extremity weakness or dysesthesia is not significantly related to any specific lumbar impairments. [Key words: back pain, diagnosis, magnetic resonance imaging, nerve compression, pain drawing, pathology]

Radiologic consultation: effect on inpatient diagnostic imaging evaluation in a teaching hospital.

RATIONALE AND OBJECTIVES: The authors evaluated radiologic consultation affecting resident physician ordering of relatively expensive imaging studies. METHODS: Requisitions (n = 180) for expensive imaging studies from three general medicine floors (two consultation floors, one control floor) were prospectively evaluated. Information on the requisitions was classified as appropriate, inappropriate, or undecided if insufficient information was provided. On the consultation floors, but not the control floor, the medical residents were contacted about all studies initially considered inappropriate or undecided before they were performed. RESULTS: Nine of 119 requisitions (7.6%) from the consultation floors were considered inappropriate. In three studies (2.5%) the imaging evaluation was modified as the result of the interaction with the radiologist. There was no significant difference in the total number of radiologic studies or percentage of the total that were expensive imaging studies when comparing the consultation floors with the control floor. CONCLUSION: Radiologic consultation on expensive imaging studies through routine review of requisitions did not significantly change their use by house staff.

Glucagon-induced small intestinal hypotonia demonstrating bleeding lymphoma.

While a patient was being evaluated for melena, a glucagon-induced hypotonic examination of the small intestine demonstrated a small ulcerated mass in the jejunum. The tubeless hypotonic examination was performed after multiple gastrointestinal series, small intestinal series, barium enemas, and visceral arteriography--including celiac and superior mesenteric arteriograms--failed to identify a bleeding site. Surgical exploration revealed three ulcerated lymphomatous lesions in the jejunum. The lack of side effects, rapidity of onset, and shortness of duration of intravenous glucagon suggest that this type of hypotonic examination of the small intestine may prove useful as an adjunct to the small intestinal series.

Extraosseous multiple myeloma simulating primary prostatic neoplasm.

The first case of multiple meyloma presenting clinically with extraskeletal prostatic involvement simulating a primary prostatic neoplasm is reported. The clinical course, pathology, and serum and urine protein findings are discussed.