Prediction of neurologic outcome in acute spinal cord injury: the role of CT and MR.

PURPOSE: 1) To determine whether MR appearances of the spinal cord in acute trauma correlate with clinical prognosis, and 2) to identify other MR and CT prognostic factors in acute spinal trauma. METHODS: Retrospective evaluation of MR, CT, and clinical examinations in 32 acute spinal trauma patients examined between 1987 and 1990. RESULTS: All 21 patients with abnormal spinal cords on MR had complete motor paralysis at presentation, compared to only three of 11 patients with normal cords. Whereas cord transection and hemorrhagic contusion had poor prognoses, 73% of patients with cord edema and 100% of patients with normal cord had useful motor function at outcome. At follow-up MR, areas of cord contusion developed into cysts, while edema resolved, leaving residual areas of myelomalacia. Associated spinal fractures, ligament injury, and cord compression were associated (P < .05) with a worse prognosis. Spondylotic changes were a significant risk factor for spinal cord injury, mediated by cord compression. CONCLUSIONS: MR and CT are valuable techniques for quantifying injury and predicting prognosis in acute spinal trauma.

Delayed neurologic deterioration in the patient with spinal trauma: role of MR imaging.

PURPOSE: To 1) correlate spinal MR features and modes of clinical presentation associated with symptomatic neurologic deterioration following longstanding spinal trauma; 2) correlate degree of neurologic deficit with spinal MR appearance in these patients; and 3) determine the relationship between new symptoms and ongoing cord compression. METHODS: Retrospective examination of MR images, and correlation with clinical data, in 94 consecutive patients. RESULTS: Sixty-seven patients presented with either an increase in degree of myelopathy or ascending neurologic level. Spinal cord atrophy (43%), syrinx (41%), and cord compression (24%) were found most frequently. Whereas in patients with complete motor and sensory deficit cord atrophy was the most frequent finding (52%), 75% of patients with useful motor function had normal spinal cords. There was a significant association (P less than .05) between cord compression and the MR findings of cord atrophy and myelomalacia, whereas a normal cord was over twice as frequent in patients without spinal cord compression. MR imaging led to an active change in management in 15% of patients, with improvement following surgery in all operated cases. CONCLUSION: Although syrinx is a frequent, and treatable cause of delayed neurologic deterioration, MR will frequently show other abnormalities such as ongoing cord compression. MR imaging should be performed urgently in all patients with new symptoms to enable early treatment to prevent irreversible loss of function.

Some vagaries of the capitellum.

The capitellum is the first epiphyseal center of the elbow to ossify. Its normal position is easily subject to misinterpretation as a separation fracture because: (1) the ossification center for the capitellum is situated anteriorly, (2) it is often tilted downward during development, and (3) its epiphysis tends to be wider posteriorly than anteriorly. The capitellum frequently fuses with the trochlea and lateral epicondyle before uniting with the humerus. We reviewed the normal anatomical configuration of the elbow. Some useful methods for evaluating the position of the normally situated and minimally displaced capitellum and distal end of the humerus are presented.

Some vagaries of the lateral epicondyle.

The early roentgenographic characteristics of ossification of the epiphysis of the normal lateral epicondyle may be misinterpreted as being due to trauma. This is primarily due to the shape of the lateral epicondyle and its apparent separation from the associated metaphysis. The following points are noted. (1) The distal part of the epiphysis fuses with the capitellum before the proximal part unites with the adjacent humerus. This frequently results in the physis appearing like a fracture. (2) The epiphysis forms the most distal part of the lateral supracondylar ridge of the humerus. (3) Ossification of the epiphysis begins at the level of the capitellar physis and proceeds first to a typical silver shape and then to a triangular shape. To assist in distinguishing between the roentgenographic appearance of normal ossification and that of a fracture of a lateral epicondyle, various fractures involving the lateral epicondylar epiphysis, the capitellum, and the associated metaphyses are discussed.

Some vagaries of the olecranon.

The maturing olecranon of the ulna is readily prone to misinterpretation because its normal radiographic characteristics may closely resemble those of fractures, for the following reasons: (1) just prior to ossification of the olecranon epiphysis, a straight sclerotic edge develops in the associated metaphysis on the proximal part of the ulna; (2) ossification of the olecranon begins in two or more centers that commonly fuse with each other before fusing with the parent bone and that may be separated widely from the metaphysis in the early stages; and (3) the physis of the olecranon frequently migrates distally into the joint and may simulate a fracture line. Features distinguishing the normal olecranon from a fracture are discussed in this paper.

Some vagaries of the medial epicondyle.

Roentgenographic data on the maturing epiphysis of the medial epicondyle of the humerus are prone to misinterpretation for the following reasons. First, fractures of the medial epicondyle may not be associated with joint effusion or metaphyseal avulsion fragments. Second, in the medial epicondyle the center of ossification, which lies posteromedial to the distal end of the humerus and is the last of the elbow epiphyses to unite with the humerus, may be quite distant from the humeral metaphysis, and differentiation of this normal characteristic from minimum avulsion is necessary. Also, multicentric ossification, although uncommon, will give the epiphysis a fragmented appearance. Finally, just before ossification of the medial epicondylar epiphysis, on its metaphyseal surface on the distal end of the humerus a sharp, straight sclerotic edge develops.

Arthrography in the diagnosis of fractures of the distal end of the humerus in infants.

Single-contrast arthrography was performed in six infants who had an injury to the elbow because the exact nature of the injury was uncertain from interpretation of the plain radiographs and clinical findings. A correct diagnosis was made in all six patients, and it significantly altered the treatment in five. Four lesions were a Salter-Harris Type-I fracture and two were a Salter-Harris Type-II fracture. Three patients had a closed reduction, two required no reduction, and one had an open reduction. Child abuse of two infants was confirmed, and it was suspected in another two.

Case report: fatal pulmonary Kaposi's sarcoma and Castleman's disease in a renal transplant recipient.

Two unusual complications of immunosuppression, Castleman's disease and Kaposi's sarcoma, occurring in a renal transplant recipient, are reported. Kaposi's sarcoma is a potentially curable condition in immunosuppressed patients if recognized and treated appropriately. In this patient, the pulmonary Kaposi's sarcoma was not diagnosed and this lead to the patient's death.

The symptomatic lumbar disc in patients with low-back pain. Magnetic resonance imaging appearances in both a symptomatic and control population.

Magnetic resonance imaging of abnormal lumbar discs in 115 symptomatic patients (184 discs) and 63 symptom-free controls (78 discs) have been compared. All symptomatic patients were proven to have discogenic pain at discography. Discs were classified into patterns 1-6 reflecting the progressive changes of nuclear degeneration as previously described. In the symptomatic patient, the more degenerate the disc the more likely it was responsible for pain (P < 0.001), but there was no statistically significant difference in the distribution of abnormal signal patterns between the two groups studied. A small number of patients in both populations demonstrated high signal from disc protrusions but this also could not be used as a predictor of pain. No abnormal lumbar disc signal pattern could be identified that specifically indicated whether a disc would be painful. Magnetic resonance imaging is accurate in determining nuclear anatomy, but until more suitable techniques become available, discography is still the only method for symptomatic assessment in low-back pain.

The pathogenesis of Schmorl's nodes in relation to acute trauma. An autopsy study.

STUDY DESIGN: Seventy thoracolumbar spines from cadavers of individuals killed in motor vehicle accidents were examined pathologically and radiologically, particularly for the occurrence of acute Schmorl's nodes. OBJECTIVES: To document whether Schmorl's nodes occur acutely as a result of trauma. SUMMARY OF BACKGROUND DATA: Theories proposed to explain the pathogenesis of Schmorl's nodes include developmental, degenerative, traumatic, and disease influences. Few studies show a direct causal relation between a traumatic episode and acute Schmorl's node formation. METHODS: Thoracolumbar spines were removed at autopsy, underwent radiography in the anteroposterior and lateral planes, fixed, sagittally cut, and underwent radiography a second time. Pathologic and radiographic examinations were performed. RESULTS: Nine acute Schmorl's nodes were detected, most in association with other acute injuries to the spine. Most acute Schmorl's nodes were present in spines from individuals aged 11-30 years, with a male to female ratio of 9:1, and were localized to the T8-L1 region. Spines from motorcyclists showed the highest percentage of acute Schmorl's nodes. No acute Schmorl's nodes were detected radiologically. CONCLUSION: Schmorl's nodes do occur acutely as the result of a single traumatic episode, and are almost always associated with other acute spinal injury. The frequency and occurrence of acute Schmorl's nodes in motorcyclists suggest that axial loading is an important mechanism. Their predominance in the T8-L1 region suggests that this region is particularly susceptible to stress.

Congenital peritoneal mesothelioma.

Only three primary peritoneal mesotheliomas in children have been previously reported. We describe a 6-wk-old girl with a papillary peritoneal mesothelioma of low grade malignancy. This is probably a congenital mesothelioma and is the youngest patient reported to date.

False positive diagnosis of subarachnoid haemorrhage on computed tomography scan.

Five cases are presented in which subarachnoid haemorrhage (SAH) was diagnosed by clinicians and/or radiologists on computed tomography (CT) scan. No macroscopic SAH was present on neuropathologic examination. In retrospect it was considered that the neurologic signs and the neuropathologic features close to the time of CT scan were in keeping with the patients being brain dead, i.e. had no cerebral blood flow at the time of the scans. On review of the CT scans it was considered the hyperdense material seen in the subarachnoid space must have been blood in congested subarachnoid blood vessels. The cases demonstrate that if a patient presents comatose and CT scan shows cerebral oedema then the presence of high attenuation material in the subarachnoid space should not necessarily be considered to represent SAH. The value of seeking radiological opinion is highlighted but even then diagnosis may be difficult.

How should an unconscious person with a suspected neck injury be positioned?

INTRODUCTION: Awareness of the risk of spinal-cord damage in moving an unconscious person with a suspected neck injury into the "lateral recovery position," coupled with the even greater risk of inadequate airway management if the person is not moved, has resulted in a suggested modification to the lateral recovery position for use in this circumstance. HYPOTHESIS: It is proposed that the modification to the lateral recovery position reduces movement of the neck. In this modification, one of the patient's arms is raised above the head (in full abduction) to support the head and neck. The position is called the "HAINES modified recovery position." HAINES is an acronym for High Arm IN Endangered Spine. METHODS: Neck movements in two healthy volunteers were measured by the use of video-image analysis and radiographic studies when the volunteers were rolled from the supine position to both the lateral recovery position and the HAINES modified recovery position. RESULTS: For both subjects, the total degree of lateral flexion of the cervical spine in the HAINES modified recovery position was less than half of that measured during use of the lateral recovery position (while an open airway was maintained in each). CONCLUSION: An unconscious person with a suspected neck injury should be positioned in the HAINES modified recovery position. There is less neck movement (and less degree of lateral angulation) than when the lateral recovery position is used, and, therefore, HAINES use carries less risk of spinal-cord damage.