The value of computed tomography in the diagnosis of low back pain. A review of 2,012 cases.

AIM: The aim of this study was to establish the effective role of CT in the diagnosis of low back pain, and whether CT features correlate with clinical signs and symptoms. METHODS: Two thousand and twelve consecutive patients, of which 866 males and 1,146 females, aged 22 to 91 years, affected by generic painful back, have been studied in the period between January 2000 and October 2002. Volumetric CT of the lumbo-sacral column was performed on all the patients, employing a Philips Tomoscan SR 7000 (Eindhoven, The Netherlands). Sections of 3 mm in thickness were obtained, employing window and level of window both for bone and soft tissues. Contrast medium was not injected. RESULTS: Regarding the distribution of lesions, 172 males were affected by one, 586 from 2 to 4, 102 more than 4 lesions; 6 subjects were without. On the contrary, 196 females had a single lesion, 611 from 2 to 4, 331 more than 4 and 8 did not have any one. In females, the age group most involved is encompassed between 51 and 80 years; the more frequent alterations, in decreasing order, were: bulging disc, synovial facet syndrome, disc herniation and vacuum phenomenon. In males incidence age related and frequency of various pathologies were overlapped to that observed in females; however the incidence of disc herniation in males is greatest between 41 to 50 years. CONCLUSIONS: Low back pain, with or without radiation to the sciatic and femoral nerves, is one of the most common diseases, involving approximately 2/3 of the adult population sooner or later in life. Anatomically the center of pain is the lumbar column (from L3 to L5), the lumbo-sacral junction, the sacrum, the sacro-iliac joints, and the sacral-coccygeal region. Generally, it is a benign syndrome; however, since a pathologic condition is recognized in 15% of cases, then this condition must always be diagnosed. The list of events producing lumbar pain seems to be endless: therefore differential diagnosis must be based on appropriate anatomic and etiologic factors, also considering that pathogenesis (due to mechanical, compression, inflammatory, and neuropathic factors) is directly influenced by social and psychologic factors. Initially a conventional X-ray was used for the diagnosis of images, subsequently, arthrography and myelography were used; today CT is useful in the detection of bone and soft tissue structures, especially using multiplanar reformatted images. It is a noninvasive procedure that usually reveals the cause of radicular compression and demonstrates lateral and intraforaminal pathologic condition well. MRI represents the last technical development. The characteristics of all these techniques are such as to achieve a full diagnosis. Their reconciled use is in relation to the current clinical question, and it also depends on various considerations, not only technical matters, but availability of equipment and costs too, even if conventional radiography must always precede every other survey.

[Metastatic bone disease. Strategies for imaging]. / La malattia ossea metastatica. Strategia della diagnostica per immagini.

Skeletal metastases represent the most common malignant bone tumor. They occur mainly in adults and even more frequently in the elderly. The most common metastases in men are from prostate cancer (60%) and in women from breast cancer (70%). Other primitive tumors responsible for bone metastases are: lung, kidney, thyroid, alimentary tract, bladder, and skin. The spine and pelvis are the most common metastatic sites, due to the presence of red (haematopoietic active) bone marrow in a high amount. As a general rule, the radiographic pattern was lytic type; other aspects were osteosclerotic, mixed, lytic vs mixed and osteosclerotic vs lytic patterns. The main symptom is pain, although many bone metastases are asymptomatic. The most severe consequences are pathologic fractures and cord compression. Clinical evaluation of patients with skeletal metastases needs multimodal diagnostic imaging, able to detect lesions, to assess their extension and localization, and eventually drive the biopsy (for histo-morphological diagnosis). These techniques give different performances in terms of sensitivity and specificity; but none of the modalities alone seems to be adequate to yield a reliable diagnostic outcome. Therefore multidisciplinary cooperation is required to optimize the screening, clinical management and follow-up of the patients. In other terms, what is the efficacy of these new diagnostic tests compared to the "older" diagnostic tests? Frequently the new procedures do not replace the older one, but it is added to the diagnostic workup, thereby increasing costs without impacting the "patient's condition". The aim of the present work is to propose an "algorithm" for the detection and diagnosis of skeletal metastases, which may be applied differently in symptomatic and asymptomatic oncologic patients. Bone scintigraphy remains the first choice technique in the evaluation of asymptomatic patients, in whom skeletal metastases are supposed. Although it has a high sensitivity, scintigraphy is unspecific. So that a negative scan response has to be re-evaluated with other methods: if clinical status remains "negative", the diagnostic route can stop. On the contrary, in patients with "positive" scan or with local symptoms and pain, the screening of metastatic lesions must be accomplished by a combination of radiography and CT: the result may be negative (for low sensitivity of conventional radiology), not conclusive (in this case bone biopsy is necessary) or symptoms are not due to metastatic lesions (i.e., osteoarthritis). CT represents an excellent mean of defining the extent of any metastatic lesions, especially those located at sites difficult to evaluate (vertebral column and pelvis). Before bone biopsy is carried out, MRI must be performed, because it is the only technique that makes it possible to distinguish between bone marrow components. It has been used most extensively in the evaluation of spine metastases. The limitation of MRI is the unspecificity of its findings, which may lead to an equivocal diagnosis, and because only part of the skeleton can be studied.

Normalization of bronchial exocrine pathology after endobronchial treatment with ambroxol.

A clinical study was performed on nine adult in-patients suffering from chronic intercrisis bronchopneumopathy, to evaluate whether a local endobronchial treatment with ambroxol could be effective in stabilizing the secretory activity of bronchial glands modified by phlogistic injury. The patients underwent bronchoscopic examination and deep biopsy, before and after treatment with local medication of ambroxol every other day for 30 days. In addition to morphometric measurements, detailed histochemical examinations were performed on the secretion of mucous acinic and glandular excretory ducts. The trial proved that the treatment with ambroxol stimulates serous acini, restoring normal production of sulphomucins and also of mucous acini, increasing the metabolic activities of acid glycoproteins and proportionally curtailing the excessive synthesis of glycoproteins. Ambroxol can therefore be considered a mucoregulating drug.

[Mesenteric cysts: a case report]. / Cisti mesenteriale: case report.

Mesenteric cysts are lesions of rare chech, they can manifest or their painful abdominal pathology or comprehensive by effect mass. Today with imaging methods, especially the U.S., diffuse with capillarity in the hospitals, it possible to point at them also by chance for others types of problems. When possible, the FNAB, is diriment by diagnostic point of view. New imaging methods give an aimed operative planning, that spares to the patient a blindly operation on an unprepared intestine.

Magnetic resonance imaging in brachial plexus injury.

Brachial plexus injury represents the most severe nerve injury of the extremities. While obstetric brachial plexus injury has showed a reduction in the number of cases due to the improvements in obstetric care, brachial plexus injury in the adult is an increasingly common clinical problem. The therapeutic measures depend on the pathologic condition and the location of the injury: Preganglionic avulsions are usually not amenable to surgical repair; function of some denervated muscles can be restored with nerve transfers from intercostals or accessory nerves and contralateral C7 transfer. Postganglionic avulsions are repaired with excision of the damaged segment and nerve autograft between nerve ends or followed up conservatively. Magnetic resonance imaging is the modality of choice for depicting the anatomy and pathology of the brachial plexus: It demonstrates the location of the nerve damage (crucial for optimal treatment planning), depicts the nerve continuity (with or without neuroma formation), or may show a completely disrupted/avulsed nerve, thereby aiding in nerve-injury grading for preoperative planning. Computed tomography myelography has the advantage of a higher spatial resolution in demonstration of nerve roots compared with MR myelography; however, it is invasive and shows some difficulties in the depiction of some pseudomeningoceles with little or no communication with the dural sac.

[Clear cell adenomyoepithelioma of the ceruminous gland]. / Adeno-mioepitelioma a cellule chiare della ghiandola ceruminosa.

Ceruminous gland tumours are rare neoplasms. We describe a case of a ceruminous tumour with complex morphology characterised by fibrous hyaline stroma bilayered epithelial ductal structures and nodules of tightly arranged clear cells with abundant Pas-positive cytoplasm. Within nodules among clear cells delicate apocrine ducts were found. Stromal tongues infiltrated with lymphocytes invaginated into nodules producing a lymphadenomatous pattern. Among clear cells, there are also numerous eosinophilic, Pas-positive refractile crystalline inclusions that appeared as floral petals (gerbera) or as a firework-like pattern. By immunohistochemistry, ductal structures were reactive for CK pan, CK7, CK18, CK19, EMA and GCDFP-15. Epithelial ductal basal cells were reactive for CK5, p63, calponin and SMA. Clear cells were weakly positive for CK18 and strongly positive for vimentin; they also displayed S100 protein and focal GFAP immunoreactivity. Interestingly clear cells lacked immunostaining for calponin, p63, caldesmone, SMA and MSA. This result supports the myoepithelial nature of clear cells, which have lost some antigenic specificities, and the diagnosis of adenomyoepithelioma of the ceruminous gland. The lesion appears morphologically benign. The patient is a 47-year-old woman with no evidence of disease after 3 years of follow-up.

The crowned dens syndrome. Evaluation with CT imaging.

PURPOSE: The purpose of this study was to verify the value of computed tomography (CT) in the diagnosis of the "crowned dens" syndrome, not only in crystal deposition diseases, but also in other rheumatic or nonrheumatic conditions. MATERIALS AND METHODS: Thirty-eight patients (15 men and 23 women; mean age 55 years; age range 35-79) with neck pain were examined and divided into two groups: (1) patients already identified as rheumatic and referred for further investigation of the atlantoaxial region; (2) patients with symptoms confined to the cervical spine, with inconclusive radiographic findings. Unenhanced CT of the cervical spine (Tomoscan SR 7000 Philips, Eindhoven, Netherlands) was performed in all patients. There were 11 cases of rheumatoid arthritis (ten women and one man), two calcium pyrophosphate dihydrate crystal deposition disease (both women), one of systemic sclerosis (a woman), one of osteoarthritis (a man), one of seronegative arthritis (a man), four of neoplasm (one woman and three men) with suspected cervical involvement, one (a man) of haematological disease (lymphoma), one (a woman) of menopausal osteoporosis, ten (five men and five women) of recent or previous trauma with suspected involvement of the skull base and first cervical vertebrae and six of unknown painful cervical dysfunction (three men and three women). RESULTS: CT demonstrated calcific deposits around the dens in 12 patients (three men and nine women), in the transverse and alar ligaments, and in the anterior atlantooccipital membrane. CT revealed horseshoe- or crown-like calcification surrounding the odontoid process. In our series, other rheumatic diseases, especially rheumatoid arthritis, showed similar irregular calcifications of the atlantoaxial joint. Discussion. In calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, the spine may be the only site of involvement, generally asymptomatic. Crystals located in the transverse ligament of the atlas give rise to the crowned dens syndrome, usually in patients affected by severe degenerative lesions of the atlantoaxial joint and peripheral chondrocalcinosis. Symptoms may be absent, or a neurological compressive syndrome may develop. Symptoms tend to worsen with age. The diagnosis is not always easy, as the symptoms are similar to those of other diseases, such as meningitis, cervicobrachial pain, occipitotemporal headache, calcific tendinitis of the longus colli muscle, spondylodiscitis and retropharyngeal abscess. CONCLUSION: CT is the gold standard in identifying crowned dens syndrome, as it is able to depict the shape and site of calcification and any bone erosions. Radiography of other joints (wrist, knee, pubic symphysis) may help to ascertain whether the disease is due to calcium pyrophosphate dihydrate or hydroxyapatite crystals, and is therefore recommended for routine patient management. Magnetic resonance imaging (MRI) is indicated for the study of neurological complications.