A new comprehensive MRI classification and grading system for lumbosacral central and lateral stenosis: clinical application and comparison with previous systems.

PURPOSE: The purpose of our study was to provide a novel schematized and comprehensive classification of causes and severity grading system for lumbosacral stenosis. MATERIALS AND METHODS: The MRI system proposed consisted of a severity grading scale for central and lateral (recess and foramen) stenosis, together with a schematized indication of the main causes of the disease (disc, arthritis, epidural lipomatosis, and their combinations). The system was applied to a cohort of patients from a single Institution in the last 2-years. Two radiologists evaluated all the MRIs to determine intra- and inter-observer reliability according to Cohen Kappa (Kc, for non-ordered categorical variables) and weighted Kappa (Kw, for ordered variables). Two orthopaedic surgeons clinically evaluated all patients and provided a schematic grading system with a central and lateral stenosis clinical score (CS-CS and LS-CS). Associations between ordinals were tested with chi-square test and measured with the Goodman and Kruskal's gamma index (Gi, with 95% confidence interval [95% CI]). Lastly, the most used previous MRI systems were applied, and their performances were compared to the new system proposed. RESULTS: One hundred and twelve patients were included (55 females-mean age 63.3 ± 10.7 years). An almost perfect intra-observer agreement for the assessment of central stenosis, foramen stenosis, and lateral recess stenosis was found (Kw = 0.929, 0.928, and 0.924, respectively). The inter-observer agreement was almost perfect for central stenosis and foramen stenosis and substantial for lateral recess stenosis (Kw = 0.863, 0.834, and 0.633, respectively). Whatever the aetiologies involved in central and lateral stenosis, the intra-observer agreement was perfect (all Kc = 1), whereas the inter-observer agreements were almost perfect for arthritis (Kc = 0.838) and lipomatosis (Kc = 0.955) and substantial for disc (Kc = 0.691) regarding central stenosis. The inter-observer agreement for the causes of lateral stenosis was lower and variable, ranging from perfect (lipomatosis) to fair (disc, Kc = 0.224). The grading system revealed a strong association with CS-CS for both readers, with GI = 0.671 (95% CI 0.535-0.807) and 0.603 (95% CI = 0.457-0.749), respectively. The association with MRI grading and LS-CS was moderate for foraminal stenosis and for the concomitant presence of foraminal and lateral recess stenosis, with Gi = 0.337 (95% CI 0.121-0.554) and Gi = 0.299 (95% CI 0.098-0.500), respectively. A weak association was found between lateral recess grading alone and LS-CS with Gi = 0.102 (95% CI 0.193-0.397). The new grading systems showed higher Gi for associations with clinical symptoms, compared with previous ones, both for CS-CS and LS-CS. CONCLUSIONS: A standardized visual grading system for lumbar spinal stenosis that takes into account all of the major contributing factors-including disc, arthritis, and lipomatosis, for the central canal, lateral recess, and neural foramina could be a useful and practical tool for defining the stenosis, lowering inter-observer variability, and directing the various treatment options.

Aneurysmal bone cyst: Is selective arterial embolization effective as curettage and bone grafting?

INTRODUCTION: Aneurysmal bone cyst (ABC) is a lytic benign bone lesion representing about 1% of all primary bone tumors. Method to treat ABC's have developed over time. The standard of care cure for ABC has been curettage with or without bone grafting of the defect but is burdened by recurrence rates of approximately 25%-31%. Based on the assumption that ABCs usually supplied by one or more pathological feeding arteries, selective arterial embolization has been described as an adjuvant preoperative procedure to reduce intra-operative hemorrhage, and as primary treatment for lesions in difficult surgical access. In the current study, we therefore asked whether (1) a single or a repeat selective arterial embolization (SAE) for treating ABCs would produce comparable healing rates compared with curettage and bone grafting; (2) evaluated the relationship of recurrence in relation to the site of the cyst, the age, and gender of the patients; and (3) the two techniques differ in term of long-term complication. MATERIAL AND METHODS: We retrospectively reviewed 265 patients who underwent curettage and bone grafting or SAE performed at our institute from 1994 to 2018. The diagnosis of ABC was always established with percutaneous CT-guided biopsy or open biopsy. Patients were followed clinically with plain radiographs or CT scan at 3, 6, 9, and 12 months then annually in the absence of symptoms. Treatment success was determined evaluating pre- and postprocedural imaging according to Chang classification. RESULTS: Two hundred and nineteen were treated with curettage and bone grafting (curettage group), and 46 with SAE Group. Of the 219 patients treated with Curettage and bone grafting (curettage group), 165 out of 219 (75.3%) experienced bone healing, while local recurrence was observed in 54 cases (24.7%) after 12 months on average (range: 3-120 months) from surgery. After the first SAE, bone ossification was seen in 27 (58.7%), without needing any further treatment. Eleven recurred patients were treated with SAE (four patients need two while seven need three SAE to heal), and eight patients with curettage and bone grafting. Thirty-eight out of 46 (82%) patients experienced bone ossification regardless the number of SAE. The overall rate of local recurrence for all patients was 26.7%. SAE group presented a lower complication rate (6%) where two patients experienced skin necrosis, and one limb-length discrepancies (2% of all cohort). DISCUSSION: The use of SAE is an attractive option to treat ABC as it combines on one hand a lower complication rate than curettage and bone grafting, on the other it can be carried out in case of nonresectable ABCs, significantly reducing the size of viable ABC lesions, fostering bone remodeling and mineralization, and most importantly, significantly improving the patient's quality of life.

Can the multiphasic computed tomography be useful in the clinical management of small renal masses?

Background Small renal masses (SRMs; ≤4 cm) represent a challenging issue. Computed tomography (CT) is widely used for investigating renal tumors even if its ability to differentiate among the different subtypes has not yet been definitively established. Purpose To assess the potential role of the morphological features and angiodynamic behavior on multiphasic CT in the preoperative evaluation of SRMs. Material and Methods The CT images of 80 patients with SRMs who underwent surgical resection at our institution were retrospectively reviewed. The morphological features, the pattern, and the quantitative analysis of enhancement were assessed for each lesion and were correlated with the histological subtypes. Results Overall, 81 SRMs were evaluated. Final pathological examination showed 30 (37%) oncocytomas, 22 (27.2%) clear cell renal cell carcinomas (ccRCCs), 16 (19.8%) papillary RCCs (pRCCs), and 13 (16%) chromophobe RCCs (chRCCs). Of the morphological features, only necrosis was significantly associated with ccRCC ( P = 0.047). The analysis of enhancement allowed the identification of two groups of lesions, based on arterial behavior: hypervascular (oncocytomas/ccRCC) and hypovascular (chRCC/pRCC) lesions. A significant difference between the two groups in terms of degree of enhancement on CT phases was found ( P < 0.05); this was also confirmed by the receiver operating characteristic (ROC) analysis. Conclusion Except for necrosis, the morphological features are not useful in making a correct diagnosis in the case of SRMs. The angiodynamic behavior on multiphasic CT showed high accuracy in differentiating between hypovascular and hypervascular tumors; this differentiation could be useful for deciding on the most appropriate clinical management of SRMs.

Anterior Nutcracker Syndrome with Left Gonadal Vein Varicosities on Multiphasic Computed Tomography: An Unexpected Cause of Pyeloureteral Junction Obstruction.

The anterior nutcracker syndrome is defined by the compression of the left renal vein between the aorta and superior mesenteric artery, usually related to the occurrence of hematuria. We report the case of an uncommon complication of the nutcracker syndrome. A 75-year-old woman was referred to our institution for left flank pain without hematuria. Multiphasic computer tomography urography showed a condition of left renal vein entrapment between the aorta and superior mesenteric artery with the development of left gonadal vein varicosities at the level of the renal hilum; a pyeloureteral junction compression with dilation of the pyelocalyceal system coexisted. To our knowledge, this is the first report of the association between nutcracker syndrome and pyeloureteral junction obstruction.

Three Unusual Cases of Nutcracker Syndrome Caused by Increased Blood Flow within the Left Renal Vein.

Nutcracker syndrome (NCS) refers to the compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It can cause both microscopic and gross haematuria, with or without flank pain. The diagnosis is often delayed in a majority of symptomatic patients. On the other hand, the use of CT in routine abdominal explorations has increased the detection of the compression of the LRV in healthy and asymptomatic patients, but its diagnostic value remains uncertain. In this paper, we report 3 cases of the NCS associated with an increased blood flow in the LRV, due to different conditions, which we believe could produce the appearance of clinical symptoms.

Imaging of Musculoskeletal Soft-Tissue Infections in Clinical Practice: A Comprehensive Updated Review.

Musculoskeletal soft-tissue infections include a wide range of clinical conditions that are commonly encountered in both emergency departments and non-emergency clinical settings. Since clinical signs, symptoms, and even laboratory tests can be unremarkable or non-specific, imaging plays a key role in many cases. MRI is considered the most comprehensive and sensitive imaging tool available for the assessment of musculoskeletal infections. Ultrasound is a fundamental tool, especially for the evaluation of superficially located diseases and for US-guided interventional procedures, such as biopsy, needle-aspiration, and drainage. Conventional radiographs can be very helpful, especially for the detection of foreign bodies and in cases of infections with delayed diagnosis displaying bone involvement. This review article aims to provide a comprehensive overview of the radiological tools available and the imaging features of the most common musculoskeletal soft-tissue infections, including cellulitis, necrotizing and non-necrotizing fasciitis, foreign bodies, abscess, pyomyositis, infectious tenosynovitis, and bursitis.

Pyogenic and Non-pyogenic Spinal Infections: Diagnosis and Treatment.

Spinal Infection (SI) is an infection of vertebral bodies, intervening disc, and/or adjoining para-spinal tissue. It represents less than 10% of all skeletal infections. There are numerous factors that predispose to developing a SI. Due to the low specificity of signs, delayed diagnosis is common. Hence, SI may be associated with poor outcomes. Diagnosis of SI must be supported by clinicopathological and radiological findings. MRI is a reliable modality of choice. Treatment options vary according to the site of the infection, disease progression, neurology, presence of instability, and general condition of the subject. Conservative treatment (orthosis/ bed-rest + antibiotics) is recommended during the early course with no/ lesser degree of neurological involvement and to medically unfit patients. Nevertheless, when conservative measures alone fail, surgical interventions must be considered. The use of concomitant antimicrobial drugs intravenously during initial duration followed by oral administration is a necessity. Controversies exist regarding the optimal duration of antimicrobial therapy, yet never given less than six weeks. Heterogeneity in clinical picture and associated co-morbidities with a range of treatment modalities are available; however, a common applicable guideline for SI does not exist. Managing SI must be tailored on a case-to-case basis.

Craniofacial Osteomas: From Diagnosis to Therapy.

An osteoma is a benign bone lesion with no clear pathogenesis, almost exclusive to the craniofacial area. Osteomas show very slow continuous growth, even in adulthood, unlike other bony lesions. Since these lesions are frequently asymptomatic, the diagnosis is usually made by plain radiography or by a computed tomography (CT) scan performed for other reasons. Rarely, the extensive growth could determine aesthetic or functional problems that vary according to different locations. Radiographically, osteomas appear as radiopaque lesions similar to bone cortex, and may determine bone expansion. Cone beam CT is the optimal imaging modality for assessing the relationship between osteomas and adjacent structures, and for surgical planning. The differential diagnosis includes several inflammatory and tumoral pathologies, but the typical craniofacial location may aid in the diagnosis. Due to the benign nature of osteomas, surgical treatment is limited to symptomatic lesions. Radical surgical resection is the gold standard therapy; it is based on a minimally invasive surgical approach with the aim of achieving an optimal cosmetic result. Reconstructive surgery for an osteoma is quite infrequent and reserved for patients with large central osteomas, such as big mandibular or maxillary lesions. In this regard, computer-assisted surgery guarantees better outcomes, providing the possibility of preoperative simulation of demolitive and reconstructive surgery.

Ectopic Prostatic Tissue May Cause Hydroureteronephrosis.

A 60-year-old man with left flank pain, fever, and nausea underwent an abdominal ultrasound and showed left hydroureteronephrosis without urinary calculi. Computed tomography urography showed moderate left hydroureteronephrosis and a hypodense paravesical mass of 1.7 cm with mild contrast enhancement just below the ipsilateral ureterovesical junction. Contrast-enhanced magnetic resonance imaging showed a 48 cc prostate and confirmed a roundish mass, protruding into the bladder, hyperintense on T2-weighted images, hypointense on T1-weighted images, and with mild inhomogeneous contrast enhancement. Cystoscopy with cold cup biopsy was carried out. Histologic analysis revealed the presence of ectopic prostatic tissue with no evidence of malignancy.