Assessment of paraspinal neurogenic tumors with diffusion-weighted MR imaging

Diagnosis and Treatment of Peripheral and Cranial Nerve Tumors with Expert Recommendations: An EUropean Network for RAre CANcers (EURACAN) Initiative

The 2021 WHO classification of the CNS Tumors identifies as "Peripheral nerve sheath tumors" (PNST) some entities with specific clinical and anatomical characteristics, histological and molecular markers, imaging findings, and aggressiveness. The Task Force has reviewed the evidence of diagnostic and therapeutic interventions, which is particularly low due to the rarity, and drawn recommendations accordingly. Tumor diagnosis is primarily based on hematoxylin and eosin-stained sections and immunohistochemistry. Molecular analysis is not essential to establish the histological nature of these tumors, although genetic analyses on DNA extracted from PNST (neurofibromas/schwannomas) is required to diagnose mosaic forms of NF1 and SPS. MRI is the gold-standard to delineate the extension with respect to adjacent structures. Gross-total resection is the first choice, and can be curative in benign lesions; however, the extent of resection must be balanced with preservation of nerve functioning. Radiotherapy can be omitted in benign tumors after complete resection and in NF-related tumors, due to the theoretic risk of secondary malignancies in a tumor-suppressor syndrome. Systemic therapy should be considered in incomplete resected plexiform neurofibromas/MPNSTs. MEK inhibitor selumetinib can be used in NF1 children ≥2 years with inoperable/symptomatic plexiform neurofibromas, while anthracycline-based treatment is the first choice for unresectable/locally advanced/metastatic MPNST. Clinical trials on other MEK1-2 inhibitors alone or in combination with mTOR inhibitors are under investigation in plexiform neurofibromas and MPNST, respectively.

Semi-supervised super-resolution of diffusion-weighted images based on multiple references

Spatial resolution of diffusion tensor images is usually compromised to accelerate the acquisitions, and the state-of-the-art (SOTA) image super-resolution (SR) reconstruction methods are commonly based on supervised learning models. Considering that matched low-resolution (LR) and high-resolution (HR) diffusion-weighted (DW) image pairs are not readily available, we propose a semi-supervised DW image SR reconstruction method based on multiple references (MRSR) extracted from other subjects. In MRSR, the prior information of multiple HR reference images is migrated into a residual-like network to assist SR reconstruction of DW images, and a CycleGAN-based semi-supervised strategy is used to train the network with 30% matched and 70% unmatched LR-HR image pairs. We evaluate the performance of the MRSR by comparing against SOTA methods on an HCP dataset in terms of the quality of reconstructed DW images and diffusion metrics. MRSR achieves the best performance, with the mean PSNR/SSIM of DW images being improved by at least 14.3%/28.8% and 1%/1.4% respectively relative to SOTA unsupervised and supervised learning methods, and with the fiber orientations deviating from the ground truth by about 6.28° on average, the RMSEs of fractional anisotropy, mean diffusivity, axial diffusivity and radial diffusivity being 3.0%, 4.6%, 5.7% and 4.5% respectively relative to the ground truth. We validate the effectiveness of the proposed network structure, multiple-reference and CycleGAN-based semi-supervised learning strategies for SR reconstruction of diffusion tensor images through the ablation studies. The proposed method allows us to achieve SR reconstruction for diffusion tensor images with a limited number of matched image pairs.

Endobronchial ultrasound-guided transbronchial needle aspiration as a diagnostic modality for schwannoma: A case report

INTRODUCTION

Schwannomas are the most common nerve sheath tumors in the paravertebral mediastinum. Although radiological imaging is helpful in diagnosing schwannomas, a definitive diagnosis is dependent on pathological features of a surgical specimen. For patients who require preoperative diagnosis, an incisional biopsy using minimally invasive surgery is preferred. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is less commonly used for suspected schwannomas.

PATIENT CONCERNS

A 48-year-old woman presented to the clinic with complaints of productive cough for >1 month, expectorating yellow and mucoid sputum approximately 4 to 5 times per day. Chest computed tomography revealed a well-circumscribed, homogeneous, soft tissue mass lesion in right upper posterior mediastinum, measuring 55 mm × 44 mm. Vocal fremitus in the right upper lung was diminished, the percussion note was slightly dull, and breath sounds were slightly reduced on auscultation. The patient was a nondrinker and nonsmoker, with no other relevant medical history. There was no significant relevant family medical history.

DIAGNOSIS

Complete blood count and blood biochemistry were within normal limits, except for an elevated erythrocyte sedimentation rate (32 mm/h). EBUS-TBNA was performed and histopathological findings were consistent with schwannoma.

INTERVENTIONS

The patient underwent schwannoma excision by thoracoscopy. Pathological findings from the surgical specimen were consistent with the EBUS-TBNA results. Based on EBUS-TBNA and postsurgical pathology, the patient was diagnosed with a right upper mediastinal schwannoma (Antoni B).

OUTCOMES

The patient experienced an uneventful postoperative recovery with no adjuvant therapy and was discharged on April 18, 2017. The patient has been followed up for 4 years and has not experienced any symptoms.

CONCLUSIONS

Cell blocks obtained from EBUS-TBNA afford the possibility of cytological examination and immunocytochemical staining, which can confirm diagnosis of schwannoma.

Added value of coronal-T1W sequence to the lumbar MR imaging protocol for low back pain

Introduction:

Magnetic resonance imaging (MRI) is the most appropriate imaging method to investigate low back pain. As low back pain is very common, a large number of MRI scans are performed.

Objective:

To evaluate the extraspinal findings and clinical effect of the T1-weighted spin echo (T1 W SE) coronal sequence added to the lumbar MRI protocol for low back pain.

Materials and methods:

In 2015, we added a T1-weighted (T1W) coronal sequence to our routine lumbar MRI protocol. We retrospectively evaluated 969 lumbar MRI images for low back pain performed with this protocol. The extraspinal MRI findings obtained from them were then grouped as associated with low back pain (Category 1) and not associated with low back pain (Category 2). We also evaluated whether the recorded incidental extraspinal findings could be detected on conventional sagittal and axial images.

Results:

Ninety-six (63%) of the extraspinal findings were associated with low back pain (Category 1) and 56 (37%), Category 2. Seventy-eight percent of the extraspinal findings were detected only on coronal-T1W images and not on conventional images.

Conclusion:

Adding coronal-T1W sequence to the routine protocol of lumbar MRI can help to identify extraspinal findings and guide clinical treatment.

The role of diffusion tensor imaging of the liver in children with autoimmune hepatitis

Purpose

To evaluate the role of diffusion tensor imaging (DTI) of the liver in children with autoimmune hepatitis (AIH).

Material and methods

A prospective study was done on 42 children with AIH (30 girls and 12 boys, with a mean age of 13 years) and 20 age- and sex-matched healthy control children. They underwent DTI of the liver and laboratory tests. Liver biopsy was done for the patients. The mean diffusivity (MD) and fractional anisotropy (FA) of the liver were calculated and correlated with the pathological results.

Results

The mean MD and FA of the liver in children with AIH were 1.42 ± 0.06 × 10^-3 mm²/s and 0.37 ± 0.11; and in the control children they were 1.55 ± 0.07 × 10^-3 mm²/s and 0.25 ± 0.03, respectively. The MD and FA were significantly different in the children with AIH compared to the control children (p = 0.001). The cutoff MD and FA used to differentiate patients from controls were 1.50 × 10^-3 mm²/s, 0.31 with AUC of 0.919 and 0.813, sensitivity of 97.6% and 66.7%, a specificity of 80% and 70%, an accuracy of 94.2% and 67.3%, PPV of 95.3 and 90.3, and NPV of 88.9 and 33.3, respectively. There was significantly lower MD and higher FA of the liver in children with AIH type I (n = 31) than type II (n = 11) (p = 0.001), and patients with (n = 9) and without (n = 33) overlap syndrome (p = 0.005).

Conclusions

We concluded that DTI parameters can help to diagnose AIH, detect its phenotyping, and give clues as to the presence of associated overlap syndrome.

Coronary artery disease imaging reporting and data system (CAD-RADS): what radiologists need to know?

The aim of this work is to review Coronary Artery Disease Imaging Reporting and Data System (CAD-RADS) that was designed to standardize reporting language and improve the communication of data among radiologists and clinicians. Stenotic lesions are graded into 5 grades ranging from 0 (no stenosis) to 5 (total occlusion), where the highest grade represents the final score. The expert consensus platform has added 4 special modifiers (non-diagnostic, stent, graft, and vulnerability) to aid patient management through linking these scores with decision algorithm and treatment plan. Adherence to standard imaging protocol; knowledge of normal, variant, and anomalous anatomy; and skillful evaluation of stenosis are important for proper utilization of this reporting system. Lastly, radiologists should be aware of the inherited benefits, limitations, and common pitfalls of this classification system.

Diffusion tensor imaging of vertebral bone marrow in children with Gaucher's disease type I and III: Pre- and post-therapy

PURPOSE

To assess diffusion tensor imaging (DTI) of the vertebral bone marrow (BM) in children with Gaucher's disease (GD) types I and III before and after therapy.

METHODS

Prospective study was conducted upon 25 children with GD type I (n = 17) and III (n = 8) and 13 age and sex-matched controls underwent DTI of vertebral BM. Mean diffusivity (MD) and fractional anisotropy (FA) of vertebral BM was calculated and correlated with genotyping, chitotriosidase, hemoglobin (HB) and, platelet count.

RESULTS

There was a statistically significant difference in MD and FA of BM between patients and controls (P = 0.001 and 0.02). The area under the curve (AUC) of MD and FA used to differentiate untreated patients from controls was 0.902 and 0.68 with sensitivity, specificity, and, accuracy 92%, 84.6%, and, 89.5% respectively. There was a significant difference in MD and FA of BM between untreated and treated patients (P = 0.001 and 0.02). AUC of MD and FA used to differentiate untreated from treated patients was 0.93 and 0.649 with sensitivity, specificity, and accuracy of 92%, 80%, and 86% respectively. There was a significant difference in MD and FA (P = 0.03, 0.001 respectively) of BM in GD with homozygous L444P mutation (n = 9) and other mutations (n = 14). Chiotriptase, HB and platelet count of patients was correlated with MD (r = -0.36, 0.42, -0.41) and FA (r = -0.47, -0.37, -0.46) respectively.

CONCLUSION

DTI of vertebral BM can help in diagnosis and monitoring patients with GD after therapy and correlated with genotyping, and hematological biomarkers of GD.

Prostate Imaging Reporting and Data System (PI-RADS): What the radiologists need to know?

We aim to review the new modifications in MR imaging technique, image interpretation, lexicon, and scoring system of the last version of Prostate Imaging Reporting and Data System version 2.1 (PI-RADS v2.1) in a simple and practical way. This last version of PI-RADS v2.1 describes the new technical modifications in the protocol of Multiparametric MRI (MpMRI) including T2, diffusion-weighted imaging (DWI), and dynamic contrast enhancement (DCE) parameters. It includes also; new guidelines in the image interpretation specifications in new locations (lesions located in the central zone and anterior fibromuscular stroma), clarification of T2 scoring of lesions of the transition zone, the distinction between DWI score 2 and 3 lesions in the transition zone and peripheral zone, as well as between positive and negative enhancement in DCE. Biparametric MRI (BpMRI) along with simplified PI-RADS is gaining more acceptances in the assessment of clinically significant prostatic cancer.

A Bayesian approach for diagnostic accuracy of malignant peripheral nerve sheath tumors: a systematic review and meta-analysis

Background

Malignant peripheral nerve sheath tumors (MPNST) carry a dismal prognosis and require early detection and complete resection. However, MPNSTs are prone to sampling errors and biopsies or resections are cumbersome and possibly damaging in benign peripheral nerve sheath tumor (BPNST). This study aimed to systematically review and quantify the diagnostic accuracy of noninvasive tests for distinguishing MPNST from BPNST.

Methods

Studies on accuracy of MRI, FDG-PET (fluorodeoxyglucose positron emission tomography), and liquid biopsies were identified in PubMed and Embase from 2000 to 2019. Pooled accuracies were calculated using Bayesian bivariate meta-analyses. Individual level-patient data were analyzed for ideal maximum standardized uptake value (SUV_max) threshold on FDG-PET.

Results

Forty-three studies were selected for qualitative synthesis including data on 1875 patients and 2939 lesions. Thirty-five studies were included for meta-analyses. For MRI, the absence of target sign showed highest sensitivity (0.99, 95% CI: 0.94-1.00); ill-defined margins (0.94, 95% CI: 0.88-0.98); and perilesional edema (0.95, 95% CI: 0.83-1.00) showed highest specificity. For FDG-PET, SUV_max and tumor-to-liver ratio show similar accuracy; sensitivity 0.94, 95% CI: 0.91-0.97 and 0.93, 95% CI: 0.87-0.97, respectively, specificity 0.81, 95% CI: 0.76-0.87 and 0.79, 95% CI: 0.70-0.86, respectively. SUV_max ≥3.5 yielded the best accuracy with a sensitivity of 0.99 (95% CI: 0.93-1.00) and specificity of 0.75 (95% CI: 0.56-0.90).

Conclusions

Biopsies may be omitted in the presence of a target sign and the absence of ill-defined margins or perilesional edema. Because of diverse radiological characteristics of MPNST, biopsies may still commonly be required. In neurofibromatosis type 1, FDG-PET scans may further reduce biopsies. Ideal SUV_max threshold is ≥3.5.

Diffusion tensor imaging of the spleen in prediction and grading of esophageal varices in cirrhotic children with portal hypertension

PURPOSE

To assess diffusion tensor imaging (DTI) of spleen in prediction and grading of esophageal varices (OV) in cirrhotic children.

METHODS

This prospective study was conducted upon 30 children with cirrhotic children with OV and 10 age-gender matched controls that underwent DTI of abdomen. Mean diffusivity (MD) and fractional anisotropy (FA) of spleen were calculated and matched with the grading of OV at endoscopy and laboratory biomarkers of portal hypertension.

RESULTS

Mean ADC of spleen in patient was significantly different (p = 0.001) from that of controls by both reviewers respectively. The cutoff ADC measurement of the spleen used for prediction of OV was ≥ 0.75 and ≥ 0.76 × 10^-3mm²/s with AUC was 0.993 and 0.997 for both reviewers respectively. The FA of the spleen in patient was different (p = 0.01) from of controls of both reviewers respectively. Cutoff FA of spleen used for prediction of OV was ≤ 0.35 and ≤ 0.36 for both observers respectively. ADC and FA of spleen was correlated with platelets count (r =  - 0.713, 0.392; p = 0.001, 0.012) and prothrombin time (r = 0.518, - 0.380; p = 0.001, 0.016).

CONCLUSION

DTI metrics of spleen can predict and grade OV and correlated with laboratory biomarkers of portal hypertension.

Diagnostic Accuracy of MRI for the Detection of Malignant Peripheral Nerve Sheath Tumors: A Systematic Review and Meta-Analysis

OBJECTIVE. This systematic review and meta-analysis evaluates the diagnostic accuracy of MRI for differentiating malignant (MPNSTs) from benign peripheral nerve sheath tumors (BPNSTs). MATERIALS AND METHODS. A systematic review of MEDLINE, Embase, Scopus, the Cochrane Library, and the gray literature from inception to December 2019 was performed. Original articles that involved at least 10 patients and that evaluated the accuracy of MRI for detecting MPNSTs were included. Two reviewers independently extracted clinical and radiologic data from included articles to calculate sensitivity, specificity, PPV, NPV, and accuracy. A meta-analysis was performed using a bivariate mixed-effects regression model. Risk of bias was evaluated using QUADAS-2. RESULTS. Fifteen studies involving 798 lesions (252 MPNSTs and 546 BPNSTs) were included in the analysis. Pooled and weighted sensitivity, specificity, and AUC values for MRI in detecting MPNSTs were 68% (95% CI, 52-80%), 93% (95% CI, 85-97%), and 0.89 (95% CI, 0.86-0.92) when using feature combination and 88% (95% CI, 74-95%), 94% (95% CI, 89-96%), and 0.97 (95% CI, 0.95-0.98) using diffusion restriction with or without feature combination. Subgroup analysis, such as patients with neurofibromatosis type 1 (NF1) versus those without NF1, could not be performed because of insufficient data. Risk of bias was predominantly high or unclear for patient selection, mixed for index test, low for reference standard, and unclear for flow and timing. CONCLUSION. Combining features such as diffusion restriction optimizes the diagnostic accuracy of MRI for detecting MPNSTs. However, limitations in the literature, including variability and risk of bias, necessitate additional methodologically rigorous studies to allow subgroup analysis and further evaluate the combination of clinical and MRI features for MPNST diagnosis.

Differentiation Between Phenotypes of Polycystic Ovarian Syndrome With Sonography

Objectives:

To differentiate between the classic (A/B) from the nonclassic (C/D) phenotypes of the polycystic ovarian syndrome (PCOS) with sonography.

Materials & Methods:

Retrospective analysis was performed upon 72 female patients with PCOS. All patients underwent transvaginal sonography. The patients were classified into classic and nonclassic phenotypes of PCOS. Image analysis was performed for the ovarian volume, follicle counts, follicle size, and endometrial plate thickness.

Results:

There were significant differences in the ovarian volume ( P = .001), follicle counts ( P = .001), follicle size ( P = .001), and endometrial plate thickness ( P = .001) between classic and nonclassic phenotypes of PCOS. The threshold value for ovarian volume, follicle count, follicle size, and endometrial plate thickness used to differentiate classic from nonclassic phenotypes were 12.5, 10.5, 5.25, and 5.75, respectively, with an area under the curve of 0.79, 0.82, 0.83, 0.77 and an accuracy of 75%, 73.6%, 79.2%, and 68.1%, respectively. The serum testosterone level and the body mass index were significantly higher in patients with classic than nonclassic phenotypes of PCOS ( P = .001, .04), respectively.

Conclusion:

Sonography findings can differentiate classic from nonclassic phenotypes of PCOS.

Bone-related disorders of the jaw: A clinico-radiological diagnostic algorithm

Bone-related disorders of the jaw (BRDJ) include a spectrum of non-neoplastic and neoplastic lesions of the maxillofacial region that have been recently classified into fibro-osseous lesions, giant cell lesions and osseous tumours. The histopathological features of BRDJ can be similar and overlie each other. Imaging is important in order to reach a specific diagnosis. However, the appearance of BRDJ on imaging is non-specific in some cases. Computed tomography (CT) and magnetic resonance imaging (MRI) are used for accurate localisation, characterisation of the tumour matrix, delineation of the lesion extension and establishment of the relation of BRDJ to the surrounding structures. Imaging is usually done to detect the relationship with the adjacent surrounding vital structures and to diagnose aggressive forms, malignant transformation and associated syndromes. The correlation of the demographic findings, the location and the clinical presentations with the imaging features are important for the diagnosis of BRDJ. The proposed clinico-radiological diagnostic algorithm with CT and MRI helps a specific diagnosis to be reached in some cases.

Added Value of Magnetic Resonance Imaging for the Evaluation of Mediastinal Lesions

The high soft tissue contrast and tissue characterization properties of magnetic resonance imaging allow further characterization of indeterminate mediastinal lesions on chest radiography and computed tomography, increasing diagnostic specificity, preventing unnecessary intervention, and guiding intervention or surgery when needed. The combination of its higher soft tissue contrast and ability to image dynamically during free breathing, without ionizing radiation exposure, allows more thorough and readily appreciable assessment of a lesion's invasiveness and assessment of phrenic nerve involvement, with significant implications for prognostic clinical staging and surgical management.

Minimally invasive debridement and drainage using intraoperative CT-Guide in multilevel spondylodiscitis: a long-term follow-up study

BACKGROUND

Spondylodiscitis is an unusual infectious disease, which usually originates as a pathogenic infection of intervertebral discs and then spreads to neighboring vertebral bodies. The objective of this study is to evaluate percutaneous debridement and drainage using intraoperative CT-Guide in multilevel spondylodiscitis.

METHODS

From January 2002 to May 2017, 23 patients with multilevel spondylodiscitis were treated with minimally invasive debridement and drainage procedures in our department. The clinical manifestations, evolution, and minimally invasive debridement and drainage treatment of this refractory vertebral infection were investigated.

RESULTS

Of the enrolled patients, the operation time ranged from 30 minutes to 124 minutes every level with an average of 48 minutes. Intraoperative hemorrhage was minimal. The postoperative follow-up period ranged from 12 months to 6.5 years with an average of 3.7 years. There was no reactivation of infection in the treated vertebral segment during follow-up, but two patients with fungal spinal infection continued to progress by affecting adjacent segments prior to final resolution. According to the classification system of Macnab, one patient had a good outcome at the final follow-up, and the rest were excellent.

CONCLUSIONS

Minimally invasive percutaneous debridement and irrigation using intraoperative CT-Guide is an effective minimally invasive method for the treatment of multilevel spondylodiscitis.

Characterization of bone metabolism in hungarian psoriatic arthritis patients: a case-control study

Background

Skeletal manifestations are predominant in psoriatic arthritis (PsA). The aim of this cross-sectional, case-control study is the complex assessment of areal and volumetric bone mineral density (BMD), fracture risk, vitamin D status and bone turnover markers, and its association with disease-related variables.

Methods

Lumbar spine (L1-L4) and femoral neck (FN) areal, and distal radius (DR) volumetric BMD, 10-year probability of major and hip osteoporotic fracture as assessed by the fracture risk assessment (FRAX) tool, markers of bone metabolism and disease activity were assessed.

Results

Upon comparison of the disease and age- and sex-matched control groups, there was a statistically significant difference in FN areal (0.952 (0.607–1.292) g/cm² vs. 1.016 (0.760–1.550) g/cm²; p = 0.001) and DR total volumetric (284.3 (138.9–470.3) mg/cm³ vs. 367.0 (287.0–412.0) mg/cm³; p < 0.001) BMD, 10 year probability for major osteoporotic (3.7% (0.7–32%) vs. 2.6% (0–17.5%); p = 0.003) and hip (0.4% (0–16%) vs. 0.05% (0–6.1%); p = 0.002) fracture and 25-hydroxyvitamin D status (47.5 (10–120) nmol/L vs. 64 (10–137; p < 0.001) nmol/L). As compared to areal assessment, volumetric BMD measurements identified a significantly higher number of patients with low bone mineral density (T-Score ≤ − 1.00) (34% vs. 88%, p < 0.001). Upon multiple linear regression analysis, disease activity score, as determined by DAS28 assessment, was an independent predictor of 10-year probability for major osteoporotic fracture (B (95%CI) = 1.351 (0.379–2.323); p = 0.007).

Conclusion

In the studied PsA cohort, disease activity was an independent predictor of 10-year probability for a major osteoporotic fracture, and complemented assessment of volumetric and areal BMD assured better efficacy at identifying those with low bone mineral density.

Imaging of vascular cognitive impairment

Vascular cognitive impairment (VCI) is a major health challenge and represents the second most common cause of dementia. We review the updated imaging classification and imaging findings of different subtypes of VCI. We will focus on the magnetic resonance imaging (MRI) markers of each subtype and highlight the role of advanced MR imaging sequences in the evaluation of these patients. Small vessel dementia appears as white matter hyperintensity, lacunae, microinfarcts, and microbleeds. Large vessel dementia includes strategic infarction and multi-infarction dementias. Hypoperfusion dementia can be seen as watershed infarcts and cortical laminar necrosis. Hemorrhagic dementia results from cerebral amyloid angiopathy and cortical superficial siderosis. Hereditary forms of VCI, caused by gene mutations such as CADASIL, should be suspected when dementia presents in young patients. Mixed dementia is seen in patients with Alzheimer's disease and the coexistence of cerebrovascular disease.

Analysis of percutaneous kyphoplasty under different types of anesthesia for the treatment of multiple osteoporotic vertebral fractures

Background

Surgeons recognize that using percutaneous kyphoplasty (PKP) under local anesthesia to treat osteoporotic vertebral fracture (OVF) prevents interference with the general situation of elderly patients suffering from multiple organ dysfunction. Surgeons can directly assess whether nerve injury occurs while the patient is awake. However, when patients with multiple osteoporotic vertebral fractures (m-OVFs) receive local anesthesia, fluoroscopy time often has to be increased, the operative time has to be extended, or the operation has to be terminated because of discomfort related to body posture. No relevant study has thus far been conducted on the type of anesthesia to administer to patients undergoing PKP for m-OVFs. This study aimed to determine which of the two types of anesthesia is more suitable for PKP for m-OVFs.

Methods

A retrospective study was conducted involving 159 patients who underwent PKP for m-OVFs from January 2016 to January 2020; 81 patients underwent PKP under general anesthesia (Group G), and 78 patients underwent PKP under local anesthesia (Group L). Clinical and adverse events were compared between the two groups.

Results

The intraoperative mean arterial pressure, average heart rate, average fluoroscopy times of each vertebral body, and operative time were less in Group G than in Group L. The visual analog scale (VAS) score was significantly lower after than before the operation. The anterior vertebral height (AVH), middle vertebral height (MVH), and kyphotic angle (KA) were significantly improved in both groups postoperatively. The improvement in VAS score, AVH, MVH, and KA in Group G were higher than those in Group L. No significant difference in the incidence of complications was observed between the two groups.

Conclusion

PKP under either general anesthesia or local anesthesia was reliable. Compared with PKP under local anesthesia, PKP under general anesthesia could more reliably maintain the stability of vital signs, alleviate preoperative pain in patients, and attain a better orthopedic effect. Moreover, the latter does not increase the complications of patients with m-OVFs. However, the high medical expense of PKP under general anesthesia is a factor to consider when choosing the type of anesthesia.

Imaging of congenital cranial dysinnervation disorders: What radiologist wants to know?

We aim to review the imaging features of congenital cranial dysinnervation disorders. Characteristic imaging findings can define subtypes of these disorders through assessment of cranial nerves, extraocular muscles, orbital, and brain abnormalities. Duane retraction syndrome shows absent or hypoplasic 6th cranial nerve and preserved extraocular muscles (EOM). Mobius syndrome shows absent 7th and 6th cranial nerves, absence of facial colliculus, flattening of the dorsal aspect of the pons, hypoplasia of the pons and medulla, and flattening of the 4th ventricular floor. Congenital fibrosis of the extraocular muscles reveals unilateral or bilateral hypoplasia or aplasia of the 3rd cranial nerve, atrophy of superior rectus and levator palpebrae superioris muscles, and atrophy of the brainstem and cerebellar hemispheres. Horizontal gaze palsy and progressive scoliosis show characteristic split pons sign, butterfly medulla, absent facial colliculi, and spinal scoliosis. HOXA1 Mutations show a bilateral absence of 6th cranial nerves with the underdeveloped inner ear. Pontine Cap Tegmental Dysplasia shows ventral pontine hypoplasia, dorsal tegmental projection into the 4th ventricle, and variable cranial nerve deficits.

Interstitial Lung Fibrosis Imaging Reporting and Data System: What Radiologist Wants to Know?

The aim of this work is to review interstitial lung fibrosis Imaging Reporting and Data System (ILF-RADS) that was designed for reporting of interstitial lung fibrosis (ILF). Findings include pulmonary and extrapulmonary findings and is subsequently designed into 4 categories. Pulmonary findings included lung volume, reticulations, traction bronchiectasis, honeycomb, nodules, cysts, ground glass, consolidation, mosaic attenuation and emphysema, and distribution of pulmonary lesions; axial (central, peripheral and diffuse), and zonal distribution (upper, middle, and lower zones). Complications in the form of acute infection, acute exacerbation, and malignancy were also assessed. Extrapulmonary findings included mediastinal, pleural, tracheal, and bone or soft tissue lesions. The lexicon of usual interstitial pneumonia (UIP) was classified into 4 categories designated as belonging in 1 of 4 categories. Lexicon of ILF-RADS-1 (typical UIP), ILF-RADS-2 (possible UIP), ILF-RADS-3 (indeterminate for UIP), and ILF-RADS-4 (inconsistent with UIP).

Pedicled Multifidus Muscle Flap To Treat Inaccessible Dural Tear In Spine Surgery: Technical Note And Preliminary Experience

OBJECTIVE

To assess the usefulness, feasibility, and limitations of pedicled multifidus muscle flaps (PMMFs) for the treatment of inaccessible dural tears during spine surgery.

METHODS

The technique of PMMF harvesting was investigated together with relevant anatomy. We prospectively evaluated 8 patients treated with the PMMF technique between January 2017 and December 2019. Results were compared with a retrospective series of 9 patients treated with a standard technique between January 2014 and December 2016. Inclusion criteria were inaccessible dural tear or dural tear judged not amenable to direct repair because of tissue loosening. Exclusion criteria were surgical treatment of intradural disease. Clinical and demographic data of all patients were collected. Clinical evaluations were performed according to American Spinal Injury Association criteria and Oswestry Disability Index. Preoperative and postoperative computed tomography was performed in all patients. The primary end point was wound healing (cerebrospinal fluid leakage, infection, and fluid collection); secondary end points were neurologic outcome and complications.

RESULTS

Control group: 1 death as a result of wound infection secondary to cerebrospinal fluid fistula and 2 patients needed lumbar subarachnoid drain; neurologic outcome: 3 patients improved and 6 were unchanged. Flap group: no wound-related complications were observed; neurologic outcome: 3 patients improved and 5 were unchanged. No flap-related complications were described. Flap harvesting was feasible in all cases, with an average 20 minutes adjunctive surgical time.

CONCLUSIONS

The PMMF technique was feasible and safe; in this preliminary experience, its use is associated with lower complications as a result of dural tears but larger series are needed to confirm its effectiveness.

Approaches to promoting bone marrow mesenchymal stem cell osteogenesis on orthopedic implant surface

Bone marrow-derived mesenchymal stem cells (BMSCs) play a critical role in the osseointegration of bone and orthopedic implant. However, osseointegration between the Ti-based implants and the surrounding bone tissue must be improved due to titanium’s inherent defects. Surface modification stands out as a versatile technique to create instructive biomaterials that can actively direct stem cell fate. Here, we summarize the current approaches to promoting BMSC osteogenesis on the surface of titanium and its alloys. We will highlight the utilization of the unique properties of titanium and its alloys in promoting tissue regeneration, and discuss recent advances in understanding their role in regenerative medicine. We aim to provide a systematic and comprehensive review of approaches to promoting BMSC osteogenesis on the orthopedic implant surface.

Diffusion tensor imaging and electrophysiology as robust assays to evaluate the severity of acute spinal cord injury in rats

Background

Diffusion tensor imaging (DTI) is an effective method to identify subtle changes to normal-appearing white matter (WM). Here we analyzed the DTI data with other examinations, including motor evoked potentials (MEPs), histopathological images, and behavioral results, to reflect the lesion development in different degrees of spinal cord injury (SCI) in acute and subacute stages.

Method

Except for 2 Sprague -Dawley rats which died from the anesthesia accident, the rest 42 female rats were randomized into 3 groups: control group (n = 6), moderate group (n = 18), and severe group (n = 18). Moderate (a 50-g aneurysm clip with 0.4-mm thickness spacer) or severe (a 50-g aneurysm clip with no spacer) contusion SCI at T8 vertebrae was induced. Then the electrophysiological assessments via MEPs, behavioral deterioration via the Basso, Beattie, and Bresnaha (BBB) scores, DTI data, and histopathology examination were analyzed.

Results

In this study, we found that the damage of WM myelin, MEPs amplitude, BBB scores and the decreases in the values of fractional anisotropy (FA) and axial diffusivity (AD) were more obvious in the severe injury group than those of the moderate group. Additionally, the FA and AD values could identify the extent of SCI in subacute and early acute SCI respectively, which was reflected in a robust correlations with MEPs and BBB scores. While the values of radial diffusivity (RD) showed no significant changes.

Conclusions

Our data confirmed that DTI was a valuable in ex vivo imaging tool to identify damaged white matter tracts after graded SCI in rat, which may provide useful information for the early identification of the severity of SCI.

Prediction of skull base osteomyelitis in necrotising otitis externa with diffusion-weighted imaging

OBJECTIVE

To predict skull base osteomyelitis in patients with necrotising otitis externa using diffusion-weighted imaging.

METHODS

A retrospective analysis was conducted of 25 necrotising otitis externa patients with skull base osteomyelitis (n = 10) or without skull base involvement (n = 14) who underwent a single-shot diffusion-weighted imaging of the skull base.

RESULTS

The respective mean apparent diffusion coefficient values of the skull base, as determined by two reviewers, were 0.851 ± 0.15 and 0.841 ± 0.14 ×10-3mm2/s for the skull base osteomyelitis patients, and 1.065 ± 0.19 and 1.045 ± 0.20 ×10-3mm2/s for the necrotising otitis externa patients without skull base involvement. The difference in apparent diffusion coefficients between the groups was significant, for both reviewers (p = 0.008 and 0.012). The optimal threshold apparent diffusion coefficient for predicting skull base osteomyelitis in necrotising otitis externa patients was 0.945 ×10-3mm2/s and 0.915 ×10-3mm2/s, with an area under the curve of 0.825 and 0.800, accuracy of 87.5 and 83.3 per cent, sensitivity of 85.7 and 90.0 per cent, and specificity of 90.0 and 78.6 per cent, for each reviewer respectively.

CONCLUSION

Apparent diffusion coefficient is a non-invasive imaging parameter useful for predicting skull base osteomyelitis in necrotising otitis externa patients.

Imaging of Neuronal and Mixed Glioneuronal Tumors

Neuronal and mixed glioneuronal tumors represent a group of neoplasms with varying degrees of neural and glial elements. Their age of presentation varies, but they are most commonly seen in children and young adults. With the exception of anaplastic ganglioglioma and other atypical variants, most lesions are low grade; however, they can have significant morbidity because of seizures, mass effect, or difficult to treat hydrocephalus. Although many tumors show overlapping clinical and imaging features, some have relatively distinctive imaging characteristics that may aid in narrowing the differential diagnosis. In this review, we discuss relevant clinical and pathologic characteristics of these tumors and provide an overview of conventional and advanced imaging features that provide clues as to the diagnosis.

Multiple neurofibromas plus fibrosarcoma with familial NF1 pathogenicity: A case report

BACKGROUND

Neurofibromatosis (NF) is a genetic disease consisting of seven types, of which types 1 to 4 are caused by a dominant autosomal gene mutation; such disease sometimes arises in patients with NF type 1. However, it remains unclear whether the origin of neurofibrosarcoma is directly linked to the incidence of NF type 1, as no reports have been published on this issue. Here, we report a case of NF1-positive multiple neurofibromas with malignant fibrosarcomatous transformation in the pleural cavity.

CASE SUMMARY

A 51-year-old male was admitted to our hospital due to fever accompanied by coughing, chest tightness and asthma for more than one month. The preliminary diagnosis was NF type 1, which was pathologically confirmed by a subsequent thoracoabdominal subcutaneous biopsy. The definitive diagnosis was neurofibrosarcoma with a pathogenic NF1 gene. The patient refused surgery and chemoradiotherapy, and died two months later. NF is a genetic disease consisting of seven types, of which types 1 to 4 are caused by a dominant autosomal gene mutation. The case reported belongs to the class of NF1-positive dominant inheritance. Neurofibrosarcoma is a malignant tumor derived from cells surrounding the peripheral nerves. However, due to the lack of previous reports, it remains unclear whether the origin of neurofibrosarcoma is directly linked to the incidence of NF type 1.

CONCLUSION

We report the first case of NF1-positive multiple neurofibromas with malignant fibrosarcomatous transformation in the pleural cavity.

Interobserver Agreement of Magnetic Resonance Imaging of Liver Imaging Reporting and Data System Version 2018

AIM

This study aimed to assess the interobserver agreement of magnetic resonance (MR) imaging of Liver Imaging Reporting and Data System version 2018 (LI-RADS v2018).

SUBJECTS AND METHODS

Retrospective analysis was done for 119 consecutive patients (77 male and 42 female) at risk of hepatocellular carcinoma who underwent dynamic contrast MR imaging. Image analysis was done by 2 independent and blinded readers for arterial phase hyperenhancement, washout appearance, enhancing capsule appearance, and size. Hepatic lesions were classified into 7 groups according to LI-RADS v2018.

RESULTS

There was excellent interobserver agreement of both reviewers for LR version 4 (κ = 0.887, P = 0.001) with 90.76% agreement. There was excellent interobserver agreement for nonrim arterial phase hyperenhancement (κ = 0.948; 95% confidence interval [CI], 0.89-0.99; P = 0.001), washout appearance (κ = 0.949; 95% CI, 0.89-1.0; P = 0.001); and enhancing capsule (κ = 0.848; 95% CI, 0.73-0.97; P = 0.001) and excellent reliability of size (interclass correlation, 0.99; P = 0.001). There was excellent interobserver agreement for LR-1 (κ = 1.00, P = 0.001), LR-2 (κ = 0.94, P = 0.001), LR-5 (κ = 0.839, P = 0.001), LR-M (κ = 1.00, P = 0.001), and LR-TIV (κ = 1.00; 95% CI, 1.0-1.0; P = 0.001), and good agreement for LR-3 (κ = 0.61, P = 0.001) and LR-4 (κ = 0.61, P = 0.001).

CONCLUSION

MR imaging of LI-RADS v2018 is a reliable imaging modality and reporting system that may be used for standard interpretation of hepatic focal lesions.

Use of percutaneous microwave ablation for the treatment of bone tumors: a retrospective study of clinical outcomes in 47 patients

Objective

The present study aimed to evaluate the short-term clinical performance and safety of percutaneous microwave ablation (MWA) techniques for the treatment of bone tumors.

Methods

This single-institution retrospective study investigated 47 cases of bone tumors treated by MWA from June 2015 to June 2018. The study included 26 patients (55.3%) with benign bone tumors and 21 patients (44.7%) with malignant bone tumors. The tumors were located in the spine or sacrum (15, 31.9%), the upper extremities (6, 12.8%), the lower extremities (17, 36.2%) and the pelvis (9, 19.1%). Outcomes regarding clinical efficacy, including pain relief, quality of life, and intervention-related complications, were evaluated before and after MWA using the visual analog scale (VAS) and the 36-item Short-Form Health Survey (SF-36) scoring system.

Results

Of the 47 patients included in this study, all of them completed follow-up examinations, with a mean follow-up duration of 4.8 ± 1.6 months (range, 2–9 months). Significantly improved VAS and SF-36 scores were recorded after the initial treatment (P<0.001), suggesting that almost 100% of patients experienced pain relief and an improved quality of life following surgery. No major intervention-related complications (e.g., serious neurovascular injury or infection) occurred during or after the treatment. We recorded only three minor posttreatment complications (6.4%, 3/47), which were related to thermal injury that caused myofasciitis and affected wound healing.

Conclusion

In our study, the short-term efficacy of MWA was considerably favorable, with a relatively low rate of complications. Our results also showed that MWA was effective for pain relief and improved patients’ quality of life, making it a feasible treatment alternative for bone tumors.

Coronal STIR sequence, a simple adjustment to routine MRI protocol for extra-spinal sciatica and sciatica-like symptoms

Background

The value of adding coronal STIR images to MR imaging of sciatica aiming to detect extra-spinal abnormalities.

Results

Additional coronal STIR images detected extra-spinal abnormalities in 20% of the patients, thereby downgraded the normal studies from 21 to 13%. The extra-spinal abnormalities included bone abnormalities (36.4%), soft tissue abnormalities (4.5%), neurological abnormalities (2.3%), gynecological abnormalities (50%), and miscellaneous (6.8%). In 6.9% of patients, the extra-spinal abnormalities explained the patients’ pain and influenced their management. Extra-spinal causes of pain significantly correlated to positive trauma and neoplasm history, normal routine protocol images, and absent nerve root impingement. Extra-spinal abnormalities were more prevalent in age groups (20–39 years).

Conclusion

Coronal STIR images (field of view: mid abdomen to the lesser trochanters) identify extra-spinal abnormalities that maybe overlooked on routine MRI protocol. It is of additional value in young adults, trauma, neoplasm, and negative routine images.

Whole-body diffusion-weighted imaging with background body signal suppression in the detection of osseous and extra-osseous metastases

Purpose

To assess the reproducibility of detection of osseous and extra-osseous metastases in cancer patients using whole-body diffusion-weighted imaging with background body signal suppression (WB-DWIBS).

Material and methods

A prospective study was conducted on 39 consecutive patients (21 females, 18 males; mean age 48 years) with metastases, who underwent WB-DWIBS on a 1.5-T MR scanner. Image analysis was performed independently by two blinded observers. Inter-observer agreement was assessed for the detection of osseous (spinal, appendicular) and extra-osseous (hepatic, pulmonary, nodal, and peritoneal) metastases.

Results

The overall inter-observer agreement of WB-DWIBS in the detection of osseous and extra-osseous metastases was excellent (κ = 0.887, agreement = 94.44%, p = 0.001). There was excellent inter-observer agreement of both observers for the detection of osseous spinal (κ = 0.846, agreement = 92.3%), osseous appendicular (κ = 0.898, agreement = 94.8 %), hepatic (κ = 0.847, agreement = 92.3%), pulmonary (κ = 0.938, agreement = 97.4%), nodal metastases (κ = 0.856, agreement = 94.9%), and peritoneal metastasis (κ = 0.772, agreement = 94.9%).

Conclusion

We concluded that WB-DWIBS is reproducible for detection of osseous and extra-osseous metastases in cancer patients.

Can imaging be the new yardstick for diagnosing peripheral neuropathy?-a comparison between high resolution ultrasound and MR neurography with an approach to diagnosis

PURPOSE

Peripheral neuropathies are a group of disorders which affect the peripheral nervous system which have been conventionally diagnosed using electrodiagnostic studies. This study was carried out to assess the role of imaging in diagnosing peripheral mononeuropathy as exact anatomical localisation of the pathology is possible using high-resolution ultrasound and MR neurography, the modalities assessed in this study.

METHOD

A hospital-based prospective analytical study was carried out in a resource-limited setting on 180 peripheral nerves in 131 patients with symptoms of peripheral mononeuropathy after taking IRB approval. Each patient underwent high-resolution ultrasound examination and MR neurography, findings of which were then compared and statistically analysed assuming electrodiagnostic findings as the gold standard.

RESULTS

Overall, the diagnostic accuracy was highest for the proton density fat-saturated MR sequence (93.89%) followed by high-resolution ultrasound (80%). The sensitivity was highest for proton density fat-saturated sequence while the T1 MR sequence had the highest specificity. Combined diagnostic accuracy of both modalities was calculated to be 93.33% with a negative predictive value of 80%. High-resolution ultrasound and MRI equally detected the cases with nerve discontinuity, while neuromas were better identified on MRI.

CONCLUSION

With the advent of higher frequency probes and improved MR field strength, imaging of peripheral nerves is possible with better accuracy. Imaging assessment of nerves allows anatomical delineation with identification of exact site of involvement. This comparative study demonstrates the role of imaging in diagnosing peripheral nerve pathologies with the accuracy of MRI as high as 93.89% which may serve as an imaging gold standard. High-resolution ultrasound, being quicker, cost effective and a comparable accuracy of 80% can serve as a reliable screening tool. This study incorporates a larger study group and compares HRUS with MRI, taking NCV as gold standard, which has not been done in the preceding studies. With this study, we conclude that these two imaging modalities are not mutually exclusive. Rather, they complement each other and can be used in conjunction as an imaging yardstick for diagnosing peripheral neuropathies.

Type I neurofibromatosis with spindle cell sarcoma: A case report

BACKGROUND

Neurofibromatosis type I (NF1) is the most frequent subtype of neurofibromatosis. Its related tumor-suppressor syndromes are characterized by a predisposition to multiple tumor types and other disorder presentations. In addition, the incidence of tumors is much higher in patients with neurofibromatosis type I. However, there are very few reports at home and abroad on this topic. Here, we present a case of NF1 with spindle cell sarcoma.

CASE SUMMARY

A 50-year-old male was found to have a right axillary mass for 20 years. Specialist examination found cafe-au-lait spots on many parts of the skin, rounded nodules in the skin, a bulge in the right armpit, touching a lump (10 cm × 6 cm, hard, unclear boundary, poor mobility, local tenderness). The anterior side of the thigh felt weakened on the opposite side; in the right groin a swollen lymph node (hard, clear border, good mobility, local tenderness). According to the results of positron emission tomography/computed tomography, puncture pathology and immunohistochemistry, genetic testing, a diagnosis of NF1 with spindle cell sarcoma was confirmed. According to the genetic testing result, the patient was given a targeted treatment with crizotinib.

CONCLUSION

Surgery, chemotherapy and radiotherapy are the main treatment methods of NF1. However, with the continuous progress of molecular biology research, molecular targeted therapy may bring benefits for patients.

Severe heterotopic ossification in a seronegative spondyloarthritis patient after cervical Bryan disc arthroplasty: A case report

BACKGROUND

Cervical disc arthroplasty (CDA) is an alternative treatment to traditional interbody fusion that maintains postoperative cervical spine mobility. However, the CDA postoperative period is impacted by osteolysis, subsidence, metallosis, or heterotopic ossification (HO). We report a case of severe HO in a seronegative spondyloarthritis patient after cervical Bryan disc arthroplasty.

CASE SUMMARY

A 34-year-old man received hybrid surgery for C4-C5 and C5-C6 arthroplasty with Bryan discs and C6-C7 arthrodesis with polyetheretherketone cage due to traumatic herniation of the intervertebral disc (HIVD). After four years, cervical spine radiographs revealed severe HO around the Bryan discs over the C4-C5 and C5-C6 levels. The magnetic resonance image revealed HIVD over the C3-C4 level with spinal cord compression. Seronegative spondyloarthritis was diagnosed after consultation with a rheumatologist. A second CDA for the adjacent segment disease HIVD with Baguera C disc over the C3-C4 level achieved an excellent outcome.

CONCLUSION

Minimizing intraoperative tissue trauma and achieving postoperative interbody stability avoid soft tissue traction to prevent HO formation after CDA.

Diagnostic value of whole-body MRI in Opsoclonus-myoclonus syndrome: a clinical case series (3 case reports)

Background

Opsoclonus-myoclonus syndrome (OMS) is a rare clinical disorder and typically occurs in association with occult neuroblastic tumor in pediatric patients. I-123 metaiodobenzylguanidine (mIBG) scintigraphy is widely adopted as screening procedure in patients with suspected neuroblastic tumor. Also, contrast-enhanced magnetic resonance imaging (MRI) or computed tomography (CT) are involved in the imaging workup, primarily for the assessment of the primary tumor region. However, the diagnostic value of whole-body MRI (WB-MRI) for the detection of occult neuroblastic tumor in pediatric patients presenting with OMS remains unknown.

Case presentation

We present three cases of patients with OMS, in whom WB-MRI revealed occult neuroblastic tumor masses, whereas scintigraphy was inconclusive:

In a 17 months old girl with OMS, WB-MRI revealed a paravertebral mass. After thoracoscopic resection, histopathology revealed a ganglioneuroblastoma.

A 13 months old boy presenting with OMS WB-MRI detected a tumor of the left adrenal gland; histopathology demonstrated a ganglioneuroblastoma after adrenalectomy.

In a 2 year old boy with OMS, immunoscintigraphy at the time of diagnosis was inconclusive. At the age of 13 years, a WB-MRI was performed due to persistent neurological symptoms, revealing a paravertebral retroperitoneal mass, which was classified as ganglioneuroblastoma.

Conclusion

In OMS, particularly in the setting of inconclusive scintigraphy, WB-MRI may be considered as a valuable alternative in the early phase of diagnostic work-up.

The benefits of radiological imaging for postoperative orthostatic headache: a case report

Background

Traditionally, the diagnosis of post-dural puncture headache (PDPH) relied upon the patient’s history regarding dural puncture and symptoms, such as orthostatic headache. However, such evidence may not always be reliable or specific. We report an unexpected diagnosis with spontaneous intracranial hypotension (SIH), which was confirmed upon examination of Magnetic Resonance (MR) images in a patient who was initially suspected to have PDPH because he had recently undergone a uncertain dural puncture.

Case presentation

A 45-year-old man had undergone a thoracic epidural catheter insertion for perioperative analgesia prior to general anesthesia induction. Due to intermittent dripping of fluid while the epidural needle was being advanced, a dural puncture was suspected. The patient complained of an orthostatic headache after recovery from surgery, therefore a PDPH was suspected. MR images revealed signs of SIH: dural sinus engorgement, contrast enhancement along the neural sleeves of the left C6–7, bilateral C7-T1, T1–2, T2–3, T3–4, T4–5, and T5–6. Computed tomography-guided epidural blood patching (EBP) was performed the following day, with the patient experiencing immediate relief of the headache.

Conclusion

The benefits of radiological imaging in this case included confirming the correct diagnosis, guiding the accurate level and proper approach of EBP, distinguishing the epidural space from the intrathecal space, and ultimately increasing the likelihood of successful EBP.

Clinical features of syphilitic myelitis with longitudinally extensive myelopathy on spinal magnetic resonance imaging

BACKGROUND

Syphilitic myelitis caused by Treponema pallidum is an extremely rare disease. However, symptomatic neurosyphilis, especially syphilitic myelitis, and its clinical features have been infrequently reported. Only a few cases of syphilitic myelitis have been documented. To the best of our knowledge, there are only 19 reported cases of syphilitic myelitis. However, the clinical features of syphilitic myelitis with longitudinally extensive myelopathy have been still not clear.

AIM

To explore the clinical features of syphilitic myelitis with longitudinally extensive myelopathy on spinal magnetic resonance imaging (MRI).

METHODS

First, we report a patient who suffered from syphilitic myelitis with symptoms of sensory disturbance, with longitudinally extensive myelopathy with "flip-flop sign" on spinal MRI. Second, we performed a literature search to identify other reports (reviews, case reports, or case series) from January 1987 to December 2018, using the PubMed and Web of Science databases with the terms including "syphilis", "neurosyphilis", "syphilitic myelitis", "meningomyelitis", "central nervous system", and "spine". We also summarized the clinical features of syphilitic myelitis with longitudinally extensive myelopathy.

RESULTS

A total of 16 articles of 20 cases were identified. Sixteen patients presented with the onset of sensory disturbance (80%), 15 with paraparesis (75%), and 9 with urinary retention (45%). Eleven patients had a high risk behavior (55%). Five patients had concomitant human immunodeficiency virus infection (25%). Serological data showed that 15 patients had positive venereal disease research laboratory test (VDRL)/treponema pallidum particle agglutination (TPHA), and 17 had positive VDRL/TPHA in cerebrospinal fluid (CSF). Seventeen patients were found to have elevated leukocytosis and protein in CSF. On MRI, 16 patients showed abnormal hyperintensities involved the thoracic spine, 6 involved the cervical spine, and 3 involved both the cervical and thoracic spine. There were 3 patients with the "flip-flop sign". All the patients were treated with penicillin, and 15 patients had a good prognosis.

CONCLUSION

Our case further raises awareness of syphilitic myelitis as an important complication of neurosyphilis due to homosexuality, especially in developing countries such as China.

Magnetic Resonance Imaging Features of Cervical Spine Intraspinal Extradural Synovial Cysts

Spinal synovial cysts are relatively uncommon and are most frequently found in the lumbar spine and rarely in the cervical spine. Intraspinal extradural cervical synovial cysts can occur and potentially cause cord/nerve root compression with symptoms of myelopathy/radiculopathy; however, most are asymptomatic and incidental findings. We conducted a literature review and present, to our knowledge, the largest imaging case series and describe the magnetic resonance imaging features of cervical synovial cysts.

Diagnosis of spinal metastasis: are MR images without contrast medium application sufficient?

OBJECTIVE

To determine the usefulness of adding contrast-enhanced (CE) magnetic resonance imaging (MRI) to conventional MRI for evaluation of spinal metastases.

MATERIALS AND METHODS

One-hundred-and-two whole spine MR examinations, obtained for metastasis work-up within a 2-month period, from 65 men and 37 women (mean age, 64 years) with extra-spinal tumor, who also underwent CE-MRI, were retrospectively evaluated by three radiologists. The number of spine segments with bone marrow involvement was interpreted using a 3-point confidence scale (probable metastasis, equivocal, probably benign) during session 1 (conventional imaging) and session 2 (addition of CE-MRI to conventional imaging). The patients were assigned to 14 categories based on the changes in confidence rating between sessions 1 and 2; these were aggregated to four groups indicating the degree of usefulness of CE-MRI: definitely useful, equivocal, not useful, and presumed non-metastatic groups. Clinical information, metastatic bone type, the number of probably metastatic segments, and anatomical level and position were compared among the former three groups.

RESULTS

The readers assigned 39-53% of cases to the definitely useful group. The number of probably metastatic segments differed significantly among the three groups for all readers (p ≤ 0.046). Age, sex, primary cancer, metastatic bone type, and anatomical level and position were similar.

CONCLUSION

Adding CE-MRI to conventional MRI was useful for objectively detecting and characterizing spinal segments with metastases in 39-53% of cases. However, there were no clinical or radiological factors that could predict the usefulness of CE-MRI in evaluating spinal metastases, except for the number of metastatic segments.

Bilateral and symmetric C1-C2 dumbbell ganglioneuromas associated with neurofibromatosis type 1: A case report

BACKGROUND

Ganglioneuroma (GN) is a rare and benign tumor that originates from autonomic nervous system ganglion cells. The most frequently involved sites are the posterior mediastinum, the abdominal cavity, and the retroperitoneal space. It rarely occurs in the cervical area, compressing the spinal cord. Neurofibromatosis type 1 (NF-1) is an autosomal dominant inheritance disorder, whose prevalence rate approximates one per 3000.

CASE SUMMARY

We report an extremely rare case of bilateral and symmetric dumbbell GNs of the cervical spine with NF-1. A 27-year-old man with NF-1 presented with a one-year history of gradually progressive right upper extremity weakness and numbness in both hands. Magnetic resonance imaging showed bilateral and symmetric dumbbell lesions at the C1-C2 levels compressing the spinal cord. We performed total resection of bilateral tumors, and the postoperative histopathological diagnosis of the resected mass was GN. After operation, the preoperative symptoms were gradually relieved without complications. To our knowledge, this is the sixth report of cervical bilateral dumbbell GNs.

CONCLUSION

In some cases, cervical bilateral dumbbell GNs could be associated with NF-1. The exact diagnosis cannot be obtained before operation, and pathological outcome is the current gold standard. Surgical resection is the most effective option, and disease outcome is generally good after treatment.

Schwannoma originating from the recurrent laryngeal nerve in a thyroid cancer patient: A case report and review of the literature

BACKGROUND

Schwannoma rarely originates from the recurrent laryngeal nerve, and there are few reports on schwannoma originating from the recurrent nerve in the mediastinum. Herein, we present an extremely rare case of schwannoma originating from the recurrent laryngeal nerve in the neck.

CASE SUMMARY

This is a case report of one patient diagnosed with thyroid cancer with schwannoma originating from the recurrent laryngeal nerve in the neck, which was incidentally found during a thyroidectomy, and a review of the literature.

CONCLUSION

Preoperative diagnostic examinations are of less use for detecting schwannoma originating from a recurrent laryngeal nerve in the neck in such small size, which may only incidentally be found during a thyroidectomy. Surgical excision with opening the capsule and shelling out the tumor is the treatment of choice. If the nerve is unable to be preserved, end-to-end recurrent laryngeal nerve anastomosis may be a simple and minimally invasive reconstruction procedure to improve phonation.

Risk factors associated with clinical adjacent segment pathology following multi-level cervical fusion surgery

Few clinical studies investigate risk factors associated with clinical adjacent segment pathology (CASP) following multi-level cervical fusion surgery. The aim is to record the incidence of postoperative CASP in patients after at least 2 years' follow-up and to identify possible risk factors that may be associated with the CASP after multi-level cervical surgery.We retrospectively reviewed patients who underwent multi-level cervical surgery in our hospital from January 2004 to February 2016. All patients underwent more than 2 years' follow-up. The diagnosis of CASP is according to clinical symptoms as well as image findings. Potential risk factors were collected from demographic data and radiographic images.A total of 301 patients after multi-level cervical surgery were analyzed. During follow-up, 28 patients (9.3%) were diagnosed as having CASP. Among these patients, 7 showed symptoms of CASP within 3 years after surgery, 6 showed symptoms between 3 and 5 years, 14 showed symptoms between 5 and 10 years, and the last one showed symptoms more than 10 years later. In the multivariate analysis, degeneration of adjacent segment (OR, 1.592; 95% CI, 1.113-2.277), decreased Cobb angle in fused vertebrae (OR, 2.113; 95% CI, 1.338-3.334) and decreased Cobb angle in cervical spine (OR, 1.896; 95% CI, 1.246-2.886) were correlated with the incidence of CASP during follow-up.The incidence of CASP following multi-level cervical surgery was 9.3% with a mean of about 70 months' follow-up. Patients with preoperative degeneration of adjacent segment and postoperative imbalance of sagittal alignment have a higher risk of developing CASP after multi-level cervical surgery.