A Prospective Cohort Study Characterizing Incidence of Dural Venous Sinus Thrombosis in Traumatic Brain Injury Patients with Skull Fractures.

BACKGROUND: Limited retrospective data suggest that dural venous sinus thrombosis (DVST) in traumatic brain injury (TBI) patients with skull fractures is common and associated with significant morbidity and mortality. Prospective data accurately characterizing the incidence of DVST in patients with high-risk TBI are sparse but are needed to develop evidence-based TBI management guidelines. METHODS: After obtaining institutional approval, 36 adult patients with TBI with skull fractures admitted to an Australian level III adult intensive care unit between April 2022 and January 2023 were prospectively recruited and underwent computed tomography venography or magnetic resonance venography within 72 hours of injury. When available, daily maximum intracranial pressure was recorded. RESULTS: Dural venous sinus abnormality was common (36.1%, 95% confidence interval 22.5%-52.4%) and strongly associated with DVST (P = 0.003). The incidence of DVST was 13.9% (95% confidence interval 6.1%-28.7%), which was lower than incidence reported in previous retrospective studies. Of DVSTs confirmed by computed tomography venography, 80% occurred in patients with extensive skull fractures including temporal or parietal bone fractures in conjunction with occipital bone fractures (P = 0.006). However, dural venous sinus abnormality and DVST were not associated with an increase in maximum daily intracranial pressure within the first 7 days after injury. CONCLUSIONS: Dural venous sinus abnormality was common in TBI patients with skull fractures requiring intensive care unit admission. DVST was confirmed in more than one third of these patients, especially patients with concomitant temporal or parietal and occipital bone fractures. Computed tomography venography is recommended for this subgroup of TBI patients.

Angioembolisation for arterial haemorrhage related to pelvic ring injury.

INTRODUCTION: Haemorrhage related to pelvic fractures has been associated with mortality rates of up to 50%. Angioembolisation for the management of pelvic haemorrhage was performed as early as 1972; however, there remains uncertainty over its exact use, timing and priority as a component of modern pelvic management protocols. METHODS: We retrospectively analysed cases of angioembolisation for arterial haemorrhage related to pelvic ring fractures at a level 1 trauma centre. Patient demographics were assessed as well as the time taken to reach the interventional radiology (IR) suite from the time of trauma and also arriving at the emergency room (ER). Other factors analysed included the volume of blood products consumed and fracture pattern. RESULTS: Fifty-four patients received pelvic angiography for pelvic ring injuries between 2006 and 2021. The average age was 45.1 (20.5) years, with the male to female ratio 2.4:1. Forty (74.1%) of these patients had embolisation to actively bleeding pelvic arterial vessels. Median time to the IR was 4.4 [IQR 3.1-8.1] hours from time of trauma and 2.5 [IQR 2.1-4.2] hours from arrival to ER. The overall mortality rate was 18.5% and the median amount of blood transfused was 4584 mL [IQR 1643.5-8026.5]. In the subset of embolised patients (n = 40), mortality rate was 10% and there was an inverse association between time from ER to IR and volume of blood product consumption (P = 0.024). CONCLUSION: Angioembolisation is a life-saving intervention in very severely injured patients and is growing in popularity as a component of modern pelvic trauma management protocols.

Towards the Development of an Integrative, Evidence-Based Suite of Indicators for the Prediction of Outcome Following Mild Traumatic Brain Injury: Results from a Pilot Study.

BACKGROUND: Persisting post-concussion symptoms (PPCS) is a complex, multifaceted condition in which individuals continue to experience the symptoms of mild traumatic brain injury (mTBI; concussion) beyond the timeframe that it typically takes to recover. Currently, there is no way of knowing which individuals may develop this condition. METHOD: Patients presenting to a hospital emergency department (ED) within 48 h of sustaining a mTBI underwent neuropsychological assessment and demographic, injury-related information and blood samples were collected. Concentrations of blood-based biomarkers neuron specific enolase, neurofilament protein-light, and glial fibrillary acidic protein were assessed, and a subset of patients also underwent diffusion tensor-magnetic resonance imaging; both relative to healthy controls. Individuals were classified as having PPCS if they reported a score of 25 or higher on the Rivermead Postconcussion Symptoms Questionnaire at ~28 days post-injury. Univariate exact logistic regression was performed to identify measures that may be predictive of PPCS. Neuroimaging data were examined for differences in fractional anisotropy (FA) and mean diffusivity in regions of interest. RESULTS: Of n = 36 individuals, three (8.33%) were classified as having PPCS. Increased performance on the Repeatable Battery for the Assessment of Neuropsychological Status Update Total Score (OR = 0.81, 95% CI: 0.61-0.95, p = 0.004), Immediate Memory (OR = 0.79, 95% CI: 0.56-0.94, p = 0.001), and Attention (OR = 0.86, 95% CI: 0.71-0.97, p = 0.007) indices, as well as faster completion of the Trails Making Test B (OR = 1.06, 95% CI: 1.00-1.12, p = 0.032) at ED presentation were associated with a statistically significant decreased odds of an individual being classified as having PPCS. There was no significant association between blood-based biomarkers and PPCS in this small sample, although glial fibrillary acidic protein (GFAP) was significantly increased in individuals with mTBI relative to healthy controls. Furthermore, relative to healthy age and sex-matched controls (n = 8), individuals with mTBI (n = 14) had higher levels of FA within the left inferior frontal occipital fasciculus (t (18.06) = -3.01, p = 0.008). CONCLUSION: Performance on neuropsychological measures may be useful for predicting PPCS, but further investigation is required to elucidate the utility of this and other potential predictors.

Improved accuracy of CT based measurements for anterior prominence of acetabular prosthesis using a novel protocol based on anatomical landmarks.

BACKGROUND: Anterior hip pain after total hip replacement (THR) can be caused by iliopsoas impingement (IPI). Validation of CT measured cup version is well published; however quantification of the anterior cup prominence has not been validated. Therefore, we did an in vitro study aiming to: (1) assess the accuracy of the current method of measuring the prominence of the acetabular component using a dry bone model; (2) develop a CT protocol based on bony anatomical landmarks that improves the accuracy of these measurements. HYPOTHESIS: We hypothesise that utilising reproducible anatomical landmarks on the acetabulum will improve the accuracy of measurement of anterior prominence at the psoas valley. METHODS: A dry bone pelvic model was implanted with bilateral acetabular cups. The cup was manipulated into ten different combinations of inclination and version, and anterior prominence directly measured in relation to the acetabular rim. A CT scan was performed for each position. Anterior prominence was then measured by two radiologists, first using standard methods (axial slice at level of centre of femoral head) and then again using a novel protocol (based on the position of the psoas valley in relation to the inferior medial acetabular notch). RESULTS: Mean errors between direct measurement of anterior prominence and radiologist reported measurements using standard protocol were 6.94mm±5.24 (SD) (95%Confidence Interval: 3.25-4.27) and 5.14mm±3.07 (95%CI: 1.9-2.5) with a tendency towards overestimation of prominence. Using an anatomical landmark based protocol; mean error was reduced to 3.0mm±1.9 (95%CI: 1.16-1.53) and 4.3mm±4.3 (95%CI: 2.67-351) on the first attempt, and to 1.7mm±1.9 (95%CI: 1.15-1.52) and 2.1mm±1.4 (95%CI: 0.87-1.15) on the second attempt. Concordance correlation improved from 0.43 (95% CI: 0.19-0.68) and 0.59 (95% CI: 0.44-0.79) using the standard protocol, to 0.88 (95%CI: 0.61-0.91) and 0.9 (95%CI: 0.56-0.92) using the novel protocol. CONCLUSIONS: There is a difference in mean error and reliability between radiologically measured values for anterior prominence and values measured directly with present methods. The use of our novel protocol based on bony acetabular landmarks, significantly improves the accuracy of measurement. This protocol may improve reproducibility and the accuracy of this measurement and aid in the decision between tenotomy or revision of the acetabular component. LEVEL OF EVIDENCE: III, in vitro study comparing diagnostic tools.

Taking heed of the 'danger space': acute descending necrotising mediastinitis secondary to primary odontogenic infection.

Descending necrotising mediastinitis (DNM) is an uncommon clinical entity which may arise secondary to primary odontogenic or neck infection in susceptible patients. Infection may spread contiguously via the alar or 'danger' space, a potential anatomical space posterior to the true retropharyngeal space.1 Spread of infection to the mediastinum almost always necessitates urgent cardiothoracic surgical intervention.2-4 This case report describes a male patient whose clinical deterioration following the diagnosis of submandibular abscess was investigated with CT imaging of the chest, where a diagnosis of DNM was made. Diagnosis was confirmed following surgical intervention and aspiration of pus from the mediastinum.

Lipoprotein metabolism in an apoB-80 familial hypobetalipoproteinemia heterozygote.

OBJECTIVE: Familial hypobetalipoproteinemia (FHBL) is characterized by mutations in APOB, the majority of these causing protein truncations, and low plasma levels of apolipoprotein (apo) B. The hypobetalipoproteinemia may be due to enhanced clearance and possibly reduced production of apoB-containing lipoproteins; the mechanism may depend on the length of the apoB truncation. We studied fasting lipoprotein metabolism in an FHBL subject heterozygous for a mutation causing a truncated apoB, apoB-80. DESIGN AND METHODS: Very low density lipoprotein (VLDL)-, intermediate density lipoprotein (IDL)-, and low density lipoprotein (LDL)-apoB kinetics were determined in the fasting state using stable isotope methods and compartmental modeling. RESULTS: Compared with lean normolipidemic controls the apoB-80 FHBL subject had an elevated VLDL-apoB fractional catabolic rate and lower LDL production. ApoB production rates and IDL- and LDL-apoB fractional catabolic rates were not different. CONCLUSION: FHBL subjects heterozygous for a mutation truncating apoB to 80% of full-length are able to produce VLDL-apoB normally, but have rapid clearance of these particles, resulting in low levels of circulating apoB.

Lipoprotein Metabolism in APOB L343V Familial Hypobetalipoproteinemia.

CONTEXT: Familial hypobetalipoproteinemia (FHBL) is a codominant disorder of lipoprotein metabolism characterized by decreased plasma concentrations of low-density lipoprotein (LDL)-cholesterol and apolipoprotein B (apoB). OBJECTIVE: The objective was to examine the effect of heterozygous APOB L343V FHBL on postprandial triglyceride-rich lipoprotein (TRL) and fasting lipoprotein metabolism. METHODS: Plasma incremental area under the curve apoB-48 and apoB-48 kinetics were determined after ingestion of a standardized oral fat load using compartmental modeling. Very low-density lipoprotein (VLDL)-, intermediate-density lipoprotein (IDL)-, and LDL-apoB kinetics were determined in the fasting state using stable isotope methods and compartmental modeling. RESULTS: The postprandial incremental area under the curve (0-10 h) in FHBL subjects (n = 3) was lower for large TRL-triglyceride (-77%; P < .0001), small TRL-cholesterol (-83%; P < .001), small TRL-triglyceride (-88%; P < .001), and for plasma triglyceride (-70%; P < .01) and apoB (-63%; P < .0001) compared with controls. Compartmental analysis showed that apoB-48 production was lower (-91%; P < .05) compared with controls. VLDL-apoB concentrations in FHBL subjects (n = 2) were lower by more than 75% compared with healthy, normolipidemic control subjects (P < .01). The VLDL-apoB fractional catabolic rate (FCR) was more than 5-fold higher in the FHBL subjects (P = .07). ApoB production rates and IDL- and LDL-apoB FCRs were not different between FHBL subjects and controls. CONCLUSIONS: We conclude that when compared to controls, APOB L343V FHBL heterozygotes show lower TRL production with normal postprandial TRL particle clearance. In contrast, VLDL-apoB production was normal, whereas the FCR was higher in heterozygotes compared with lean control subjects. These mechanisms account for the marked hypolipidemic state observed in these FHBL subjects.

Nucleus pulposus deformation in response to rotation at L1-2 and L4-5.

BACKGROUND: Spinal rotation couples with lateral flexion as a composite movement. Few data report the in vivo mechanical deformation of the nucleus pulposus following sustained rotation. MRI provides a non-invasive method of examining nucleus pulposus deformation by mapping the hydration signal distribution within the intervertebral disc. METHODS: T1 weighted coronal and sagittal lumbar images and T2 weighted axial images at L1-2 and L4-5 were obtained from 10 asymptomatic subjects (mean age 29, range: 24-34 years) in sustained flexed and extended positions plus combined positions of left rotation with flexion and extension. Nucleus pulposus deformation was tracked by mapping the change in hydration profiles from coronal and sagittal pixel measurements. FINDINGS: An average sagittal change in position of 44° (SD 14.5°) from flexion to extension was recorded between L1 and S1 (range: 18°- 60°) resulting in a mean anterior nucleus pulposus deformation of 16% of disc hydration profile (range: 3.5%-19%) in 19/20 discs. When rotation was combined with either flexion or extension, mean coronal deformation was 4.8% (SD-5.1%; range: 0.4%-15%). Lateral nucleus pulposus deformation direction varied in rotation (44% deformed left and 56% deformed right). Intersegmental lateral flexion direction more strongly predicted nucleus pulposus deformation direction with 75% deforming contralaterally. INTERPRETATION: Nucleus pulposus deformation direction in young subjects was more predictable following sagittal position change than in rotation combined with flexion or extension. Deformation magnitude was reduced in rotated positions. Intersegmental lateral flexion was a stronger predictor of nucleus pulposus deformation direction.

B vitamins and magnetic resonance imaging-detected ischemic brain lesions in patients with recent transient ischemic attack or stroke: the VITAmins TO Prevent Stroke (VITATOPS) MRI-substudy.

BACKGROUND AND PURPOSE: Elevated concentrations of homocysteine are associated with cerebral small vessel disease (CSVD). B-vitamin supplementation with folate and vitamins B12 and B6 reduces homocysteine concentrations. In a substudy of the VITAmins TO Prevent Stroke (VITATOPS) trial, we assessed the hypothesis that the addition of once-daily supplements of B vitamins would reduce the progression of CSVD-related brain lesions. METHODS: A total of 359 patients with recent stroke or transient ischemic attack, who were randomly allocated to double-blind treatment with placebo or b vitamins, underwent brain MRI at randomization and after 2 years of B-vitamin supplementation. MR images were analyzed blinded to treatment allocation. Outcomes related to the prespecified hypothesis were progression of white matter hyperintensities and incident lacunes. We also explored the effect of B-vitamin supplementation on the incidence of other ischemic abnormalities. RESULTS: After 2 years of treatment with b vitamins or placebo, there was no significant difference in white matter hyperintensities volume change (0.08 vs 0.13 cm3; P=0.419) and incidence of lacunes (8.0% vs 5.9%, P=0.434; odds ratio=1.38). In a subanalysis of patients with MRI evidence of severe CSVD at baseline, b-vitamin supplementation was associated with a significant reduction in white matter hyperintensities volume change (0.3 vs 1.7 cm3; P=0.039). CONCLUSIONS: Daily B-vitamin supplementation for 2 years did not significantly reduce the progression of brain lesions resulting from presumed CSVD in all patients with recent stroke or transient ischemic attack but may do so in the subgroup of patients with recent stroke or transient ischemic attack and severe CSVD. CLINICAL TRIAL REGISTRATION: http://vitatops.highway1.com.au/. Unique identifier: NCT00097669 and ISRCTN74743444.

Thymic tissue is not evident on high-resolution computed tomography and [¹8F]fluoro-deoxy-glucose positron emission tomography scans of aviraemic HIV patients with poor recovery of CD4⁺ T cells.

Some previously immunodeficient HIV patients responding to antiretroviral therapy display poor recovery of CD4⁺ T cells. Evaluation of the contribution of thymic function requires sensitive detection and quantitation of metabolically active thymic tissue. We describe patients with low but detectable thymopoiesis assessed as circulating CD4⁺ naive T cells expressing CD31. High-resolution computed tomography and PET scans found no residual thymic tissue even though metabolic activity was demonstrable by PET in lymph nodes.

Treatment of refractory anterior knee pain using botulinum toxin type A (Dysport) injection to the distal vastus lateralis muscle: a randomised placebo controlled crossover trial.

OBJECTIVES: This randomised controlled crossover trial examined the efficacy of botulinum toxin type A (BoNT-A) injection, plus an exercise programme, to remediate chronic anterior knee pain (AKP) associated with quadriceps muscle imbalance. METHODS: 24 individuals with refractory AKP received either BoNT-A (500 U Dysport) or the same volume saline injection to the vastus lateralis (VL) muscle and performed home exercises focusing on re-training the vastus medialis (VM) muscle. All subjects were offered open-label injection at 12 weeks. Knee-related disability (anterior knee pain scale; AKPS) and activity-induced pain (10 cm visual analogue scale) at 12 weeks were the primary outcomes. Peak isometric extensor force was recorded and normalised VL:VM ratios were derived from simultaneous surface electromyography. Self-reported pain and disability measures were collected at six time points to a mean of 20±8 months. RESULTS: 14 subjects received BoNT-A and 10 placebo injection. Improvement at 12 weeks was significantly greater for BoNT-A compared with placebo-injected subjects for the AKPS (p<0.03), pain on kneeling (p<0.004), squatting (p<0.02) and level walking (p<0.04). At week 12, five placebo subjects crossed over to open-label injection. At 24 weeks, 16 of 19 BoNT-A-injected and two of the remaining five placebo-injected subjects were either satisfied or very satisfied with treatment outcomes. Improvements were maintained in 11 of 14 BoNT-A-injected and two of five placebo subjects available at longer-term follow-up. CONCLUSION: BoNT-A injection produced a greater reduction in pain and disability than placebo injection in carefully selected patients with chronic AKP related to quadriceps muscle imbalance.

Brain abnormalities detected on magnetic resonance imaging of amphetamine users presenting to an emergency department: a pilot study.

OBJECTIVES: To determine the prevalence of occult brain abnormalities in magnetic resonance imaging of active amphetamine users. DESIGN, SETTING AND PARTICIPANTS: Prospective convenience study in a tertiary hospital emergency department (ED). Patients presenting to the ED for an amphetamine-related reason were eligible for inclusion. We collected demographic data, drug use data, and performed a mini-mental state examination (MMSE). MAIN OUTCOME MEASURES: The proportion of patients with an abnormality on their MRI scan. RESULTS: Of 38 patients enrolled, 30 had MRI scans. Nineteen were male and their mean age was 26.7 +/- 5.4 years (range 19-41 years). The mean age of first amphetamine use was 18 years (range 13-26 years). Sixteen patients used crystal methamphetamine (mean amount 2.5 g/week), nine used amphetamine ("speed") (mean amount 2.9 g/week), and 23 used ecstasy (mean amount 2.3 tablets/week). Marijuana was smoked by 26 (mean amount 5.9 g/week), and 28 drank alcohol (mean amount 207 g/week). The median MMSE score was 27/30 (interquartile range, 26-29). Abnormalities on brain MRI scans were identified in six patients, most commonly an unidentified bright object (n = 4). CONCLUSION: In this pilot study of brain MRI of young people attending the ED with an amphetamine-related presentation, one in five had an occult brain lesion. While the significance of this is uncertain, it is congruent with evidence that amphetamines cause brain injury.

Bridging the communication gap between public and private radiology services.

The delay in transfer of imaging studies when a patient moves between hospitals and between public and private systems has been a barrier to expedient and safe patient management. There is also suboptimal reporting when patients have serial imaging undertaken partly in the private sector and partly in the public sector, because of inability to access previous imaging for comparison. Availability of a DICOM (Digital Imaging and Communications in Medicine) server enables sharing of health information, including imaging data, across various sites and jurisdictions. In Perth, Western Australia, we have successfully introduced electronic image transfer between five public teaching hospitals and three large private practices with different picture archiving and communication systems.

Humoral factors enhance fracture-healing and callus formation in patients with traumatic brain injury.

BACKGROUND: Scientific evidence is mounting for an association between traumatic brain injury and enhanced osteogenesis. The aim of this study was to correlate the in vitro osteoinductive potential of serum with the features of fracture-healing and the extent of brain damage in patients with severe traumatic brain injury and bone fracture. METHODS: Patients with a long-bone fracture and a traumatic brain injury (seventeen patients) or without a brain injury (twenty-four patients) were recruited. The Glasgow Coma Scale score was determined on admission. Radiographs of the fracture were made before surgery, at six weeks, and at three, six, and twelve months after surgery. The time to union was estimated clinically and radiographically, and the callus ratio to shaft diameter was calculated. Serum samples were collected at six, twenty-four, seventy-two, and 168 hours after injury, and their osteogenic potential was determined by measurement of the in vitro proliferation rate of the human fetal osteoblastic cell line hFOB1.19. RESULTS: Patients with a traumatic brain injury had a twofold shorter time to union (p = 0.01), a 37% to 50% increased callus ratio (p < 0.01), and their sera induced a higher proliferation rate in hFOB cells (p < 0.05). A linear relationship was revealed between hFOB cell proliferation rates and the amount of callus formed (p < 0.05). The Glasgow Coma Scale score was correlated with the callus ratio on both radiographic projections (p < 0.05), time to union (p = 0.04), and the proliferation rate of hFOB cells at six hours after injury (p = 0.03). CONCLUSIONS: Patients with a severe brain injury release unknown humoral factors into the blood circulation that enhance and accelerate fracture-healing.

Clinical utility of calcaneal quantitative ultrasonometry and thoracic kyphosis assessments in identifying vertebral fractures in community settings.

OBJECTIVE: Individuals with existing vertebral fractures may not be aware that they are at high risk of subsequent fractures. We investigated if calcaneal quantitative ultrasonometry (QUS) and assessment of thoracic kyphosis could discriminate a group of older women with prevalent vertebral fracture from those without. METHODS: One hundred four women (mean age 71.3 +/- 5.8 yrs) underwent dual-energy x-ray absorptiometry (DEXA) bone mineral density (BMD; lumbar spine and hip), calcaneal QUS, and video rasterstereographic thoracic kyphosis measurements. They were dichotomized into a group with prevalent vertebral fracture (VF, n = 24) or without vertebral fracture (NVF, n = 80). RESULTS: Univariate variables associated with the VF group included broadband ultrasound attenuation (BUA; age-adjusted OR 1.96, 95% CI 1.12-3.42, p = 0.018); speed of sound (SOS; age-adjusted OR 2.01, 95% CI 1.09-3.70, p = 0.026); and thoracic kyphosis (age-adjusted OR 1.72, 95% CI 1.01-2.92, p = 0.049). A composite model (BUA and thoracic kyphosis) had higher area under the receiver-operating characteristic curve (AUC = 0.75) compared to lumbar spine DEXA BMD (AUC = 0.50, p = 0.0004) and total hip DEXA BMD (AUC = 0.60, p = 0.057). CONCLUSION: Reduced calcaneal QUS values and greater thoracic kyphosis were found to be significantly associated with the group of women with prevalent vertebral fractures. A composite risk score (BUA and thoracic kyphosis) had better discriminatory power than the individual risk factor of (low) DEXA BMD.

An MRI investigation of intervertebral disc deformation in response to torsion.

BACKGROUND: The nucleus pulposus deforms towards an area of least compression in response to offset loading, however, there is a lack of data reporting the deformation patterns of nuclear material in rotated positions of the lumbar spine. Our purpose was to assess a novel methodology using MRI to track nuclear deformation in response to flexion and extension positions, and the combined positions of flexion with left rotation and extension with left rotation, at L1-2 and L4-5. METHODS: Three asymptomatic female subjects, mean age 27 years, underwent T2 weighted MRI sequences in flexed, extended, and left rotated positions combined with flexion and extension. A pixel profile technique was employed to determine direction and magnitude of nuclear deformation. RESULTS: In 5 of 6 discs examined, deformation of the nucleus occurred anteriorly in extension and posteriorly in flexion. Left rotation resulted in migration of nuclear material to the right in 9 of 12 discs. Of the three discs that demonstrated a right nuclear migration, two occurred at L4-5 and one at L1-2. INTERPRETATION: This methodology demonstrated that nucleus pulposus deformation can be measured reliably in various positions achieved within the confines of the MRI. The consistent migration of nuclear material following sagittal plane movement and the less consistent response to rotation positions suggest other asymmetrical loading on the intervertebral disc may accompany rotation.

Identification and staging of pancreatic tumours using computed tomography, endoscopic ultrasound and mangafodipir trisodium-enhanced magnetic resonance imaging.

Pancreatic malignancy can be staged by a number of different investigations, either alone or in combination. The purpose of the present study was to compare the use of endoscopic ultrasound, CT and mangafodipir trisodium-enhanced MRI for the staging of pancreatic malignancy, particularly with respect to determining resectability prior to surgery. Twenty-seven patients referred for the investigation of a suspected pancreatic malignancy were entered into the trial. All patients had contrast-enhanced CT, gadolinium and mangafodipir trisodium-enhanced MRI, and endoscopic ultrasound (EUS). Images were assessed for nodal staging, tumour staging and resectability for each investigation, and the results compared with findings at surgery. The results for the accuracy of MRI, CT and EUS, in detecting T4 disease versus T3 or lower was 78, 79 and 68%, respectively; nodal involvement was 56, 63 and 69%, respectively; and overall resectability (including the T stage, presence of involved nodes and metastases) was 83, 76 and 63%, respectively. There was no significant difference demonstrated between the three tests. The present study suggests that for patients referred for investigation and staging of pancreatic malignancy, EUS and MRI scanning convey little advantage over contrast-enhanced CT. Furthermore, although mangafodipir trisodium improved the conspicuity of pancreatic tumours, it has little influence on T staging.

Unilateral lumbosacral facet joint dislocation without associated fracture.

In the lumbosacral spine, unilateral facet joint dislocation is an infrequent injury, which is often associated with fractures at the involved or other lumbar levels. The rare occurrence of unilateral lumbosacral facet joint dislocation without any associated fractures is presented with CT and MRI, and surgical correlation. To our knowledge, cross-sectional imaging of this injury has not previously been described in the published literature.