Safety profile and technical success rate of computed tomography-guided atlanto-axial lateral articulation injections.

OBJECTIVE: To describe the technique, safety profile, and outcome of computed tomography (CT)-guided atlanto-axial lateral articulation injections performed at our institution. METHODS: Consecutive cases of all CT-guided atlanto-axial injections performed from January 2017 to April 2022 at our institution were searched in the electronic medical records. Patient charts were reviewed for demographics, characterization of pain, potential altered anatomy, pain level before and immediately after the procedure, procedure technique, complications, and follow-up outcomes, if available. RESULTS: Forty-five injections in 40 different patients were included. The average age was 67.4 years, and 28 (70%) of the patients were female. Of the 45 injections, 43 (96%) were technically successful. The average change in pain score (0-10) from immediately before to immediately after the injection was -3.36 (SD = 2.87, range = -8 to +3). Of all injections, 14 (31%) had a postprocedural pain score of zero. In 2 cases (4%), patients reported an increase in pain score immediately after the injection. In 3 cases (7%), transient non-vertebral artery vascular uptake of contrast was documented during the procedure, which could be cleared with needle repositioning. There were no complications. CONCLUSION: CT-guided atlanto-axial lateral articulation injection is a safe procedure with a high technical success rate. It allows for direct visualization of vital structures and provides an alternative option to the traditional fluoroscopic guidance, especially in cases of prior technically unsuccessful fluoroscopically guided injection or altered anatomy.

Bilateral lunotriquetral coalition: a dynamic four-dimensional computed tomography technical case report.

Lunotriquetral coalitions are the most common form of carpal coalition wherein the cartilage between the lunate and triquetrum ossification centers failed to undergo apoptosis. This technical case report examines the arthrokinematics of bilateral lunotriquetral coalitions with dissimilar Minnaar types in one participant with one asymptomatic wrist and one wrist with suspected distal radioulnar joint injury. Static and dynamic (four-dimensional) CT images during pronosupination were captured using a photon-counting detector CT scanner. Interosseous proximity distributions were calculated between the lunotriquetral coalition and adjacent bones in both wrists to quantify arthrokinematics. Interosseous proximity distributions at joints adjacent to the lunotriquetral coalition demonstrate differences in median and minimum interosseous proximities between the asymptomatic and injured wrists during resisted pronosupination. Altered kinematics from lunotriquetral coalitions may be a source of ulnar-sided wrist pain and discomfort, limiting the functional range of motion. This case report highlights potential alterations to wrist arthrokinematics in the setting of lunotriquetral coalitions and possible associations with ulnar-sided wrist pain, highlighting anatomy to examine in radiographic follow-up. Furthermore, this case report demonstrates the technical feasibility of four-dimensional CT using photon-counting detector technology in assessing arthrokinematics in the setting of variant wrist anatomy.

Successful fusion versus pseudarthrosis after spinal instrumentation: a comprehensive imaging review.

PURPOSE: Following spinal instrumentation and fusion, differentiating between successful arthrodesis and pseudoarthrosis on imaging can be challenging. Interpretation of such examinations requires understanding both the expected evolution of postoperative findings and the subtle indicators of pseudoarthrosis across multiple imaging modalities. Due to this level of intricacy, many clinicians lack familiarity with the subject beyond the more rudimentary concepts. METHODS: This review provides an in-depth overview of the imaging of the post-operative spine, with particular emphasis on differentiating between pseudoarthrosis and arthrodesis. RESULTS: A comprehensive overview of imaging of the post-operative spine is given, including the most common imaging modalities utilized, the expected post-operative findings, imaging findings in pseudoarthrosis, and imaging definitions of fusion. CONCLUSION: Differentiating between pseudoarthrosis and arthrodesis in the postoperative spine is complex, and requires a robust understanding of various findings across many different modalities.

Injection into the Space of Okada During Transforaminal Epidural Steroid Injections.

OBJECTIVE: Ensuring medication delivery to the epidural space is crucial for effective transforaminal epidural steroid injections. Epidural needle placement is determined by injecting a small amount of contrast at the final needle position. The purpose of this study is to illustrate the appearance of contrast flow in the retrodural retroligamentous space of Okada during computed tomography- and fluoroscopy-guided cervical and lumbar transforaminal epidural steroid injections. DESIGN: This retrospective study will use a series of cases to demonstrate contrast within the space of Okada during epidural transforaminal steroid injections. SETTING: Tertiary medical center. SUBJECTS: Study subjects are adult patients who underwent transforaminal epidural steroid injection at our institution. METHODS: Cases were identified through the use of a search engine of existing radiology reports at our institution. Epidural steroid injection procedural reports were searched for the terms "Okada" and "retrodural space." Images from the procedure were reviewed by the authors (all proceduralists with dedicated training in spinal injections) to confirm the presence of contrast within the space of Okada. RESULTS: This case series illustrates six examples of contrast injection into the retrodural space of Okada during cervical and lumbar transforaminal epidural steroid injections. CONCLUSIONS: Contrast uptake in the retrodural space of Okada may be seen during transforaminal epidural injections. Although relatively uncommon, it is likely underrecognized. It is extremely important that providers who perform transforaminal epidural steroid injections be familiar with this non-epidural contrast flow pattern so they can adjust needle positioning to deliver steroid to the epidural space.

Accuracy of Ultrasound Compared to Magnetic Resonance Imaging in the Diagnosis of Thumb Ulnar Collateral Ligament Injuries: A Prospective Case Series.

This prospective case series compared the accuracy of ultrasound (US) to magnetic resonance imaging (MRI) in differentiating complete displaced (CD) thumb ulnar collateral ligament (UCL) tears from nondisplaced injuries in 10 patients with suspected traumatic thumb UCL injuries. Ultrasound identified 100% (2 of 2) of MRI-documented CD tears, both of which were further confirmed during surgical repair. Ultrasound identified the absence of CD tears in the remaining 8 patients. Although MRI is the reference standard imaging modality for characterizing thumb UCL injuries, ultrasound should be considered an accurate, cost-effective, and alternative imaging modality to differentiate surgical versus nonsurgical thumb UCL injuries.

Normal Pacinian corpuscles in the hand: radiology-pathology correlation in a cadaver study.

OBJECTIVE: To provide microdissection and histological confirmation of normal Pacinian corpuscles prospectively identified using MRI in a cadaver model. METHODS: 3-T MRI of a cadaveric hand specimen was performed with fiduciary markers on the skin. Based on previous descriptions, subcutaneous nodules representing presumed Pacinian corpuscles were localized with respect to the skin markers, and their sizes and depths were recorded. Focused ultrasound was performed to attempt to visualize the corpuscles. Subsequent microdissection was then performed and the presence and location of Pacinian corpuscles were recorded and compared with the findings on MRI. Histological evaluation for each identified corpuscle was performed. RESULTS: The MRI demonstrated 11 T2-hyperintense palmar subcutaneous nodules around the second through fifth metacarpophalangeal joints. None was visible sonographically. The first eight were dissected and proved to be normal Pacinian corpuscles histologically. In sites devoid of subcutaneous nodules on MRI, subsequent dissection failed to reveal any corpuscles. CONCLUSION: On MRI, normal Pacinian corpuscles appear as round or oval, T2-hyperintense subcutaneous nodules in the palms, clustered around the metacarpophalangeal joints, and should not be mistaken for pathological conditions.

MRI appearance of the anomalous volar radiotriquetral ligament in true Madelung deformity.

OBJECTIVE: To characterize the MRI appearance of the anomalous volar radiotriquetral ligament in cases of classic Madelung deformity. MATERIALS AND METHODS: With institutional review board approval, a search of the radiology information system was performed to identify cases of potential Madelung deformity using variations of the criteria "Madelung deformity." Cases of classic Madelung deformity were included based on the following criteria: dorsal subluxation of the ulnar head, volar tilt of the distal radius, increased radial inclination of greater than 25°, triangulation of the carpus, and presence of Vickers ligament defined as an anomalous volar radiolunate ligament. Patients with a history of wrist trauma or severe degenerative change distorting anatomy were excluded. The resulting cases were reviewed to characterize the anomalous radiotriquetral ligament. RESULTS: Eight cases of classic Madelung deformity in 6 patients were identified. All 8 cases were characterized by the presence of an anomalous radiotriquetral ligament, which was more conspicuous than Vickers ligament. None of the excluded pseudo-Madelung deformity cases displayed a Vickers ligament or radiotriquetral ligament. CONCLUSION: The radiotriquetral ligament is an anomalous ligament that is a constant and distinguishing finding in classic Madelung deformity in this study. Awareness of the radiotriquetral ligament and distinguishing it from Vickers ligament on imaging studies and at surgery may have clinical implications that need to be further investigated.

Ultrasonography of Plantar Fibromatosis: Updated Case Series, Review of the Literature, and a Novel Descriptive Appearance Termed the "Comb Sign".

The purpose of this series is to review the appearance of plantar fibromatosis with high-resolution ultrasonography (US) and highlight a new imaging sign termed the "comb sign." A retrospective study was performed for patients with a clinical diagnosis of plantar fibromatosis. Charts of 43 patients (age range, 26-77 years; mean age, 54 years) were reviewed to gather patient demographics and symptoms. Several US characteristics were evaluated with emphasis on any new imaging features. A total of 57 plantar fibromas in 43 patients were examined. Plantar fibromatosis was seen as a lobular marginated oval nodule along the superficial plantar fascia involving the central or medial cord, often at the middle third (84%) of the plantar fascia, showing posterior acoustic enhancement (65%), mixed echogenicity (82%), and intralesional vascularity (53%). Slightly more than half (51%) of the lesions showed a previously unrecognized appearance, designated the comb sign. This sign was more commonly seen in the setting of larger fibromas (P < .05). Plantar fibromatosis is usually a clinical diagnosis that can be aided by a typical US appearance. Although the imaging characteristics are largely similar to prior literature, this series suggests that most show mixed echogenicity and posterior acoustic enhancement, and approximately half show internal vascularity. A new US sign, termed the comb sign, shows alternating bands of hypoechogenicity and isoechogenicity, particularly in larger plantar fibromas, and can help in further characterization.

Subfascial fat herniation: sonographic features of back mice.

Three adult patients are described with sonographic features of subfascial fat hernation. Each patient presented to the musculoskeletal ultrasound department at our institution for the evaluation of a palpable mass of the low back. Subfascial fat hernation, also known as back mice and fibro-fatty nodule, are an uncommon cause of a palpable mass in the low back or low back pain. They are small mobile subcutaneous nodules in a characteristic location near the posterior superior iliac spine. This entity has not been described in the radiology literature. These cases are presented in order to demonstrate the sonographic findings of back mice and to describe key anatomic features.

Pacinian corpuscles: an explanation for subcutaneous palmar nodules routinely encountered on MR examinations.

Pacinian corpuscles, the main touch receptors to pressure and vibration, are ubiquitous in the deep dermis and hypodermis of the fingers and palms. Nevertheless, their existence is largely unknown to most radiologists. We frequently noted hyperintense nodules in the palms of patients on water-sensitive MRI sequences, but were unable to explain their etiology. We recently encountered two patients who had Pacinian corpuscles identified at surgical exploration and pathological analysis. Pre-operative MRI examinations in these patients showed T2 hyperintense subcutaneous palmar nodules corresponding to these corpuscles in a pattern identical to those seen incidentally in other patients. Descriptions from the dermatopathological and orthopedic literature closely correspond to our MRI observations. Based on these data, we hypothesize that the MRI finding that we previously noted represents normal Pacinian corpuscles.

The nearly invisible intraneural cyst: a new and emerging part of the spectrum.

OBJECTIVE The authors have observed that a subset of patients referred for evaluation of peroneal neuropathy with "negative" findings on MRI of the knee have subtle evidence of a peroneal intraneural ganglion cyst on subsequent closer inspection. The objective of this study was to introduce the nearly invisible peroneal intraneural ganglion cyst and provide illustrative cases. The authors further wanted to identify clues to the presence of a nearly invisible cyst. METHODS Illustrative cases demonstrating nearly invisible peroneal intraneural ganglion cysts were retrospectively reviewed and are presented. Case history and physical examination, imaging, and intraoperative findings were reviewed for each case. The outcomes of interest were the size and configuration of peroneal intraneural ganglion cysts over time, relative to various interventions that were performed, and in relation to physical examination and electrodiagnostic findings. RESULTS The authors present a series of cases that highlight the dynamic nature of peroneal intraneural ganglion cysts and introduce the nearly invisible cyst as a new and emerging part of the spectrum. The cases demonstrate changes in size and morphology over time of both the intraneural and extraneural compartments of these cysts. Despite "negative" MR imaging findings, nearly invisible cysts can be identified in a subset of patients. CONCLUSIONS The authors demonstrate here that peroneal intraneural ganglion cysts ride a roller coaster of change in both size and morphology over time, and they describe the nearly invisible cyst as one end of the spectrum. They identified clues to the presence of a nearly invisible cyst, including deep peroneal predominant symptoms, fluctuating symptoms, denervation changes in the tibialis anterior muscle, and abnormalities of the superior tibiofibular joint, and they correlate the subtle imaging findings to the internal fascicular topography of the common peroneal nerve. The description of the nearly invisible cyst may allow for increased recognition of this pathological entity that occurs with a spectrum of findings.

Recognition of peroneal intraneural ganglia in an historical cohort with "negative" MRIs.

BACKGROUND: The objective of this study was to review an historical cohort of patients with peroneal neuropathy and magnetic resonance imaging (MRI) read as negative for mass or cyst to determine if occult peroneal intraneural ganglion cysts can be identified on subsequent imaging review and to use this as an estimation of how under-recognized this pathologic entity is. METHOD: The patient cohort utilized in this study was a previously published control cohort of 11 patients with peroneal neuropathy and MRI read as negative for mass or cyst. Clinical history, neurologic examination, and MRI studies of the knee were reviewed for each of the included patients. The primary outcome of interest was the presence of peroneal intraneural ganglion cyst on MRI. RESULTS: Overall, 7 of 11 (64%) patients in this historical "normal" cohort had evidence of a peroneal intraneural ganglion cyst on subsequent review of imaging. Deep peroneal-predominant weakness, knee pain, and tibialis anterior-predominant denervation/atrophy were seen more commonly in patients in whom an intraneural cyst was identified. CONCLUSIONS: This retrospective cohort study provides evidence that peroneal intraneural ganglion cysts are an historically under-recognized cause of peroneal neuropathy, with 64% of this historical "negative" cohort having evidence of a cyst on subsequent imaging review. Larger studies are needed to determine the treatment ramifications of identifying small cysts and to determine the clinical features suggestive of an intraneural ganglion cyst.

Science to Practice: What Causes Arterial Infarction in Transforaminal Epidural Steroid Injections, and Which Steroid Is Safest?

Transforaminal epidural steroid injections (TFESIs) are associated with rare but devastating neurologic complications. Every published case has been associated with a particulate steroid suspension, and the presumed but not proven mechanism is embolization and occlusion of end arterioles. Through an in vivo murine model and in vitro experiments on human red blood cells (RBCs), the study by Laemmel et al (1) in this issue of Radiology elucidates the potential mechanisms for steroid-induced vascular compromise. Unlike dexamethasone (a nonparticulate steroid solution), saline, and the particulate steroid cortivazol, other particulate steroids (prednisolone, methylprednisolone, and triamcinolone) caused often immediate and complete cessation of capillary blood flow, with RBC (not steroid particle) aggregates and alteration of RBC morphologic structure into spiculated RBCs. Thus, the study strengthens evidence in support of the higher safety profile in TFESI for dexamethasone, the nonparticulate and U.S. Food and Drug Administration-recommended steroid of choice, compared with particulate steroids. The results should not be considered proof that cortivazol has not or could not cause neurologic infarction during a TFESI. Rather, experiments such as those by Laemmel et al should foster more research, particularly in the arena of novel therapeutic agents (nonparticulate steroids and nonsteroidal drugs alike).

Comprehensive Assessment of Osteoporosis and Bone Fragility with CT Colonography.

PURPOSE: To evaluate the ability of additional analysis of computed tomographic (CT) colonography images to provide a comprehensive osteoporosis assessment. MATERIALS AND METHODS: This Health Insurance Portability and Accountability Act-compliant study was approved by our institutional review board with a waiver of informed consent. Diagnosis of osteoporosis and assessment of fracture risk were compared between biomechanical CT analysis and dual-energy x-ray absorptiometry (DXA) in 136 women (age range, 43-92 years), each of whom underwent CT colonography and DXA within a 6-month period (between January 2008 and April 2010). Blinded to the DXA data, biomechanical CT analysis was retrospectively applied to CT images by using phantomless calibration and finite element analysis to measure bone mineral density and bone strength at the hip and spine. Regression, Bland-Altman, and reclassification analyses and paired t tests were used to compare results. RESULTS: For bone mineral density T scores at the femoral neck, biomechanical CT analysis was highly correlated (R(2) = 0.84) with DXA, did not differ from DXA (P = .15, paired t test), and was able to identify osteoporosis (as defined by DXA), with 100% sensitivity in eight of eight patients (95% confidence interval [CI]: 67.6%, 100%) and 98.4% specificity in 126 of 128 patients (95% CI: 94.5%, 99.6%). Considering both the hip and spine, the classification of patients at high risk for fracture by biomechanical CT analysis--those with osteoporosis or "fragile bone strength"--agreed well against classifications for clinical osteoporosis by DXA (T score ≤-2.5 at the hip or spine), with 82.8% sensitivity in 24 of 29 patients (95% CI: 65.4%, 92.4%) and 85.7% specificity in 66 of 77 patients (95% CI: 76.2%, 91.8%). CONCLUSION: Retrospective biomechanical CT analysis of CT colonography for colorectal cancer screening provides a comprehensive osteoporosis assessment without requiring changes in imaging protocols.

Imaging and Clinical Characteristics Predict Near-Term Disablement From Bone Metastases: Implications for Rehabilitation.

OBJECTIVE: To distinguish which patients with bone metastases are at risk for near-term disablement in order to assist clinicians in assessing the appropriateness of referrals for rehabilitation services. DESIGN: Prospective cohort study. SETTING: National Cancer Institute-designated comprehensive cancer center imbedded in a tertiary medical center. PARTICIPANTS: Data were collected from members (n=78) of a patient cohort (N=311) with stage IIIB or IV non-small-cell lung cancer or extensive-stage small-cell lung cancer who developed new or progressive imaging-confirmed bone metastases during the 2-year course of the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional capabilities were assessed at 3- to 4-week intervals over the study's 2-year duration with the Activity Measure for Post-Acute Care Computer Adaptive Testing. RESULTS: Seventy-eight participants developed new or progressive bone metastases during the study. Most were men, and 83% had non-small-cell lung cancer. Metastases were most frequently located in the ribs (n=62), pelvis (n=49), or the thoracic (n=60) and lumbar spine (n=44). While neither the number of bone metastases nor their specific location was associated with near-term changes in patient mobility, their association with pain or a focal neurologic deficit was strongly associated with large declines in mobility. Similarly, patients whose imaging studies revealed new metastases and the expansion of established metastases were more likely to lose mobility. CONCLUSIONS: The total burden, specific locations, and overall distribution of bone metastases did not predict disablement. Patients with lung cancer-associated bone metastases are at markedly increased risk for declining mobility when their metastases are expanding in size and increasing in number, or are associated with pain or with new neurologic deficits.

The adductor magnus "mini-hamstring": MRI appearance and potential pitfalls.

OBJECTIVE: To examine the anatomic MRI characteristics of the adductor magnus mini hamstring (AMMH) and explore its involvement in cases of hamstring avulsion. MATERIALS AND METHODS: An IRB-approved retrospective review of patients undergoing "hamstring protocol" MRI between March 2009 and June 2014 was performed. Two musculoskeletal radiologists recorded multiple AMMH anatomic characteristics and involvement in cases of hamstring avulsion. RESULTS: Seventy-six AMMHs were analyzed in 66 patients [35 females and 31 males, mean age 49.3 ± 15.2 years (range 17-81)]. Eleven percent of AMMHs were poorly visualized, 51 % visualized, and 37 % well visualized. Seven percent demonstrated round, 73 % ovoid, and 21 % flat/lenticular tendon morphologies. Most (88 %) demonstrated typical origins. Average cross-sectional area (CSA) was 22.4 ± 10.6 mm² (range 6-56), diameter was 7.2 ± 2.5 mm (range 2.9-15), medial distance from the semimembranosus tendon was 7.5 ± 2.5 mm (range 3-14), and tendon length was 6.8 ± 3.3 cm (range 1.2-14.1). There was no gender difference in AMMH anatomic measurements or correlation between age and CSA or diameter. Of 17 complete hamstring avulsion cases, the AMMH was intact in 13, partially torn in 3, and completely torn in 1. CONCLUSION: The AMMH is a constant finding with variable anatomic characteristics. It is visualized or well visualized by MRI in 88 % of cases and is a sizable tendon located in close proximity to the semimembranosus tendon. Because it is uncommonly completely torn (6 %) in cases of complete hamstring avulsion, radiologists should be aware of its presence and appearance to avoid diagnostic confusion.

Dual-energy CT for the diagnosis of gout: an accuracy and diagnostic yield study.

OBJECTIVES: To assess the accuracy of dual-energy CT (DECT) for diagnosing gout, and to explore whether it can have any impact on clinical decision making beyond the established diagnostic approach using polarising microscopy of synovial fluid (diagnostic yield). METHODS: Diagnostic single-centre study of 40 patients with active gout, and 41 individuals with other types of joint disease. Sensitivity and specificity of DECT for diagnosing gout was calculated against a combined reference standard (polarising and electron microscopy of synovial fluid). To explore the diagnostic yield of DECT scanning, a third cohort was assembled consisting of patients with inflammatory arthritis and risk factors for gout who had negative synovial fluid polarising microscopy results. Among these patients, the proportion of subjects with DECT findings indicating a diagnosis of gout was assessed. RESULTS: The sensitivity and specificity of DECT for diagnosing gout was 0.90 (95% CI 0.76 to 0.97) and 0.83 (95% CI 0.68 to 0.93), respectively. All false negative patients were observed among patients with acute, recent-onset gout. All false positive patients had advanced knee osteoarthritis. DECT in the diagnostic yield cohort revealed evidence of uric acid deposition in 14 out of 30 patients (46.7%). CONCLUSIONS: DECT provides good diagnostic accuracy for detection of monosodium urate (MSU) deposits in patients with gout. However, sensitivity is lower in patients with recent-onset disease. DECT has a significant impact on clinical decision making when gout is suspected, but polarising microscopy of synovial fluid fails to demonstrate the presence of MSU crystals.

Sonographically guided posterior subtalar joint injections via the sinus tarsi approach.

OBJECTIVES: To determine the feasibility and accuracy of sonographically guided posterior subtalar joint (PSTJ) injections performed through the sinus tarsi. METHODS: A single experienced operator completed 10 sonographically guided PSTJ injections via the sinus tarsi on 10 unembalmed cadaveric ankle-foot specimens. Injections were performed using a 17-5-MHz linear transducer, a 25-gauge, 50-mm needle, and an out-of-plane, anterior-to-posterior needle trajectory parallel to the calcaneal surface. Sonographic assessment for fluid in the posterior and lateral PSTJ recesses, sinus tarsi, and peroneal tendon sheath was performed before and after injections of 2 and 4 mL of tap water. Two additional specimens were injected with a contrast agent: 1 via the sonographically guided approach and another by a computed tomographically guided approach. RESULTS: All 10 sonographically guided PSTJ tap water injections were accurate, distending both the posterior and lateral PSTJ recesses. In addition, all 10 specimens showed posterior recess distension by 2 mL, whereas only 2 specimens (20%) showed lateral recess distension at this volume. By 4 mL, both recesses were clearly distended in all specimens. Both contrast agent injections produced similar PSTJ computed tomographic arthrograms and patterns of recess distension similar to the sonographically guided tap water injections. No sonographically guided PSTJ injection placed fluid in the peroneal tendon sheath. CONCLUSIONS: Sonographically guided PSTJ injections via the sinus tarsi can accurately and specifically deliver injectate into the PSTJ while monitoring injectate flow within the posterior recess. The sinus tarsi approach may be used as an alternative technique to perform sonographically guided PSTJ injections when clinically appropriate.

Validation of a CT-derived method for osteoporosis screening in IBD patients undergoing contrast-enhanced CT enterography.

OBJECTIVES: Osteoporosis and bone fractures are of particular concern in patients with inflammatory bowel disease (IBD). Biomechanical computed tomography (BCT) is an image-analysis technique that can measure bone strength and dual-energy X-ray absorptiometry (DXA)-equivalent bone mineral density (BMD) from noncontrast CT images. This study seeks to determine whether this advanced technology can be applied to patients with IBD undergoing CT enterography (CTE) with IV contrast. METHODS: Patients with IBD who underwent a CTE and DXA scan between 2007 and 2011 were retrospectively identified. Femoral neck BMD (g/cm(2)) and T-scores were measured and compared between DXA and BCT analysis of the CTE images. Femoral strength (Newtons) was also determined from BCT analysis. RESULTS: DXA- and CTE-generated BMD T-score values were highly correlated (R(2)=0.84, P<0.0001) in this patient cohort (n=136). CTE identified patients with both osteoporosis (sensitivity, 85.7%; 95% confidence interval (CI), 48.7-97.4 and specificity, 98.5%; 95% CI, 94.5-99.6) and osteopenia (sensitivity, 85.1%; 95% CI, 72.3-92.6 and specificity, 85.4%; 95% CI, 76.6-91.3). Of the 16 patients who had "fragile" bone strength by BCT (placing them at the equivalent high risk of fracture as for osteoporosis), 6 had osteoporosis and 10 had osteopenia by DXA. CONCLUSIONS: CTE scans can provide hip BMD, T-scores, and clinical classifications that are comparable to those obtained from DXA; when combined with BCT analysis, CTE can identify a subset of patients with osteopenia who have clinically relevant fragile bone strength. This technique could markedly increase bone health assessments in IBD patients already undergoing CTE to evaluate small bowel disease.

A novel VCP mutation underlies scapuloperoneal muscular dystrophy and dropped head syndrome featuring lobulated fibers.

INTRODUCTION: Valosin-containing protein (VCP) is a ubiquitously expressed, multifunctional AAA-ATPase protein. Its dominant mutations cause hereditary inclusion body myopathy associated with Paget disease of bone and frontotemporal dementia (IBMPFD) or amyotrophic lateral sclerosis. The pattern of muscle weakness in IBMPFD patients is variable and includes limb-girdle, scapuloperoneal, distal, or axial distributions. CASE REPORT: We report a 63-year-old man with progressive scapuloperoneal weakness, head drop, and hyperCKemia since age 40 years. Electromyography showed myopathic changes and rare myotonic discharges. Muscle biopsy revealed numerous lobulated fibers, few fibers with glycogen accumulation, and rare fibers with polyglucosan bodies. Rimmed vacuoles and congophilic inclusions, often seen in IBMPFD, were absent. VCP sequencing identified a novel heterozygous c. 1160G>A mutation resulting in p.Asn387Ser substitution. CONCLUSIONS: Our patient broadens the pathological spectrum of VCP-myopathy and emphasizes the importance of VCP analysis in patients with scapuloperoneal muscular dystrophy despite the absence of Paget disease, dementia, rimmed vacuoles, or intracellular amyloid deposition.