Finger Pain as an Uncommon Primary Manifestation of Lung Carcinoma.

A 54-year-old patient presented with progressive pain for one month in the second finger of the right hand with an emphasis on the proximal interphalangeal (PIP) joint. Subsequent magnetic resonance imaging (MRI) showed a diffuse intraosseous lesion at the base of the middle phalanx with destruction of the cortical bone and extraosseous soft tissue. An expansively growing chondromatous bone tumor, e.g., a chondrosarcoma, was suspected. After incisional biopsy, the pathologic findings finally revealed, surprisingly, a metastasis of a poorly differentiated non-small cell adenocarcinoma of the lung. This case illustrates a rare but important differential diagnosis for painful finger lesions.

Clinical and radiological mid- to long-term investigation of anterior lumbar stand-alone fusion: Incidence of reoperation and adjacent segment degeneration.

Introduction: Anterior stand-alone fusion (ASAF) devices have been developed in an attempt to reduce adjacent segment degenerative changes observed with posterior instrumented fusion techniques. Research question: The purpose of this study was to assess mid- to long-term clinical and radiological results following ASAF at the lumbosacral junction with special emphasis on the assessment of adjacent level pathologies.Materials & Methods: Clinical outcome scores and radiological data were acquired within an ongoing single-center prospective cohort study. Progression of adjacent level degeneration was evaluated based on MRI scans according to the Pfirrmann and Weishaupt classification system by two independent radiologists. Results: The results from 37 patients (FU â€‹≥ â€‹5 years) demonstrated high satisfaction rates and significant improvements in VAS and ODI scores. N â€‹= â€‹8 patients (21.6%) had to undergo subsequent surgery at the cranially adjacent level. The incidence of adjacent level disc degeneration and adjacent facet joint degeneration was 24.3% and 35.1%, respectively. More pronounced degenerative changes of the adjacent level discs (p â€‹= â€‹0.005) and facet joints (p â€‹= â€‹0.042) prior to surgery and a lower segmental lordosis reconstruction at the lumbosacral junction (p â€‹= â€‹0.0084) were identified as potential risk factors for the development of subsequent adjacent level pathologies. Discussion & Conclusion: The study revealed satisfactory clinical results at a mid-to long-term FU of ≥5 years. The incidence of adjacent level degeneration was higher than initially expected. Patients with preexisting radiographic signs of degenerative adjacent level changes have a higher risk for subsequent deterioration necessitating reoperation at the adjacent segment at later stages. Furthermore, adequate intraoperative segmental lordosis reconstruction at the index segment is paramount as the present data reveal this to be a key protective factor for adjacent segment preservation.

Lumbar burner and stinger syndrome in an elderly athlete.

Burner or stinger syndrome is a rare sports injury caused by direct or indirect trauma during high-speed or contact sports mainly in young athletes. It affects peripheral nerves, plexus trunks or spinal nerve roots, causing paralysis, paresthesia and pain. We report the case of a 57-year-old male athlete suffering from burner syndrome related to a lumbar nerve root. He presented with prolonged pain and partial paralysis of the right leg after a skewed landing during the long jump. He was initially misdiagnosed since the first magnet resonance imaging was normal whereas electromyography showed denervation. The insurance company refused to pay damage claims. Partial recovery was achieved by pain medication and physiotherapy. Burner syndrome is an injury of physically active individuals of any age and may appear in the cervical and lumbar area. MRI may be normal due to the lack of complete nerve transection, but electromyography typically shows pathologic results.

Anterior stand-alone fusion revisited: a prospective clinical, X-ray and CT investigation.

PURPOSE: The purpose of this study was to assess the mid-term clinical and radiological results as well as patient safety in terms of complication and reoperation rates in patients treated with a novel anterior stand-alone fusion (ASAF) device (Synfix-LR, DePuy Synthes, West Chester, PA, USA) in a cohort of patients with predominant and intractable low back pain originating from monosegmental degenerative disc disease at the lumbosacral junction. METHODS: Clinical outcome scores visual analog scale (VAS), Oswestry disability index (ODI) and patient satisfaction rates were acquired within the framework of an ongoing single-center prospective clinical trial. Evaluation of radiological data included segmental and global lumbar lordosis, neuroforaminal height and width. Interbody fusion was assessed from post-operative CT scans. The minimum follow-up (FU) was 12 months. RESULTS: 71 out of an initial 77 patients were available for final FU (92.2 % FU rate) after a mean FU of 35.1 months (range 12.0-85.5 months). The overall results revealed a highly significant improvement from baseline VAS and ODI levels (p < 0.0001). 77.5 % (n = 55/71) of all patients reported a 'highly satisfactory' (n = 37/71; 52.1 %) or a 'satisfactory' (n = 18/71; 25.4 %) outcome; 22.5 % of patients were not satisfied. The overall complication rate was 12.7 % (n = 9/71). Two cases required post-operative revision surgery (2.8 %). Radiographical analysis demonstrated a highly significant increase of segmental lordosis from 16.1° to 26.7° (p < 0.0001). A high rate of solid interbody fusion was confirmed in 97.3 % of all cases (n = 36/37). CONCLUSION: The current study delineates satisfactory clinical results following ASAF at the lumbosacral junction. Patient safety was demonstrated with acceptable complication and low reoperation rates. Radiological data demonstrated a significant reconstruction of lordosis at the lumbosacral junction. Solid interbody fusion was achieved in 97.3 % of all cases in a highly selected cohort with optimal predisposition for fusion. ASAF may serve to avoid a variety of negative side effects for a considerable number of patients which, otherwise, would have been candidates for posterior instrumented fusion techniques.

Influence of lumbar intervertebral disc degeneration on the outcome of total lumbar disc replacement: a prospective clinical, histological, X-ray and MRI investigation.

INTRODUCTION: The role of fusion of lumbar motion segments for the treatment of axial low back pain (LBP) from lumbar degenerative disc disease (DDD) without any true deformities or instabilities remains controversially debated. In an attempt to avoid previously published and fusion-related negative side effects, motion preserving technologies such as total lumbar disc replacement (TDR) have been introduced. The adequate extent of preoperative DDD for TDR remains unknown, the number of previously published studies is scarce and the limited data available reveal contradictory results. The goal of this current analysis was to perform a prospective histological, X-ray and MRI investigation of the index-segment's degree of DDD and to correlate these data with each patient's pre- and postoperative clinical outcome parameters from an ongoing prospective clinical trial with ProDisc II (Synthes, Paoli, U.S.A.). MATERIALS AND METHODS: Nucleus pulposus (NP) and annulus fibrosus (AF) changes were evaluated according to a previously validated quantitative histological degeneration score (HDS). X-ray evaluation included assessment of the mean, anterior and posterior disc space height (DSH). MRI investigation of DDD was performed on a 5-scale grading system. The prospective clinical outcome assessment included visual analogue scale (VAS), Oswestry Disability Index (ODI) scores as well as the patient's subjective satisfaction rates. RESULTS: Data from 51 patients with an average follow-up of 50.5 months (range 6.1-91.9 months) were included in the study. Postoperative VAS and ODI scores improved significantly in comparison to preoperative levels (p < 0.002). A significant correlation and interdependence was established between various parameters of DDD preoperatively (p < 0.05). Degenerative changes of NP tissue samples were significantly more pronounced in comparison to those of AF material (p < 0.001) with no significant correlation between each other (p > 0.05). Preoperatively, the extent of DDD was not significantly correlated with the patient's symptomatology (p > 0.05). No negative influence was associated with increasing stages of DDD on the postoperative clinical outcome parameters following TDR (p > 0.05). Increasing stages of DDD in terms of lower DSH scores were not associated with inferior clinical results as outlined by postoperative VAS or ODI scores or the patient's subjective outcome evaluation at the last FU examination (p > 0.05). Conversely, some potential positive effects on the postoperative outcome were observed in patients with advanced stages of preoperative DDD. Patients with more severe preoperative HDS scores of NP samples demonstrated significantly lower VAS scores during the early postoperative course (p = 0.02). CONCLUSION: Increasing stages of DDD did not negatively impact on the outcome following TDR in a highly selected patient population. In particular, no preoperative DDD threshold value was identified from which an inferior postoperative outcome could have been deduced. Conversely, some positive effects on the postoperative outcome were detected in patients with advanced stages of DDD. Combined advantageous effects of progressive morphological structural rigidity of the index segment and restabilizing effects from larger distraction in degenerated segments may compensate for increasing axial rotational instability, one of TDR's perceived disadvantages. Our data reveal a "therapeutic window" for TDR in a cohort of patients with various stages of DDD as long as preoperative facet joint complaints or degenerative facet arthropathies can be excluded and stringent preoperative decision making criteria are adhered to. Previously published absolute DSH values as contraindication against TDR should be reconsidered.

The fate of facet joint and adjacent level disc degeneration following total lumbar disc replacement: a prospective clinical, X-ray, and magnetic resonance imaging investigation.

STUDY DESIGN: Prospective clinical, x-ray, and magnetic resonance imaging investigation following total lumbar disc replacement (TDR) with ProDisc II (Synthes, Paoli, PA). OBJECTIVE: To examine the progression of adjacent level degeneration (ALD), facet joint degeneration (FJD) as well as associated risk factors following TDR. SUMMARY OF BACKGROUND DATA: Fusion procedures have been associated with adjacent level morbidities and facet joint pathologies in a considerable number of patients. Whether the incidence of these negative side effects can be reduced with TDR remains unestablished. METHODS: Clinical outcome scores Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and patient satisfaction rates were acquired within the framework of an ongoing prospective study with ProDisc II. The mean index-level ROM was established for every patient over the entire postoperative period from multiple flexion/extension x-ray images. The progression of ALD and FJD was evaluated from pre- and postoperative magnetic resonance images by 2 independent radiologists. RESULTS: Results from 93 patients with an average follow-up of 53.4 months (range, 24.1-98.7 months) were included in this study. The overall results revealed a significant improvement from preoperative VAS and ODI levels (P < 0.0001).The incidence of ALD was 10.2% (n = 11/108 levels). The degenerative changes were mild and occurred late after surgery (mean, 65.2 months; range, 37.9-85.6 months). There was no significant correlation between index-level ROM and the occurrence of ALD (P > 0.05).Progression of FJD was observed in 20.0% of all facet joints (n = 44/220). FJD occurred significantly more often following TDR at the lumbosacral junction in comparison to the level above the lumbosacral junction (P < 0.02) and was observed more frequently at index-levels than at nonindex levels (P < 0.001).The degenerative changes were associated with a negative influence on postoperative outcome parameters VAS and ODI (P < 0.03) that were already detected early after surgery. The mean postoperative ROM was significantly lower in patients with progression of FJD in comparison to the remaining cohort (P < 0.0001). CONCLUSION: TDR proved to have a beneficial effect with respect to adjacent level disc preservation. The degenerative changes were mild, occurred late after surgery and did not reveal a negative effect on postoperative clinical outcome. There was no significant correlation between index-level ROM and the occurrence of ALD (P > 0.05).TDR was, however, associated with a progression of index-level FJD in a considerable number of patients, particularly at the lumbosacral junction. Lower segmental mobility and less favorable clinical results point to the fact that a particular cohort of patients may predominantly be affected in which TDR shows inferior compatibility with the index-segment's biomechanics.

Magnetic resonance imaging signs of iliotibial band friction in patients with isolated medial compartment osteoarthritis of the knee.

BACKGROUND: The purpose of this retrospective study was to assess the frequency of magnetic resonance imaging (MRI) signs of iliotibial band friction (ITBF) in patients with advanced medial compartment knee osteoarthritis. MATERIAL AND METHODS: Proton density-weighted (PDw) fat-saturated (fatsat) MR images (1.5 T, slice thickness (SL) 2.5-3 mm, eight-channel phased array coil) of 128 patients with isolated advanced osteoarthritis of the medial knee compartment and complete or subtotal (>80%) loss of cartilage were evaluated. There were 41 men and 87 women. Mean age was 63 years, range 34-89 years. The control group consisted of 94 patients with medial meniscus degeneration without cartilage loss (56 men and 38 women, mean age 50 years, range 16-89 years). MRI signs of ITBF were evaluated in both groups [poorly defined abnormalities of signal intensity and localized fluid collection lateral, distal or proximal to the lateral epicondyle; signal intensity abnormalities superficial to or deep by the iliotibial band (ITB)]. Transverse images were evaluated separately. Consensus evaluation using all imaging planes was performed. RESULTS: Of 128 patients with osteoarthritis, 95 had moderate or advanced MRI signs of ITBF (74.2%). Eighty-nine patients (69.5%) had advanced degeneration of the meniscus. In the control group, 26 of 94 patients had only moderate MRI signs of ITBF. There was a statistically significant difference between both groups for the presence of MR signs of ITBF (P

Diagnosis of osteoporosis: visual assessment on conventional versus digital radiographs.

In many radiological departments conventional radiography has been replaced by digital radiography. Therefore, the purpose of this study was to analyze the visual detection of osteopenia/osteoporosis with both digital and conventional radiographs. In 286 patients we retrospectively evaluated radiographs of the lumbar spine in two planes. One hundred twenty-eight patients had conventional and 158 patients had digital radiographs. Patients with pre-existing vertebral fractures were excluded. Four experienced musculoskeletal radiologists blinded to the values of DXA and to the patients' ages assessed independently from each other whether the bone density of the lumbar spines was normal or decreased. The results of dual X-ray absorptiometry served as the standard of reference. The threshold value for the diagnosis of osteopenia was a T-score less than -1 SD according to the WHO classification of osteoporosis. Sensitivity/specificity was 86%/36% for conventional and 72%/47% for digital radiographs. The overall diagnostic accuracy was 68% for conventional and 64% for digital radiographs. Eighty percent of the patients with osteopenia and 96% of the patients with osteoporosis were correctly assessed as true positive on conventional radiographs and 65% (osteopenia) and 82% (osteoporosis) on digital radiographs. Interobserver agreement was markedly lower for digital (35%) than for conventional radiographs (73%). However, the differences were not statistically significant. There is no major difference in diagnostic accuracy in the assessment of osteopenia/osteoporosis using digital and conventional radiographs, respectively. However, the high interobserver variance on digital radiographs indicates that visual assessment of osteoporosis/osteopenia is problematic, which may be due to image processing and postprocessing algorithms that manipulate the visual aspect of bone density.

Dose reduction in multislice computed tomography.

OBJECTIVE: Evaluation of the attenuation-based on-line modulation of tube current on multislice computed tomography (CT) to explore the potential of this dose-saving technique. METHODS: Fifty-five patients with follow-up CT examinations were scanned without and with a CARE Dose (Siemens Medical Solutions, Erlangen, Germany). The applied dose, image noise, and subjective image quality were evaluated. The reduction in patient exposure was determined by obtaining the effective milliamperes per second for each reconstructed scan and the absolute dosage requirement for the whole scan. RESULTS: The dose reduction achieved by applying the attenuation-based on-line modulation of tube current was 29.4% +/- 3.1% (P=0.002) for all scans, 30.5% +/- 3.2% (P=0.002) for the thorax scans, 29.7% +/- 2.9% (P=0.002) for the abdomen scans, and 28.7% +/- 2.7% (P=0.003) for the thorax and abdomen scans together. No significant restrictions in image quality were observed. CONCLUSIONS: Remarkable dose reduction can be obtained using the attenuation-based on-line modulation of tube current on multislice CT without compromising image quality.

Quantification of C2 cervical spine rotatory fixation by X-ray, MRI and CT.

Atlanto-axial rotatory displacement is known to be a cause of childhood torticollis and may as well be responsible for chronic neck pain after rear-end automobile collisions. The objective was to determine whether quantification of C2 malrotation is possible by plain radiographs in comparison to CT as the golden standard. MR imaging was evaluated as to whether it was of equal value in the detection of bony landmarks. C2 vertebra of five human cadaveric cervical spine specimens, ligamentously intact, were rotated using a Steinmann pin in steps of 5 degrees up to 15 degrees right and 15 degrees left. Plain radiographs, CT and MRI images were taken in each rotational step. Data were analyzed for quantification of C2 rotation by three independent examiners. A rotation of 5 degrees led to a spinous process deviation (SPD) from the midline of 3 mm as measured on an a.p. plain radiograph. A coefficient of rotation was calculated (1.62 degrees mm(-1)). Data analyzed by three examiners revealed a small coefficient of variation (0.03). MRI and CT measurements showed comparable results for the quantification of rotation; however, in both techniques the 15 degrees rotation was underestimated. Quantification of upper cervical spine malrotation was possible on plain radiographs using the SPD and a rotation coefficient. MRI and CT were equally successful in the assessment of C2 malrotation.

Diagnosis of acute fractures of the extremities: comparison of low-field MRI and conventional radiography.

The aim of this study was to compare low-field MRI (0.2 T) and conventional radiography for the detection of acute fractures of the distal part of the extremities. X-ray and MRI examinations of 78 (41 fractures, 37 without fracture) patients with the clinical suspicion of an acute fracture in the distal part of the extremities were compared. Four experienced radiologists, two for each of the two modalities, independently analyzed the images. Interobserver variability and receiver operating characteristic (ROC) analysis for both methods were established. The MRI and conventional radiography revealed an accuracy of 81.4 and of 79.5%, respectively, in the detection of acute fractures. The diagnostic accuracy of MRI to detect fractures in the hand and forefoot proved to be significantly inferior to conventional X-ray examinations. On the other hand, MRI achieved a better accuracy for the examination of bones near a large joint. The interobserver variability for both methods was rated as moderate. In ROC analysis both methods were rated as good. There was no statistical difference of the accuracy between low-field MRI and conventional radiography in the detection of acute fractures of the distal part of the extremities. Consequently, a routine use of low-field MRI as an alternative to conventional radiography to diagnose acute fractures of the extremities seems not to be justified.

Inter and intraobserver variability in DePalma's classification of shoulder calcific tendinitis.

OBJECTIVE: To determine the intraobserver reproducibility and interobserver reliability of DePalma and Kruper's classification of calcific tendinitis of the rotator cuff. The result of this classification influences the choice of therapeutic procedures in patients with symptomatic calcific tendinitis. METHODS: Plain anteroposterior radiographs of shoulders from 100 patients with symptomatic calcified deposits of the rotator cuff were classified according to the criteria of DePalma and Kruper by 6 independent observers at 2 different time points within 4 months. The kappa values of intraobserver reproducibility and interobserver reliability were calculated. RESULTS: Kappa values of intraobserver reproducibility had a mean of 0.487 (SD 0.094); kappa values of interobserver reliability were 0.234 for the first test and 0.273 for the second test. CONCLUSION: Determination of intraobserver reproducibility gave satisfactory to sufficient results and interobserver reliability was satisfactory for both tests indicating that studies based on the classification of DePalma and Kruper should be interpreted cautiously.

Morphology and topography of intraosseous ganglion cysts in the carpus: an anatomic, histopathologic, and magnetic resonance imaging correlation study.

PURPOSE: To assess the morphology, topography, frequency, and etiology of intraosseous carpal ganglions. METHOD: Two hundred and eighty formalin fixed cadaveric wrists (mean age 80.3 +/- 9.7 years, range 40 to 101 years) were radiographed. Fifty specimens suspicious for cyst-like bone lesions underwent magnetic resonance imaging (T1w and proton density-fat-saturated images, 1.5T). Dissection, articular surface assessment, and histological examination were performed. Cystic lesions with adjacent destruction of the hyaline cartilage were classified as degenerative and were excluded. RESULTS: In 27 of the 50 specimens, 48 ganglion cysts (GC) were found. Prevalence of GC was 9.6%. Of 48 intraosseous carpal GC, 41 (85%) were in a peripheral location; 27/48 (56%) were located at the palmar carpus. GC had a macroscopic and microscopic relationship to the insertion of degenerated ligaments. They developed near longitudinally orientated bone surfaces, which serve as insertion for ligaments and are exposed to tension loading. CONCLUSIONS: Unlike degenerative cysts, ganglion cysts do not erode the hyaline articular cartilage and almost always have a continuity with the capsular ligaments. Intraosseous carpal ganglion cysts are probably the result of mucoid degeneration of adjacent ligaments.

Acute osteoporotic and neoplastic vertebral compression fractures: fluid sign at MR imaging.

PURPOSE: To evaluate the occurrence, location, and shape of the fluid sign in acute osteoporotic and neoplastic vertebral compression fractures at magnetic resonance (MR) imaging. MATERIALS AND METHODS: The study group comprised 87 consecutive patients with acute vertebral compression fractures due to osteoporotic (n = 52) or neoplastic (n = 35) infiltration. The MR imaging protocol included nonenhanced T1-weighted spin-echo and short inversion time inversion-recovery sequences and a 1.5-T system. Readers blinded to the outcome documented the occurrence, shape, and location of the fluid sign with consensus. The fluid sign was correlated with the cause, age, and severity of the fracture. The diagnosis was confirmed with surgery, follow-up MR imaging, clinical follow-up, or unequivocal imaging findings. Wilcoxon and chi(2) tests were used to assess significance. RESULTS: In fractured vertebral bodies, the fluid sign was adjacent to the fractured end plates and exhibited signal intensity isointense to that of cerebrospinal fluid. The fluid sign was linear (n = 16), triangular (n = 5), or focal (n = 2) and was significantly associated with osteoporotic fractures (21 [40%] of 52; P <.001). The fluid sign occurred in two (6%) of 35 neoplastic compression fractures. Histologic examination demonstrated osteonecrosis, edema, and fibrosis at the site of the fluid sign. There was a tendency toward older fractures exhibiting the fluid sign, but this relationship was not significant (P >.05). In osteoporotic fractures, the fluid sign was significantly associated with fracture severity (P <.05). CONCLUSION: The fluid sign is featured in acute vertebral compression fractures that show bone marrow edema. It can be an additional sign of osteoporosis and rarely occurs in metastatic fractures.

Magnetic resonance imaging as a supplement for the clinical staging system of Durie and Salmon?

BACKGROUND: This study evaluated the prognostic value of a three-grade staging system of spinal involvement using magnetic resonance imaging (MRI) in patients with multiple myeloma and determined its usefulness as an independent parameter in the staging system of Durie and Salmon. METHODS: Seventy-seven previously untreated patients with multiple myeloma underwent MRI of the thoracic and lumbar spine with unenhanced T1-weighted spin echo and short-tau inversion time inversion recovery sequences. The patients were evaluated according to their infiltration patterns and the extent of bone marrow involvement was staged using a three-grade scale: Stage I, no focal or diffuse infiltration; Stage II, 1-10 foci or mild diffuse infiltration; Stage III, more than 10 foci or strong diffuse infiltration. RESULTS: The infiltration patterns had no significant effect on survival. Of 77 patients, 25 would have been understaged using the standard staging system of Durie and Salmon without the findings of MRI and 8 patients would have been understaged if the staging was based only on MRI. The combination of the staging system of Durie and Salmon and MRI was highly significant with respect to survival (P < 0.0001, log rank analysis). MRI staging I-III was independent of the staging system of Durie and Salmon (Cox regression model). CONCLUSIONS: A three-grade staging of spinal MRI provides a significant prognostic tool for patients with multiple myeloma. The authors propose including it in the staging system of Durie and Salmon.