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PubMed2005

Kyphoplasty versus vertebroplasty to increase vertebral body height: a cadaveric study.

PURPOSE: To prospectively compare the vertebral height restoration achieved with kyphoplasty and vertebroplasty in fresh cadavers by using multi-detector row computed tomography (CT). MATERIALS AND METHODS: Institutional review board approval was not required because the donors had registered in and consented to an anatomic gift program prior to their death. Thirty-seven vertebrae were harvested from four donated cadavers of elderly female individuals (mean age, 82 years; age range at death, 73-87 years). The vertebrae were dissected free of the surrounding muscles and imaged with multi-detector row CT. Compression fractures were induced, and the vertebrae were again imaged. The vertebrae were randomized to be treated with kyphoplasty (n = 19) or vertebroplasty (n = 18) and were then imaged at multi-detector row CT. The anterior, central, and posterior vertebral body heights and wedge angles were measured in the midsagittal plane of the reformatted images. The amount of cement injected was determined by weighing the vertebrae before and after treatment. The statistical significance of changes in vertebral body height, wedge angle, and weight with the two treatment techniques was evaluated with the independent t test or Mann-Whitney U test. RESULTS: The increase in vertebral height was greater with kyphoplasty than with vertebroplasty (5.1 mm vs 2.3 mm, respectively; P < .05). The original vertebral height was restored in 93% of vertebrae with kyphoplasty and in 82% with vertebroplasty (P < .05). There was a greater decrease in wedge angle with kyphoplasty than with vertebroplasty (3.1 degrees vs 1.6 degrees, respectively); however, this difference was not significant (P > .05). There was no significant difference in the amount of cement injected with kyphoplasty and vertebroplasty (P > .05). CONCLUSION: Kyphoplasty increased vertebral body height more than vertebroplasty in this model of acutely created fractures in fresh cadaver specimens.

Aged↗

PubMed1987

Vertebral mineral status: assessment with single- versus multi-section CT.

A volumetric approach to quantitative single-energy computed tomography (CT) of the spine for trabecular bone evaluation was compared with the accepted single-section method in 32 thoracic and lumbar vertebral bodies from six cadaveric specimens. Both 5-mm and 10-mm contiguous section sequences afforded greater sample volumes, mean mineral equivalent values, and precision than did the single midplane section technique. These findings can be explained by inhomogeneous trabecular distribution, differential bone resorption rates for various cancellous regions, and nonuniform deposition of marrow fat. Scoliosis may modify the net influence of these factors owing to altered biomechanical forces. Although the single-section method affords optimal sensitivity to early or subtle alterations in vertebral trabecular bone density, it may misrepresent the status of the total cancellous volume. Because three-dimensional histographic analysis includes structurally important peripheral trabeculae in determinations of mean mineral equivalent values, it may more accurately reflect vertebral body strength and risk of compression fracture.

Biomechanical Phenomena↗

PubMed1989

Avascular necrosis of the vertebral body: MR imaging.

Five patients with plain radiographic evidence of a compressed vertebra containing an intravertebral vacuum cleft indicative of avascular necrosis underwent magnetic resonance (MR) imaging. In these patients, the T2-weighted images revealed a distinct appearance consisting of marked and discrete hyperintensity at the location of the intravertebral cleft. T1-weighted images were hypointense in this region. Recognition of this pattern is important in the MR imaging evaluation of compression fractures of the vertebral body so that confusion with malignancy or infection may be avoided, thereby obviating additional diagnostic studies.

Aged↗

PubMed1991

Trabecular structure: preliminary application of MR interferometry.

A new approach to probe the structure of trabecular bone in the vertebral bodies in humans was evaluated, and preliminary data are presented. The proposed method is based on the hypothesis that the presence of two physical phases--bone and bone marrow--causes a magnetic field distribution across the imaging voxel. The resulting spread in resonance frequency produces line broadening, which is measured as the decay rate of the region of interest signal intensity that has the properties of an interferogram. The interferogram is the result of two principal chemically shifted components of bone marrow--fat and water--getting in and out of phase with one another while being attenuated by T2* processes from the magnetic field distribution within the measuring volume. The time constant for the decay (T2*) can then be obtained by means of curve-fitting techniques. T2* in healthy persons is found to increase slightly with age. However, patients with osteoporosis (low bone mineral density and/or spine compression fractures) have significantly prolonged T2* values, which are interpreted as arising from an increase in the intertrabecular space.

Adolescent↗

PubMed1992

Multiple myeloma: appearance at MR imaging.

Magnetic resonance (MR) imaging examinations of the lumbar spine and clinical and laboratory findings in 32 patients with multiple myeloma were reviewed. On T1-weighted images, signal intensity (SI) of the vertebrae approximated that of muscle in 14 cases and was intermediate (between the SIs of muscle and fat) in 18. Definite foci of decreased SI were seen in eight cases (25%), and foci of increased SI, representing fatty infiltration, were seen in 12 (38%). On T2-weighted images, SI approximated that of muscle in 17 cases and was intermediate in 15. Definite foci of increased SI were seen in 17 (53%). Of 38 vertebral compression fractures (including 18 in nine additional patients), foci of abnormal SI consistent with tumor on either T1- or T2-weighted images were seen in 19 cases (50%). There was no correlation between MR imaging findings and laboratory or bone marrow findings. Foci of presumed tumor were better or exclusively shown on T2-weighted images in 11 of 17 patients (65%) with identifiable focal disease. Other suggestions of multiple myeloma on T1-weighted images may be the absence of fatty replacement or a generalized decrease in SI.

Female↗

PubMed1994

Multiple myeloma: MR patterns of response to treatment.

PURPOSE: To assess changes in the magnetic resonance (MR) appearance of the spine in patients with multiple myeloma who responded to chemotherapy. MATERIALS AND METHODS: Twenty patients with multiple myeloma underwent MR imaging of the spine before and after chemotherapy. Sagittal T1-weighted images were obtained before and after administration of contrast material. MR patterns of marrow involvement before treatment were classified as focal, diffuse, or variegated. The changes seen on MR images after treatment were analyzed and correlated with the clinical response as defined with standard criteria. RESULTS: Patterns of complete response included resolution of marrow abnormality or persistent abnormality without enhancement or with peripheral rim enhancement. Conversion of a diffuse to a variegated or focal pattern and a decrease in the amount of marrow abnormality with persistent enhancement were observed in patients who showed a partial response. Ten patients sustained new or progressive compression fractures after successful therapy. CONCLUSION: Recognition of spinal MR patterns of response to treatment supported the occurrence of remission in patients with multiple myeloma. MR findings may help clarify response to therapy in patients with equivocal clinical changes or nonsecretory myeloma.

Adult↗

PubMedDate not supplied

Spectrum of imaging findings in hyperextension injuries of the neck.

Nonphysiologic hyperextension and lateral forces acting on the cervical spine and soft-tissue structures of the neck can result in a wide spectrum of injury patterns. Multiple factors (eg, patient age; the underlying morphologic features of the cervical spine; the magnitude, vector, and maximal focus of the force) all influence the observed patterns and the severity of injury. A review of the 5-year trauma database in two trauma centers revealed various injury patterns that were frequently recognized in patients with clinical evidence or historical documentation of a predominant hyperextension mechanism. Injuries included anterior arch avulsion and posterior arch compression fractures of the atlas, odontoid fractures, traumatic spondylolisthesis and teardrop fracture of C2, laminar and articular pillar fractures, and hyperextension dislocation injuries. More severe injuries were observed in patients with underlying predisposing conditions (eg, degenerative spondylosis, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis). Knowledge of the involved biomechanical factors provides a framework for understanding these injury patterns. Diagnostic imaging, especially computed tomography and magnetic resonance imaging, plays a fundamental role in the assessment of patients with suspected cervical injury. Furthermore, cross-sectional imaging facilitates the recognition of accompanying injuries to the face, the head, and the vascular structures of the neck.

Biomechanical Phenomena↗

PubMedDate not supplied

Renal magnesium wasting, hypomagnesemic hypocalcemia, hypocalciuria and osteopenia in a patient with glycogenosis type II.

We describe a patient with late-onset glycogenosis type II with renal magnesium wasting, hypomagnesemic hypocalcemia, hypocalciuria and osteopenia. He was admitted to our hospital for evaluation of lower limb weakness and mild deterioration of liver function. Serum magnesium and calcium were low with low-to-normal levels of PTH in the patient. Echocardiogram revealed marked concentric hypertrophy of the left ventricle. An X-ray film of his spine showed a thoracic (Th12) vertebral compression fracture. Bone mineral density of the lumbar spine L2-L4 showed a reduced value. Kidney, liver and muscle biopsies were performed. These were found to have histologic features consistent with glycogenosis type II. In addition, accumulation of PAS-positive material in the cytoplasmic vacuoles of the tubular epithelium was present only in the distal tubules. An oral magnesium supplement was useful in helping to correct the hypomagnesemia, despite the presence of renal magnesium wasting in our patient. Magnesium supplement was also sufficient to maintain normal serum calcium concentrations. However, the hypocalciuria persisted in our patient despite correction of hypomagnesemia. In conclusion, the consistent association between the glycogen accumulation in distal tubules, renal magnesium wasting, hypomagnesemic hypocalcemia and hypocalciuria, in the absence of other identifiable reasons, suggests a cause-and-result relationship. Also, the combination of renal magnesium wasting, hypomagnesemia and hypocalciuria is a picture similar to that of Gitelman's syndrome in our patient. The glycogen accumulation in distal tubules may cause renal magnesium wasting and hypocalciuria through tubular injury. Therefore, we may speculate that the present case has glycogenosis type II-associated Gitelman's-like syndrome.

Adult↗

PubMed2002

Does the neurologist contribute to the care of patients with chronic back pain?

OBJECTIVE: To review the disposition and outcome of patients with back pain seen in a neurology clinic, and determine the value of the neurologist's input. BACKGROUND: Back pain is a common cause of referral to the neurology clinic, but it is not clear how much the neurologist contributes to the care of such patients. DESIGN/METHODS: We reviewed all new patients and new consultations seen for the following reasons: low back pain; 'sciatica'; 'back and leg pain', and 'spinal stenosis'. Patients were evaluated by a single attending neurologist at a general neurology clinic over a 2-year period (January 1997 through December 1998). RESULTS: During the 2-year period, there were 97 patients seen for the above reasons. The chief complaint was low back pain alone in 73, while it was combined with another symptom in 24 (leg pain in 18, buttock or hip pain in 6). Thirty-three patients were self-referred, 56 were referred by a healthcare professional, 3 were referred by attorneys, and the referral source was unclear in 5. Median age was (range 25-90) years. Forty-eight were males. Based on the clinical data (history and examination), clinical diagnoses were radiculopathy in 28, myelopathy in 2, uncomplicated spondylosis in 27, and other non-neurologic conditions in 45. Tests performed after the visit included X-rays in 31, CT in 1, MRI in 16, and EMG in 17. 'Final' diagnoses were radiculopathy in 29 patients, myelopathy in 2 (total neurologic n = 30), uncomplicated spondylosis in 27, and other non-neurologic diagnoses in 41 (total non-neurologic n = 67). The non-neurologic diagnoses included periarticular pain, bursitis, muscle strain, soft tissue injury, and vertebral compression fractures. Final dispositions in the non-neurologic group (n = 67) were: nonsteroidal anti-inflammatories (NSAIDs) in 34 patients; analgesics or muscle relaxants in 37; physical therapy for 19, and none (including rest and observation) for 22. Four patients were referred for epidural blocks. (Many patients had more than one final disposition.) Final dispositions in the neurologic group (n = 39) were: physical therapy (n = 9); NSAIDs (n = 12); analgesics or muscle relaxants (n = 12), and epidural blocks (n = 3). Three patients were referred for surgery, but only 1 had an operation. CONCLUSIONS: Of patients with back pain and related symptoms seen in a neurology clinic, about two thirds have non-neurologic conditions. These patients are usually treated symptomatically with medications, rest, and physical therapy, all of which could be managed by primary care physicians. In the neurologic group, the vast majority is treated in the same way as the non-neurologic group. When more specific measures are needed, such as surgery or pain management procedures (e.g., epidural blocks), then the patients could be evaluated directly by the proper specialist (pain management or spine surgery) rather than the neurologist. The neurologist's input does not significantly affect the diagnosis or the management, so that the neurologist appears to have no useful role in the management of such patients.

Adult↗

PubMed2002

A rare combination of sites of involvement by Mycobacterium intracellulare in a hemodialysis patient: multifocal synovitis, spondylitis, and multiple skin lesions.

PURPOSE: Atypical mycobacterial infection is a rare but serious hazard in immunocompromised patients including those undergoing maintenance hemodialysis and immunosuppressive therapy. Recognition of unusual involvement patterns is important. METHODS: We describe an extremely rare combination of complications caused by such an organism in a patient with end-stage renal disease: spinal osteolysis and multiple skin lesions associated with synovitis. RESULTS: The patient had received a renal allograft 18 years previously but developed infection with Mycobacterium avium-M. intracellulare complex including dermatologic manifestations, spondylitis, and synovitis involving the wrist and lateral malleolus after initiation of hemodialysis when the transplanted kidney failed. An empirical antibiotic regimen failed to alleviate skin lesions or fevers, or to lower an elevated C-reactive protein concentration, until the patient's dose of methylprednisolone was increased to treat mild adrenal insufficiency. The increase resulted in rapid resolution of skin lesions. A compression fracture 6 months later was attributed to spondylitis caused by the same organism. CONCLUSIONS: We suspect that spondylitis represented the primary focus of M. intracellulare infection.

Female↗

PubMed1995

POEMS syndrome in Chinese.

POEMS (polyneuropathy, organomegaly, endocrine disturbance, M-protein and skin hyperpigmentation) syndrome occurring in Chinese has been inadequately described. Here we report our experience of 12 Chinese patients with the syndrome. This series is similar to those reported from Japan and from the Western world by the predominance of middle-aged males. Diabetic mellitus, a common feature in POEMS syndrome, was not present in our patients. M-protein of the lambda type was demonstrated in 7 patients by immunoelectrophoresis or by immunofixation electrophoresis. Osteosclerosis in Chinese patients is not as common as in patients reported from Japan or from the Western world; a common radiographic finding in our patients was a compression fracture of the thoraco-lumbar spine with or without sclerotic and lytic lesions. The condition has a grave prognosis; 9 patients die within 4 years after onset of the disease despite various kinds of treatment.

Adult↗

PubMed1989

Anterior thoracic extradural hematoma in a 5-year-old child.

Four hours following a motor vehicle accident, a 5-year-old girl developed a complete motor and sensory paraplegia below the sixth thoracic level (T6). The plain X-rays and MRI scan identified nondisplaced compression fractures of the T3-T6 vertebrae, associated with an anterior T3-T5 epidural hematoma. Following an emergency T3-T6 laminectomy, the sensory findings disappeared, while the motor deficit took 2 weeks to resolve. This case report emphasizes the value of the MRI scan in assessing pediatric spinal trauma, while underscoring the unique characteristics of acute epidural spinal hematomas.

Accidents, Traffic↗

PubMedDate not supplied

Calcitonin and calcium combined therapy in osteoporosis: effects on vertebra trabecular bone density.

Calcitonin is a hormone produced by the parafollicular cells of the thyroid gland. Like calcium salts, calcitonin acts by reducing bone resorption. In this study, 26 osteoporotic patients were given 100 IU salmon calcitonin for 10 days and, thereafter, 100 IU calcitonin every other day for 80 days combined with 1000 mg/day calcium salts. Prior to and after the combined therapy, the mean trabecular bone densities from the levels of thoracic 12 and lumbar 1 and 2 were obtained and routine thoracic and lumbar radiography performed. Combined calcitonin and calcium therapy for 3 months produced significant increases in vertebra trabecular bone density. The evaluation of the trabecular bone density and the number of non-traumatic compression fractures in 26 osteoporotic patients prior to the therapy did not indicate any close relationship between them. It is concluded that, in addition to other factors reported previously, microtraumas during daily activities have some effect on the incidence of fractures.

Bone and Bones↗

PubMedDate not supplied

Roentgenographic skeletal injury patterns in parachute jumping.

A total of 90,000 parachute jumps made during a 1 year period resulted in 615 (0.68%) injuries secondary to jumping. Of these 615 cases, 70 jumpers (0.08%) had 71 skeletal injuries as confirmed by roentgenographic examination. Forty-one (57.7%) of the 71 injuries involved the ankle, and 12 (16.9%) were compression fractures of the thoracolumbar spine. The remaining injuries were distributed as follows: shoulder, six (8.5%); calf, six (8.5%); pelvis, 3 (4.2%); foot, two (2.8%); and thigh, one (1.4%). The various mechanisms leading to these injuries are presented.

Adolescent↗

PubMedDate not supplied

Chronic repetitive unrecognized flexion injury of the cervical spine (high jumper's neck).

Unrecognized flexion injuries of the cervical spine may lead to late instability and neurologic damage. These hidden flexion injuries may be from acute or chronic traumatic episodes. Cervical spine instability was seen in an amateur high jumper as a result of chronic repetitive flexion loading of her cervical spine due to incorrect landing technique. The instability from these types of flexion injuries is generally unrecognized on a routine lateral radiograph. The presence of slight anterior subluxation, simple compression fractures, or subtle kyphotic angulation at one cervical level should alert the physician to this diagnosis. Flexion extension views are useful to demonstrate this instability. Occupations and sports which involve repetitive flexion stress to the cervical spine are at risk for this type of late instability. Therefore, in high jumping careful attention to safe techniques of landing is of utmost importance.

Adolescent↗

PubMedDate not supplied

Arthroscopic findings after shoulder dislocation.

The purpose of this study was to evaluate prospectively the arthroscopic findings of the unstable shoulder, to provide insights into the causes and mechanisms of shoulder instability, and to establish a rationale for using special surgical procedures. Arthroscopic examination was performed on 212 patients who had at least 1 documented shoulder dislocation. Of these 212 patients, 184 (87%) patients had anterior glenoid labral tears, 168 (79%) patients had ventral capsule insufficiency, 144 (68%) patients had Hill-Sachs compression fractures, 116 (55%) patients had glenohumeral ligament insufficiency, 30 (14%) patients had complete rotator cuff tendon tears, 26 (12%) patients had posterior glenoid labral tears, 14 (7%) patients had superior labrum anterior and inferior lesions. As this prospective study shows, multiple morphologic changes are associated with instability of the glenohumeral joint; there is no single cause for an unstable shoulder. Arthroscopic examination of the shoulder before surgery revealed a significant amount of information that would have been undetected without the aid of expensive diagnostic tools. For instance, the labrum and rim of the anteroinferior glenoid showed typical abnormalities corresponding to different entities of anterior instability.

Adult↗

PubMedDate not supplied

A prospective naturalistic study of electroconvulsive therapy in late-life depression.

We performed a prospective, naturalistic study using standardized clinical rating scales to characterize the effect of electroconvulsive therapy (ECT) on mood, cognition, and medical status in late-life depression. Over a 16-month period, 40 patients aged 60 years and over who fulfilled DSM-III criteria for a major depressive episode received a total of 42 ECT courses. Three patients (7%) developed significant medical complications: one had a syncopal episode due to arrhythmia, and two had symptomatic vertebral compression fractures. Confusion was noted during 13 courses (31%) and persisted at discharge in four (10%). More than half the patients were either psychotic or demented on admission, and all but three had been either unresponsive or intolerant to pharmacotherapy. All patients experienced a decrease in their depressive symptoms and more than two thirds were in complete or partial remission at discharge. Patients with psychotic depression experienced a greater improvement than patients with nonpsychotic depression, and patients with organic mental disorders experienced the same improvement as other patients. This study confirms that ECT is a safe and effective treatment of depression in late life.

Aged↗

PubMed1998

Use of maxillary and mandibular splints for restoration of normal occlusion following jaw trauma in a cat: a case report.

A compression fracture of the maxilla in a young cat was treated by splinting the maxillary canine teeth. Wire-reinforced composite resin was used to keep these teeth from tipping palatally. This technique stabilized the fracture with anatomic reduction and minimal invasion of the tissues. A mandibular symphyseal separation was also stabilized with a cerclage wire and composite resin bonded wire fixation of the mandibular canine teeth. Two years later, occlusion was normal.

Animals↗