Intra-articular osteoid osteoma in the femoral neck of an 18-year-old man: a case report.

OBJECTIVE: This case study presents the delayed diagnosis, surgical management, and postsurgical follow-up of an intra-articular osteoid osteoma of the left femoral neck in an 18-year-old male patient with special emphasis on discussing the confusing clinical and imaging characteristics of the lesion often associated with delayed diagnosis and increased morbidity. CLINICAL FEATURES: The patient initially complained of left knee and hip pain at which time conventional radiographs were reported as normal. In magnetic resonance imaging studies, the diagnosis of intra-articular osteoid osteoma of the femoral neck was suggested; however, working diagnoses also included old posttraumatic injury, hip infection, juvenile chronic arthritis, and posttraumatic arthritis. The correct diagnosis was made 31 months after presentation based on computed tomography depiction of the lesion. INTERVENTION AND OUTCOME: Pain associated with the tumor was alleviated after surgical removal with minimal loss of motion and muscle atrophy 19 months after tumor excision. CONCLUSION: Clinicians and radiologists should be aware of the potentially confusing clinical and imaging findings associated with intra-articular osteoid osteoma of the hip. Early correlation between juvenile joint pain and imaging abnormalities as well as the use of thin slice computed tomography imaging could reduce the time to diagnose the lesion and prevent unnecessary morbidity.

Adherence to radiography guidelines for low back pain: a survey of chiropractic schools worldwide.

OBJECTIVE: This study describes instruction provided at chiropractic schools worldwide on the use of spine radiography and compares instruction with evidence-based guidelines for low back pain. METHODS: Individuals responsible for radiology instruction at accredited chiropractic schools throughout the world were contacted and invited to participate in a Web-based survey. The survey included questions on the role of conventional radiography in chiropractic practice and instruction given to students for its use in patients with acute low back pain. RESULTS: Of the 33 chiropractic schools identified worldwide, 32 (97%) participated in the survey. Consistent with the guidelines, 25 (78%) respondents disagreed that "routine radiography should be used prior to spinal manipulative therapy," 29 (91%) disagreed that there "was a role for full spine radiography for assessing patients with low back pain," and 29 (91%) disagreed that "oblique views should be part of a standard radiographic series for low back pain." However, only 14 (44%) respondents concurred with the guidelines and disagreed with the statement that there "is a role for radiography in acute low back pain in the absence of 'red flags' for serious disease." CONCLUSIONS: This survey suggests that many aspects of radiology instruction provided by accredited chiropractic schools appear to be evidence based. However, there appears to be a disparity between some schools and existing evidence with respect to the role of radiography for patients with acute low back pain without "red flags" for serious disease. This may contribute to chiropractic overutilization of radiography for low back pain.

Glenoid hypoplasia: a report of 2 patients.

OBJECTIVE: This article discusses the imaging findings, clinical findings, and conservative chiropractic management of 2 patients with glenoid hypoplasia. CLINICAL FEATURES: Conventional radiographs of both patients revealed a hypoplastic glenoid bilaterally. Notch-like defects along with signs of degenerative disease were evident within the lower portion of the glenoid rims bilaterally in 1 patient and in the left glenoid rim of the other patient. Magnetic resonance imaging revealed a degenerative cyst or cortical defect in one patient along the anterior humeral head. The second patient showed a small slightly lobulated cystic region just posterior to the glenoid rim, consistent with the appearance of a synovial or ganglion cyst. Computed tomography with 3-dimensional reconstruction in 1 patient confirmed the presence of large posterior and superior osteophytes arising from the significantly hypoplastic glenoid. These images also revealed a slight posterior subluxation of the humeral head, widening of the anterior glenohumeral joint space, and retroversion of the glenoid. INTERVENTION AND OUTCOME: Treatment consisted of manual joint manipulation, soft tissue therapies, and therapeutic exercise for both patients. Both patients experienced improvements in symptoms, function, and physical examination findings. CONCLUSIONS: Glenoid hypoplasia is a developmental anomaly of the scapular neck which is predominantly bilateral and symmetric. Cross-sectional imaging studies should be considered in patients with symptoms that fail to improve over time. Conservative chiropractic care may be effective in managing symptoms in patients with glenoid hypoplasia.

Diagnostic imaging guideline for musculoskeletal complaints in adults-an evidence-based approach-part 2: upper extremity disorders.

PURPOSE: To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for upper extremity disorders. METHODS: A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research was invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer-reviewed by practicing chiropractors and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. Dissemination and implementation strategies are discussed. RESULTS: Recommendations for diagnostic imaging guidelines of adult upper extremity disorders are provided, supported by over 126 primary and secondary citations. The overall quality of available literature is low, however. On average, 44 Delphi panelists completed 1 of 2 rounds, reaching over 88% agreement on all 32 recommendations. Peer review by specialists reflected high levels of agreement and perceived ease of use of guidelines and implementation feasibility. CONCLUSIONS: The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders.

PURPOSE: To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for spinal disorders. METHODS: A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research were invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer reviewed by practicing chiropractors, and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. RESULTS: Recommendations for diagnostic imaging guidelines of adult spine disorders are provided, supported by more than 385 primary and secondary citations. The overall quality of available literature is low, however. On average, 45 Delphi panelists completed 1 of 2 rounds, reaching more than 85% agreement on all 55 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. Dissemination and implementation strategies are discussed. CONCLUSIONS: The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

Diagnostic imaging practice guidelines for musculoskeletal complaints in adults--an evidence-based approach: introduction.

PURPOSE: Imaging technology can improve patient outcomes by allowing greater precision in diagnosing and treating patients. However, there is evidence that overuse, underuse, and misuse of imaging services occur. The purpose of this project was to develop evidence-based diagnostic imaging practice guidelines for musculoskeletal complaints for use by doctors of chiropractic and other primary health care professionals. METHODS: An electronic search of the English and French language literature (phase 1) was conducted on several databases. Cross references, and references provided by clinicians, were also used. Independent assessment of the quality of the citations used to support recommendations in the guidelines was performed using the QUADAS, the AGREE,and the SPREAD evaluation tools. A first draft of a diagnostic imaging practice guideline was produced, using the European Commission's Referral Guidelines for Imaging document as a template. Results were sent to 12 chiropractic specialists for a first external review. A modified Delphi process, including 149 international experts, was used to generate consensus on recommendations for diagnostic imaging studies. The reliability of proposed recommendations was further tested on field chiropractors and on a group of specialists both in chiropractic and in medicine in both Canada and the United States. All recommendations were graded according to the strength of the evidence. RESULTS: The research procedure resulted in the recommendations for diagnostic imaging guidelines of adult extremity and spine disorders supported by more than 685 primary and secondary citations. High levels of agreement among Delphi panelists were reached for all proposed recommendations. Comments received by specialists were generally very favorable and reflected high levels of agreement with the proposed recommendations, perceived ease of use of guidelines, and implementation feasibility. CONCLUSIONS: These evidence-based diagnostic imaging practice guidelines are intended to assist chiropractors and other primary care providers in decision making on the appropriate use of diagnostic imaging for specific clinical presentations. In all cases, the guidelines are intended to be used in conjunction with sound clinical judgment and experience. Application of these guidelines should help avoid unnecessary radiographs, increase examination precision,and decrease health care costs without compromising the quality of care. All guidelines are documents to be refined and modified regularly with new information and experience.

Diagnostic imaging practice guidelines for musculoskeletal complaints in adults--an evidence-based approach. Part 1. Lower extremity disorders.

PURPOSE: The aim of this study was to develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging of lower extremity disorders. METHODS: A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of Diagnostic Accuracy Studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (Radiation Protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research were invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer reviewed by field chiropractors, and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. RESULTS: Recommendations for diagnostic imaging guidelines of adult lower extremity disorders are provided, supported by more than 174 primary and secondary citations. Except for trauma, the overall quality of available literature is low. On average, 57 Delphi panelists completed 1 of 2 rounds, reaching more than 83% agreement on all 56 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. CONCLUSIONS: The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Dissemination and implementation strategies are discussed. Future research is needed to validate their content.

A case of vertebral metastasis with pathologic c2 fracture.

OBJECTIVE: This report discusses a patient with a pathologic fracture of the C2 vertebra secondary to osteolytic metastasis from squamous cell carcinoma of the lung. CLINICAL FEATURES: The patient was a 68-year-old man with a chief complaint of neck pain who was referred by his physician to a chiropractic office. The initial onset of neck pain began after a forceful sneeze that resulted in a sensation of "a twig snapping" in the neck. Radiographs revealed osteolytic destruction and pathologic fracture of the C2 spinous process. INTERVENTION AND OUTCOME: The patient was referred back to his primary care physician, who then referred him to an oncologist, who immediately initiated a course of radiation therapy and pain medication. Palliative care by the chiropractor consisted of soft tissue massage of the cervical spine musculature to treat associated muscle spasms and pain. The patient responded well to gentle myofascial therapy. However, the osteolytic destruction of the C2 posterior elements progressed, resulting in an unstable subluxation of C2 and associated cord compression. The spine was stabilized with a rigid collar, but the metastatic destruction progressed, eventually resulting in quadriplegia and subsequent death from respiratory distress. CONCLUSION: Patients with a history of cancer complaining of new onset of back or neck pain should be assumed to have vertebral metastasis until proven otherwise. Trivial trauma should be taken seriously in these cases and investigated with appropriate clinical, laboratory, and imaging examinations. Vertebral malignancies may be a contraindication to spinal manipulation; however, the chiropractic physician plays a significant role in early detection and diagnosis.

Merkel cell carcinoma arising from the subcutaneous fat of the arm with intact skin.

BACKGROUND: Merkel cell carcinoma is a rare malignant neuroendocrine neoplasm characteristically arising from the dermis of sunlight-exposed skin. It rarely arises outside the skin. OBJECTIVE: We present a patient with primary Merkel cell carcinoma arising from subcutaneous fat, with no involvement of the overlying skin. We describe the clinical manifestations and magnetic resonance imaging (MRI) findings. METHODS: We report a 63-year-old woman with a primary lesion of Merkel cell carcinoma that arose from the subcutaneous fat layer of the left arm. The lesion presented as a subcutaneous nodule with intact overlying skin. MRI showed that the nodular lesion was located entirely in the subcutaneous fat layer, with no involvement of the dermis. Peritumoral infiltration around the lesion and enlarged lymph nodes deep to the lesion were noted. The patient received wide excision of the lesion with dissection of the regional lymph nodes and adjuvant radiotherapy and chemotherapy. RESULTS: Histopathologic examination confirmed the diagnosis of Merkel cell carcinoma with local lymphatic metastasis, and the lesion was completely located in the subcutaneous fat, with no involvement of the dermis. These findings were well correlated with MRI findings. CONCLUSION: Primary Merkel cell carcinoma may arise from the subcutaneous fat and present as an entirely subcutaneous lesion with intact skin. MRI is helpful to evaluate the local extension of the lesion and regional lymphatic metastasis.

Xanthoma of the sacrum.

Xanthoma is a lesion containing abundant foamy histiocytes most commonly occurring in superficial soft tissues such as skin, subcutis, or tendon sheaths. The involvement of deep skeletal structures, however, is rare and has only been infrequently reported in the English literature. Most xanthomas occur in patients with hyperlipidemic disorders. We report a case of a xanthoma in the sacrum and ilium of a patient with hyperlipidemia type IIa, who had chronic lower back pain for more than 20 years. On radiographs the lesion appeared multiloculated and osteolytic with a thin sclerotic border and containing multiple nodular calcifications within its matrix. Computed tomographic images revealed a presacral soft-tissue mass that also infiltrated the adjacent sacroiliac joint and iliac fossa. On histologic examination, abundant areas of xanthoma cells and cholesterol clefts, typical of xanthoma, were present. The patient received simple curettage of the lesion, and his symptoms were markedly relieved.

Eosinophilic fasciitis in a military recruit: MRI evaluation with clinical correlation.

Eosinophilic fasciitis (EF) is an uncommon connective tissue disease. We report a patient with EF who presented with episodic swelling and stiffness of his legs and forearms in combination with peripheral eosinophilia. Imaging studies of the legs and forearms, including computed tomography (CT) and magnetic resonance imaging (MRI), clearly demonstrated the characteristic finding of fascial thickening. The complete clinical imaging and pathological findings are described in this report. Cross-sectional imaging is useful in diagnosing EF and in the appropriate clinical scenario may be helpful in differentiating EF from other connective tissue diseases.