Transforaminal versus intra-articular facet corticosteroid injections for the treatment of cervical radiculopathy: a randomized, double-blind, controlled study.

BACKGROUND AND PURPOSE: Transforaminal corticosteroid injections can be performed in the management of cervical radiculopathy but carry the risk of catastrophic complications. This study compares the efficacy of transforaminal and facet corticosteroid injections at 4 weeks' follow-up. MATERIALS AND METHODS: We randomly assigned 56 subjects to receive CT-guided transforaminal (15 men, 13 women; mean age, 52 years; range, 28-72 years) or facet (8 men, 20 women; mean, 44 years; range, 26-60 years) injections. The primary outcome was pain severity rated on a Visual Analog Scale (0-100). Secondary outcomes were the Neck Disability Index and the Medication Quantitative Scale. RESULTS: In the intention-to-treat and as-treated analyses, for a mean baseline score, facet injections demonstrated a significant pain score reduction of 45.3% (95% CI, 21.4-69.2) and 37.0% (95% CI, 9.2-64.7), while transforaminal injections showed a nonsignificant pain score reduction of 9.8% (95% CI, +11.5-31.2) and 17.8% (95% CI, +6.6-42.2). While facet injections demonstrated an improvement in the Neck Disability Index score of 24.3% (95% CI, +2.9-51.5) and 20.7% (95% CI, +6.2-47.6) as opposed to transforaminal injections of 9.6% (95% CI, +15.2-34.4) and 12.8% (95% CI, +11.2-36.7), the results were not statistically significant. Noninferiority of facet to transforaminal injections was demonstrated for baseline pain scores of ≤60, while noninferiority analysis was inconclusive for baseline pain scores of ≥80 and for the Neck Disability Index. Neither intervention showed a significant medication-intake score reduction with time. CONCLUSIONS: Facet injections are effective for the treatment of cervical radiculopathy and represent a valid and safer alternative to transforaminal injections.

A prospective pilot study investigating the musculoskeletal pain in postmenopausal breast cancer patients receiving aromatase inhibitor therapy.

BACKGROUND: Although arthralgia is a known adverse effect of aromatase inhibitor (ai) treatment in postmenopausal breast cancer patients, few studies have carried out a comprehensive evaluation of the nature, onset, and incidence of musculoskeletal (msk) pain in these patients. We therefore used a pilot study to identify conditions or markers predictive of pain. METHODS: For 24 weeks, we monitored 30 eligible postmenopausal women starting ai therapy. Pre-existing and incident msk conditions and pain were assessed clinically and with ultrasonography of the hands and wrists. In addition, patient questionnaires were used to assess pain before and during ai therapy. Biochemical markers were measured at baseline and at regular intervals after anastrozole therapy began. Gene profiling studies were carried out before and 48 hours after the initial ai administration. RESULTS: Over the 24-week study period, 20 participants (67%) showed no pain symptoms; 5 (17%) experienced low or moderate pain at baseline, which did not increase with ai treatment; and during therapy, 5 (17%) showed exacerbation of pain attributable to osteoarthritis of the hand and to finger flexor tenosynovitis. Although all 30 participants had some degree of msk conditions before anastrozole therapy started, the pre-existing conditions did not necessarily predispose the women to increased pain during anastrozole treatment. Higher levels of urinary N-telopeptides of type i collagen were associated with the groups presenting pain, suggesting a higher extent of pre-existing bone resorption, without significant evolution over the 24-week treatment period. Slightly higher levels of 1,25(OH)(2) vitamin D(3) were observed at baseline in patients with pain increase, but did not significantly change during treatment; however, average levels of 25(OH) vitamin D(3) increased, likely because of supplementation. Although biochemical markers did not discriminate efficiently between pain groups, a signature of 166 genes in peripheral blood mononuclear cells was identified that could stratify patients into the various groups observed in this pilot study. The gene signature was enriched in components of inflammatory signalling and chemokine expression, of antitumoural immunity pathways, and of metabolic response to hormones and xenobiotics, although no clinically significant association could be made in the present study, considering the small number of patients. Nevertheless, the observed trend suggests the feasibility of developing surrogate predictive markers of msk pain. Patient compliance was high in this study and was not affected by pain exacerbation. CONCLUSIONS: Baseline msk assessment showed pre-existing causes for pain in most of the study patients before initiation of the ai. Exacerbation of existing osteoarthritis pain and tenosynovial symptoms was the primary cause of pain increase. Musculoskeletal pain assessment at baseline and prompt treatment of pain symptoms may help to optimize adherence to ai therapy. The value of routinely assessing inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate was not supported by our pilot study. Gene expression profiles in peripheral blood mononuclear cells may be further explored in larger-scale studies as stratification markers to identify patients at risk of developing arthralgia.

Calcific shoulder tendinitis: treatment with modified US-guided fine-needle technique.

PURPOSE: To evaluate clinical response to treatment of calcified tendinitis of the shoulder by using a modified percutaneous ultrasonography (US)-guided fine-needle technique. MATERIALS AND METHODS: Thirty shoulders of 30 consecutive patients (23 women, seven men; mean age, 47.4 years) with chronic shoulder pain (average duration, 43.1 months) refractory to medical treatment were treated percutaneously by using a fine needle and US guidance. Patients were prospectively evaluated by using a shoulder pain and disability index consisting of 13 items and divided into two subcategories: pain and disability. The patient completed the questionnaire before the procedure and during the follow-up visit approximately 1 month later. A diagnostic US examination was also performed at that time. RESULTS: There was a statistically significant improvement in the shoulder pain and disability index total score (27.0%) and the pain (30.5%) and disability (23.9%) scores. According to the index, these results indicate a significant clinical response. CONCLUSION: This modified US-guided fine-needle technique for calcified tendinitis of the shoulder appears to be an effective therapy and was less aggressive than previously described percutaneous techniques.

Lumbar facet joint synovial cyst: percutaneous treatment with steroid injections and distention--clinical and imaging follow-up in 12 patients.

PURPOSE: To determine the imaging characteristics of lumbar facet joint synovial cysts after percutaneous treatment with steroid injections and distention of the cyst and to correlate these findings with the clinical outcome. MATERIALS AND METHODS: Clinical outcome and imaging findings were retrospectively studied in 12 patients (four men, eight women) aged 45-79 years (mean, 60 years) with a symptomatic lumbar facet joint synovial cyst treated with percutaneous steroid injections. At varying times after the procedure, patients were contacted for clinical follow-up, and repeat imaging was performed to verify the status of the cyst. RESULTS: Excellent pain relief was achieved in nine (75%) of 12 patients. At follow-up imaging, the cyst completely regressed in six (67%) of these nine patients, partially regressed in two (22%) patients, and was unchanged in one (11%) patient. One (8%) of the 12 patients had transient pain relief, with recurrence of symptoms at short intervals after each of three injections. No pain relief was achieved in two (17%) of 12 patients. CONCLUSION: Image-guided percutaneous steroid injections are often effective in the treatment of lumbar facet joint synovial cysts and may result in complete regression of the cyst.

Role of ultrasound in musculoskeletal infections.

Ultrasound is able to play a key role in the management of musculoskeletal soft tissue infections. It is an easily accessible imaging modality that can be used immediately after plain radiographs have been obtained. Quick diagnosis is essential in the clinical setting of musculoskeletal infection because delay can lead to significant morbidity. In addition to its diagnostic capabilities, US offers a safe, real-time, and convenient technique to perform immediately a guided-needle aspiration of any suspicious fluid collection. US provides the most efficient way to document quickly an infection of the musculoskeletal soft tissues and to identify the offending micro-organism.

Imaging of musculoskeletal and spinal infections in AIDS.

The diagnosis of common and opportunistic infections in patients with HIV begins with clinical suspicion and involves relatively standard methodology. Musculoskeletal infection is sometimes the first manifestation of an HIV infection. In patients with HIV, the infections tend to be more advanced at presentation, occur in unusual sites, are caused by a wider spectrum of pathogens, and tend to show an inadequate or delayed response to therapy. The index of suspicion for musculoskeletal infections should be high when reviewing imaging studies of patients with HIV.

Imaging of fungal, viral, and parasitic musculoskeletal and spinal diseases.

There are many nonbacterial infections that have musculoskeletal manifestations and radiologic findings. These infections produce a limited range of tissue responses, depending on the organism, the tissue compartment affected, and the immune competence of the host. Diagnosis is dependent on obtaining an appropriate travel or geographic history, the clinical and laboratory features, and on occasion the specific radiologic findings.

Posterior ankle impingement syndrome: MR imaging findings in seven patients.

PURPOSE: To report the magnetic resonance (MR) imaging findings in seven patients with posterior ankle impingement (PAI) syndrome. MATERIALS AND METHODS: Seven patients-three ballet dancers, one badminton player, one soccer player, one hockey player, and one construction worker-who presented with posterior ankle pain were assessed with MR imaging. Their clinical records and imaging studies were reviewed. The MR imaging studies were assessed for the presence of abnormal bone marrow signal intensity, osseous lesions, and soft-tissue abnormalities. RESULTS: One patient was treated surgically. In all patients, MR imaging demonstrated abnormal bone marrow signal intensity in the os trigonum and/or lateral talar tubercle, consistent with bone contusions. Two patients had a fragmented os trigonum or lateral tubercle, and two had a pseudoarthrosis of the posterolateral talus. Increased signal intensity was seen with distention of the posterior recess of the tibiotalar joint in two patients and with distention of the posterior recess of the subtalar joint in four patients. Three patients had fluid accumulation in the flexor hallucis longus tendon sheath. CONCLUSION: Bone contusions of the lateral talar tubercle and os trigonum are prevalent MR imaging findings of PAI syndrome. MR imaging clearly depicts the osseous and soft-tissue abnormalities associated with PAI syndrome and is useful in the assessment of this condition.

Musculoskeletal infections: US manifestations.

One of the most important prognostic factors in patients with musculoskeletal infections is the delay in establishing therapy. Early diagnosis of septic arthritis requires analysis of joint fluid. Ultrasonography (US) is a rapid, portable, sensitive technique for confirming the presence of joint effusions. The study can be easily repeated for follow-up of lesions. US allows real-time guidance of fluid aspiration and can reduce the risk of contaminating other anatomic compartments, especially in the hands, wrists, and feet. Radiography provides complementary information and should be performed in conjunction with US. US is the imaging modality of choice for diagnosis of superficial abscesses. Dynamic compression with the US probe and color Doppler imaging can facilitate detection of superficial abscesses. US may help in the early diagnosis of osteomyelitis by demonstrating subperiosteal or juxtacortical fluid collections and by providing guidance for aspiration of these collections. Evaluation of osseous involvement requires additional imaging; a US examination with normal results does not allow exclusion of bone infection. US is not degraded by metallic artifact and may be useful in cases of osteomyelitis complicating metallic fixation in an extremity. After initial radiography, US can play an important role in the management of musculoskeletal infections.

Vertebral involvement in SAPHO syndrome: MRI findings.

We report on the MRI findings in the vertebrae and surrounding soft tissues in two patients with the SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis). The MRI findings include abnormal bone marrow signal, either focal or diffuse, of the vertebral bodies and posterior elements; hyperintense paravertebral soft tissue swelling and abnormal signal of the intervertebral discs. These changes are consistent with discitis and osteitis.

Sonography of Achilles tendon xanthomas in patients with heterozygous familial hypercholesterolemia.

OBJECTIVE: Xanthomas are an essential diagnostic criteria of familial hypercholesterolemia. The objective of this study was to determine if xanthomas of the Achilles tendon can be revealed on sonography when the condition is clinically unsuspected in patients with heterozygous familial hypercholesterolemia. SUBJECTS AND METHODS: Ninety-four patients (52 females, 42 males; 12-73 years old; mean age, 44 years) with a proven diagnosis of heterozygous familial hypercholesterolemia were studied. Achilles tendons of these patients were clinically evaluated and examined with sonography. Size and echo structure of the Achilles tendons were categorized as normal, having hypoechoic nodules (grade 1), or diffusely hypoechoic with a heterogeneous echo structure (grade 2). RESULTS: Sixty-two patients had positive physical examination findings for Achilles tendon xanthomas. Fifty-seven (92%) of these patients had abnormally large tendons (> or =7.1 mm) on sonography. Grade 1 or grade 2 echo structure compatible with xanthomatosis was found in at least one Achilles tendon of all 62 patients. Of the 94 patients in the study group, 32 patients had negative or indeterminate physical examination findings for Achilles tendon xanthomas. Sonography showed that two (6%) of these patients had an enlarged (> or =7.1 mm) Achilles tendon. Grade 1 or grade 2 echo structure compatible with xanthomatosis was found in 26 (81%) of these 32 patients. CONCLUSION: Sonography is significantly more sensitive than physical examination for the detection of Achilles tendon xanthomas in patients with heterozygous familial hypercholesterolemia and normal-sized Achilles tendons. Our study suggests that sonography may play an important role in the early diagnosis of heterozygous familial hypercholesterolemia.

Imaging of bursae around the shoulder joint.

The authors present a review of the anatomy of the major bursae around the shoulder joint and discuss the use of the different imaging modalities which demonstrate their radiologic features. The calcified subacromial-subdeltoid bursa has a characteristic appearance on plain radiographs. When inflamed it can be visualized by ultrasound and magnetic resonance imaging. Calcific bursitis may involve the subcoracoid bursa. This bursa may mimic adhesive capsulitis of the shoulder or complete rotator cuff tear when injected inadvertently during shoulder arthrography. Less well known are three coracoclavicular ligament bursae. These are also subject to calcific bursitis and have a typical radiologic appearance.

MRI of the knee: a simplified approach.

Magnetic resonance imaging (MRI) of the knee is the most frequently performed musculoskeletal MRI examination and, after initial study with plain radiographs, has supplanted arthrography and arthroscopy as the imaging procedure of choice in the investigation of internal derangement and arthritic disorders of the knee. Knee MRI is a highly accurate, noninvasive procedure that provides exquisite depiction of the soft tissues and bone marrow. In this article a simplified approach to knee MRI is presented, including a practical discussion on the basics of MRI physics, review of the normal anatomy, and illustration of the most commonly encountered pathologic conditions.