Percutaneous cervical discectomy: retrospective comparison of two different techniques.

AIM: To compare clinical success and patient satisfaction of percutaneous cervical nucleoplasty (PCN) and percutaneous cervical discectomy (PCD) in contained cervical disc herniation treatment. MATERIALS AND METHODS: We retrospectively identified 50 consecutive patients in our institution: 24 underwent the PCD treatment and 26 patients were treated by the PCN procedure. All patients complained of radicular pain with or without neck pain; diagnosis of contained cervical disc herniation was obtained by MRI; all patients had received conservative therapy which did not result in symptom improvement. Exclusion from our series consisted of patients who had undergone previous surgery at the indicated level, or those with myelopathy, or those in whom more than a sole herniation was treated in the same session. Overall procedure time, fluoroscopy time, radiation dose and complications were recorded. The MacNab scale score was used to assess clinical success in terms of pain relief at 2- and 6-month follow-up. After 4-6 months, a cervical MRI was obtained in 24 patients. RESULTS: Neither major nor minor complications were reported. Regarding patient satisfaction, overall median modified MacNab score was excellent both at 2 and 6 months after treatment. No significant statistical difference was found in mean modified MacNab score at 2 and 6 months among patients grouped by treatment choice (p = 0.319 and 0.847, respectively); radiation dose was inferior in PCN group than in PCD, with no significant statistical difference. CONCLUSION: PCD and PCN were found to be safe and effective in terms of pain relief in contained cervical herniation treatment.

The role of ethylene-vinyl alcohol copolymer in association with other embolic agents for the percutaneous and endovascular treatment of type Ia endoleak.

AIM: To evaluate safety, technical and clinical success of embolization of type Ia endoleak (T1a EL) using ethylene-vinyl alcohol copolymer as embolic agent alone or in combination with other materials. MATERIALS AND METHODS: Five patients presented T1a EL after endovascular repair of aortic aneurysms (EVAR) with radiological evidence of expanding sac size; in particular, three had contained rupture. In one patient, proximal cuff insertion was previously performed, in three patients proximal cuff was urgently inserted but T1a EL persisted; one patient, previously treated with Ovation Abdominal Stent Graft System, was directly proposed for endovascular treatment. In all cases, endovascular embolization was successfully performed and the transfemoral approach was always chosen; in one case it failed and translumbar approach by direct puncture of the sac was required. Used embolization agents were glue, ethylene-vinyl alcohol copolymer (Onyx) and coils in three cases, n-butyl cyanoacrylate and Onyx in one case, Onyx and coils in the last case. RESULTS: Technical success rate was 100% as well as clinical success. No major or minor complication, including non-target embolization, was registered. Clinical success was 100% until today and the sac diameter remained stable in four patients and decreased in one. CONCLUSIONS: Onyx may be considered a suitable embolic agent in the treatment of patients with type Ia endoleaks after EVAR, after failure of conventional treatments such as prolonged balloon inflation of the aortic neck or deployment of large bare stent.

Cone beam computed tomography and its image guidance technology during percutaneous nucleoplasty procedures at L5/S1 lumbar level.

OBJECTIVE: To demonstrate the feasibility of percutaneous nucleoplasty procedures at L5/S1 level using cone beam CT (CBCT) and its associated image guidance technology for the treatment of lumbar disc herniation (LDH). MATERIALS AND METHODS: We retrospectively reviewed 25 cases (20 men, 5 women) of LDH at L5/S1 levels. CBCT as guidance imaging was chosen after a first unsuccessful fluoroscopy attempt that was related to complex anatomy (n = 15), rapid pathological changes due to degenerative diseases (n = 7) or both (n = 3). Technical success, defined as correct needle positioning in the target LDH, and safety were evaluated; overall procedure time and radiation dose were registered. A visual analog scale (VAS) was used to evaluate pain and discomfort pre-intervention after 1 week and 1, 3, and 6 months after the procedure. RESULTS: Technical success was 100 %; using CBCT as guidance imaging the needle was correctly positioned at the first attempt in 20 out of 25 patients. Neither major nor minor complications were registered during or after the procedure. The average procedure time was 11 min and 56 s (range, 9-15 min), whereas mean procedural radiation dose was 46.25 Gy.cm2 (range 38.10-52.84 Gy.cm2), and mean fluoroscopy time was 5 min 34 s (range 3 min 40 s to 6 min 55 s). The VAS pain score decreased significantly from 7.6 preoperatively to 3.9 at 1 week, 2.8 at 1 month, 2.1 at 3 months, and 1.6 at 6 months postoperatively. CONCLUSIONS: CBCT-guided percutaneous nucleoplasty is a highly effective technique for LDH with acceptable procedure time and radiation dose.

ePTFE stent graft in non-steno-occlusive arterial disease: 2 centers retrospective study.

PURPOSE: We report our experience regarding use of Fluency stent graft (Bard, Murray Hill, NJ, USA) for the treatment of peripheral aneurysms, pseudoaneurysms, arteriovenous fistulae, dissections and arterial ruptures, lacerations or perforations. METHODS AND MATERIALS: This two-center study included 59 patients (40 M, 19 F) with a mean age of 64.37 years (range 20-91 years). In total 61 lesions were treated, so subdivided: 10 true aneurysms, 26 pseudoaneurysms, 5 iatrogenic arteriovenous fistulae, 20 arterial ruptures, lacerations or perforations. RESULTS: Immediate technical success was obtained in 60 of 61 lesions (98.3 %); in 1 case (pseudoaneurysm of hepatic artery) additional embolization of the gastroduodenal artery with microcoils was needed. Follow-up was available for 57 patients and 59 lesions; mean period was 23.52 months (range 1-60 months). At 1-year primary patency was 89.47 %, whereas secondary patency was 96.4 %. CONCLUSION: Endovascular application of Fluency stent graft seems to offer an effective, and durable less invasive alternative to standard surgical techniques for the treatment of peripheral aneurysms, pseudoaneurysms, iatrogenic arteriovenous fistulae and arterial ruptures, or penetrating injuries.

Hand-Wrist Disorders in Chainsaw Operators: A Follow-Up Study in a Group of Italian Loggers.

Despite the mechanization process implemented in arboriculture, logging tasks are still manually performed by chainsaw operators, which therefore are exposed to the risk of developing hand-wrist musculoskeletal disorders. Our research aimed to: (a) define whether the slight changes observed in 2017 showed an evolution to overt diseases; (b) study some risk determinants for these diseases such as age, working experience, and performing a secondary job. We recruited in a two-year follow-up study, 38 male forestry workers performing logging tasks employed in the Sicilian Forestry Department located in Enna. All the subjects underwent: (1) personal data collection; (2) administration of questionnaire addressed at upper limbs symptoms with a hand chart; (3) physical examination of the upper limbs, including Tinel's and Phalen's maneuvers; (4) ultrasound investigation of the hand-wrist area. In the two-year follow-up study we registered an overall increasing in wrist disorders, thus we can assume that forestry workers may be a target population for wrist diseases and deserve a particular attention in workers' health surveillance programs. Interestingly, the prevalence of wrist-hand disorders resulted to be higher in younger workers.

Clinical and radiological features of mesenteric panniculitis: a critical overview.

The mesenteric panniculitis is a rare form of inflammation that mainly involves the mesenteric adipose tissue. The etiology remains unknown and the disease has been associated with various conditions such as cancer, abdominal trauma, previous surgery, autoimmune diseases and obesity. Mesenteric panniculitis can be divided into two main groups: the mesenteric panniculitis with only the inflammation and degeneration of the mesenteric fat, and the retractile panniculitis, mainly fibrotic, with retraction of the surrounding structures. From a radiological point of view, there are two main signs: the fat ring sign, which is the presence of normal fat around vessels and lymph nodes, and the pseudocapsula around the lesion. In this paper, we present the imaging and clinical features of mesenteric panniculits with particular reference to the differential diagnosis and the possible etiological associations. (www.actabiomedica.it).

Intra-caval Percutaneous Radiofrequency Ablation for a Neuroendocrine Tumor (NET) Metastasis in Transplanted Liver.

Less than 1% of patients with liver metastases from neuroendocrine tumors (NETs) are susceptible to liver transplantation. We report a case of a patient transplanted 13 years ago for NET metastases, with a lesion histologically proved for NET metastasis located at the cava vein anastomosis. He was treated with percutaneous radiofrequency ablation (RFA) after a first failed attempt of endovascular approach. The vascular heat sink, which RFA is susceptible to, was considered an advantage in this case, since it restricted the propagation of heat only to the tissue located in the very proximity of the RFA antenna, protecting the inferior vena cava vessel walls. This positive result may suggest an additional use of RFA in selected challenging cases.

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study.

BACKGROUND AND AIM: The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal. METHODS: Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment. RESULTS: In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn't change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn't change significantly. CONCLUSIONS: Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It's not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree.

Intravoxel Incoherent Motion (IVIM) Diffusion Weighted Imaging (DWI) in the Periferic Prostate Cancer Detection and Stratification.

The aim of this study was to compare the Intravoxel Incoherent Motion (IVIM) parameters between healthy Peripheral Zone (PZ), Benign Prostatic Hyperplasia (BPH) and Prostate Cancer (PCa) and compare them to assess whether there was correlation with Gleason Score (GS) grading system. Thirty-one patients with suspect of PCa underwent 1.5T Multi-Parametric Magnetic Resonance Imaging (MP-MRI) with endorectal coil with a protocol including T2WI, DWI using 10 b values (0, 10, 20, 30, 50, 80, 100, 200, 400, 1000 s/mm2) and DCE. Monoexponential and IVIM model fits were used to calculate both apparent diffusion coefficient (ADC) and the following IVIM parameters: molecular diffusion coefficient (D), perfusion-related diffusion coefficient (D*) and perfusion fraction (f). The ADC and D values were significantly lower in the PCa (0.70 ± 0.16 × 10-3 mm2/s and 0.88 ± 0.31 × 10-3 mm2/s) compared to those found in the PZ (1.22 ± 0.20 × 10-3 mm2/s and 1.78 ± 0.34 × 10-3 mm2/s) and in the BPH (1.53 ± 0.23 × 10-3 mm2/s and 1.11 ± 0.28 × 10-3 mm2/s). The D* parameter was significantly increased in the PCa (5.35 ± 5.12 × 10-3 mm2/s) compare to the healthy PZ (3.02 ± 2.86 × 10-3 mm2/s), instead there was not significantly difference in the PCa compare to the BPH (5.61 ± 6.77 × 10-3 mm2/s). The f was statistically lower in the PCa (9.01 ± 5.20%) compared to PZ (10.57 ± 9.30%), but not significantly different between PCa and BPH (9.29 ± 7.29%). The specificity, sensitivity and accuracy of T2WI associated with DWI and IVIM were higher (100, 98 and 99%, respectively) than for T2WI/DWI and IVIM alone (89, 92 and 90%, respectively). Only for ADC was found a statistical difference between low- and intermediate-/high-grade tumors. Adding IVIM to the MP-MRI could increase the diagnostic performance to detect clinically relevant PCa. ADC values have been found to have a rule to discriminate PCa reliably from normal areas and differed significantly in low- and intermediate-/high-grade PCa. In contrast, IVIM parameters were unable to distinguish between the different GS.

Virtual Dissection by Ultrasound: Probe Handling in the First Year of Medical Education.

OBJECTIVES: The aim of the present study was to assess the educational plan of first-year students of medicine by analyzing their scores in ultrasound body scanning. METHODS: Since 2009, the San Paolo Medical School (Milan, Italy) has vertically integrated the study of anatomy with ultrasound-assisted virtual body dissection. Three modules were supplied: musculoskeletal system, heart and abdomen pelvis. 653 first-year students were trained. The students alternated as mutual model and operator. A skillfulness score was assigned to each student. The scores were consequently listed. Nonparametric exact multiple contrast tests were employed to determine relative group effects. RESULTS: Statistical analysis showed that: no gender-related differences were found (0:49; p=0.769); peer learners performed less well than peer tutors (0.677; p=0); between modules, scores in the musculoskeletal system (pMS=0.726) tend to be higher (p<0.001) than those obtained in the heart and abdomen pelvis (pH=0.398; pAP=0.375 p=0.270); significant differences were found compared to the beginning of the project's academic year. CONCLUSION: The students considered this didactic course an engaging and exciting approach. Acceptance of peer teaching was extraordinarily high. Autonomous exercitation allowed the students to improve self-criticism and enhance their own skills. The level of expertise obtained by peer tutors and by peer learners can be considered satisfactory. The main objective of training future physicians on personal stethoechoscope with the necessary competence seems to have been successfully started.

Magnetic resonance imaging and positron emission tomography in the diagnosis of neurodegenerative dementias.

Neuroimaging, both with magnetic resonance imaging (MRI) and positron emission tomography (PET), has gained a pivotal role in the diagnosis of primary neurodegenerative diseases. These two techniques are used as biomarkers of both pathology and progression of Alzheimer's disease (AD) and to differentiate AD from other neurodegenerative diseases. MRI is able to identify structural changes including patterns of atrophy characterizing neurodegenerative diseases, and to distinguish these from other causes of cognitive impairment, e.g. infarcts, space-occupying lesions and hydrocephalus. PET is widely used to identify regional patterns of glucose utilization, since distinct patterns of distribution of cerebral glucose metabolism are related to different subtypes of neurodegenerative dementia. The use of PET in mild cognitive impairment, though controversial, is deemed helpful for predicting conversion to dementia and the dementia clinical subtype. Recently, new radiopharmaceuticals for the in vivo imaging of amyloid burden have been licensed and more tracers are being developed for the assessment of tauopathies and inflammatory processes, which may underlie the onset of the amyloid cascade. At present, the cerebral amyloid burden, imaged with PET, may help to exclude the presence of AD as well as forecast its possible onset. Finally PET imaging may be particularly useful in ongoing clinical trials for the development of dementia treatments. In the near future, the use of the above methods, in accordance with specific guidelines, along with the use of effective treatments will likely lead to more timely and successful treatment of neurodegenerative dementias.

Dual-phase CT for the assessment of acute vascular injuries in high-energy blunt trauma: the imaging findings and management implications.

Acute vascular injuries are the second most common cause of fatalities in patients with multiple traumatic injuries; thus, prompt identification and management is essential for patient survival. Over the past few years, multidetector CT (MDCT) using dual-phase scanning protocol has become the imaging modality of choice in high-energy deceleration traumas. The objective of this article was to review the role of dual-phase MDCT in the identification and management of acute vascular injuries, particularly in the chest and abdomen following multiple traumatic injuries. In addition, this article will provide examples of MDCT features of acute vascular injuries with correlative surgical and interventional findings.

MR Arthrography: a proposal for solution optimization with lidocaine. An in vitro experience.

PURPOSE: Pain on capsule distension in painful joints may affect feasibility of the MR Arthrography. We tried to overcome this limitation by adding a local anesthetic (lidocaine) to the paramagnetic contrast agent solution. We aimed at: a) investigating which contrast agent dilution provides the best signal-to-noise ratio in the SE T1 sequences; b) evaluating the effects of lidocaine on the signal intensity and on the viscosity of the solutions; assessing the viscosity of solutions containing iodinated contrast agent. MATERIALS AND METHODS: The paramagnetic contrast agent was diluted with saline and lidocaine at various concentrations. Signal intensity was measured with a 1.5 Tesla superconductive MR unit with a dedicated head coil; we used T1-weighted spin-echo sequence. The viscosity coefficient of the solutions was analyzed and compared with that of solutions containing iodinated contrast agents (but not lidocaine). RESULTS: Signal intensity is also unaffected by variations in the concentration of lidocaine, which does not interfere with the biphasic behavior of Gadolinium. Viscosity is scarcely affected by changes in lidocaine concentration when the paramagnetic contrast agent concentration is not changed. CONCLUSIONS: The optimal signal-to-noise ratio in T1-weighted sequences is provided by 0.4%, contrast agent dilution but contrast agent-saline solutions, with(out) lidocaine, cannot be considered steady and signal intensity values change over time. The addition of lidocaine does not significantly influence the signal-to-noise ratio and the viscosity of the solutions. The low viscosity of the paramagnetic contrast agent appears to favor quicker spread of the solution, even in tiny defects; thanks to its anesthetic effect, lidocaine could facilitates execution of the examination in painful joints without affecting the diagnostic result.