Anatomical variations of the recurrent laryngeal nerve according to the inferior thyroid artery and their clinical impact in patients undergoing thyroidectomy.

BACKGROUND: Recurrent laryngeal nerve identification is the 'gold standard' in thyroidectomy, to determine nerve function security and prevent severe complications. This study assessed the topographical relationship between the recurrent laryngeal nerve and the inferior thyroid artery in patients undergoing total thyroidectomy, and determined its clinical impact. METHODS: A retrospective study was performed of patients undergoing total thyroidectomy in a single tertiary centre over a six-month period. RESULTS: Sixty-four patients were included. Among the 128 recurrent laryngeal nerve dissections, the nerve was identified traversing the inferior thyroid artery anteriorly in 27.3 per cent, with equal distribution between the two sides. No significant sex association was reported. One patient had transient vocal fold palsy, and hypocalcaemia was observed in 21.9 per cent, yet there was no statistical association with the topographical variation of the recurrent laryngeal nerve. CONCLUSION: Almost one-third of patients had an anatomical variation in which the recurrent laryngeal nerve ran superiorly to the inferior thyroid artery. Recurrent laryngeal nerve variation had no clinical impact on local complications or hypocalcaemia.

Restoration of the degenerated cervical intervertebral space: how much should we distract? A magnetic resonance imaging study.

The aim of the study was to quantify normal cervical disc space measurements and to generate a normal values' database. Furthermore, during operative restoration of a degenerated intervertebral disc, it is difficult to calculate the amount of distraction required to restore the collapsed space to its normal height. A secondary purpose is personalizing the anatomical correction. Therefore, we expressed disc height based on measurements of its neighboring disc as an equation, by using simple linear regression. We reviewed MRI studies from asymptomatic healthy subjects (16 men-24 women, mean age 27.25 years). We measured midsagittal anterior, middle and posterior vertebral body and disc height, and disc diameter from C3 to T1 vertebra. We calculated mean disc height, disc height index (DHI) and disc convexity index per spinal level. C6-7 mean and anterior disc height were significantly greater than all respective measurements, except C5-6 (p<0.01). Middle C6-7-disc height was significantly greater compared to respective measurements in every other level (p<0.01). C5-6, C6-7 and C7-T1 mean disc height is significantly greater in men. Middle disc height is the greatest among disc heights in every spinal level. DHI does not differ between sexes, it increases from C3-4 to C5-6 with a slight decrease in C6-7, while its value significantly decreases in C7-T1 (p<0.0001). These measurements could be used for anatomical, individualized restoration of the degenerated intervertebral disc; thus, avoiding overdistraction. Our data could improve preoperative templating or implant design.

Symptomatic cervical perineural (Tarlov) cyst: a case report.

BACKGROUND: Perineural (Tarlov) cysts are benign, usually asymptomatic, cerebrospinal fluid filled cysts of the spine, most often found in the sacral region. DESCRIPTION OF CASE: We report a Tarlov cyst, located in the cervical spine, in a 44-year-old woman who presented with a 3-week history of radicular symptoms of the right C6 root. The perineural cyst was identified at the C5-C6 level following magnetic resonance imaging of the cervical spine. A conservative approach was chosen, with the use of a soft cervical collar for two weeks, a 15-day-course of oral non-steroidal anti-inflammatory medication and instructions concerning limitation of her activities. The outcome of this approach was 90% improvement of her symptoms 24 months after her diagnosis. CONCLUSION: This is the first report of a cervical Tarlov cyst treated conservatively without the use of oral or injected steroids. The perineural cyst should be included in the differential diagnosis of patients presenting with radicular symptoms. Hippokratia 2015, 19 (1): 76-77.

Acute calcific tendinitis of the longus colli muscle: case report and review of the literature.

PURPOSE: Acute calcific tendinitis of the longus colli muscle (or retropharyngeal tendinitis) is an aseptic inflammatory process characterized by acute posterior neck pain, neck stiffness and dysphagia or odynophagia. Awareness of its existence is crucial in the differential diagnosis, because many other conditions, such as retropharyngeal abscess, meningitis or disc herniation, show similar clinical features. We present a case exhibiting an uncommon symptom (torticollis) and a brief literature review to emphasize the risk of misdiagnosis. METHODS: A 36-year-old woman presented with neck stiffness and torticollis accompanied by dysphagia and prevertebral space sensitivity on the second day. RESULTS: The diagnosis was established by computed tomography (CT), the gold standard for identifying the presence of prevertebral oedema and calcific deposition associated with retropharyngeal tendinitis. Treatment with NSAIDs and low doses of corticosteroids relieved the symptoms within 48 h. CONCLUSIONS: Retropharyngeal tendinitis is an underreported entity in the literature and orthopaedists should become aware of its existence. Misdiagnosis of this important mimicker may lead to unnecessary antibiotics administration and interventions in the retropharyngeal space.

Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip.

Sixty-three fingertip amputations in 50 patients were reconstructed using a homodigital neurovascular island flap technique based on a single neurovascular pedicle without further shortening of the distal phalanx. The procedure was carried out under regional anaesthesia, using a tourniquet and magnifying loupes. All of the flaps survived and achieved normal or adequate two-point discrimination without any painful scar or cold hypersensitivity. Fifteen patients had some loss of distal interphalangeal joint extension. The technique is simple and presents an excellent method for fingertip reconstruction in Allen type II, III and IV injuries.

Increased signal intensity on fat-suppressed three-dimensional T1-weighted pulse sequences in patellar tendon: magic angle effect?

OBJECTIVE: To assess the frequency of increased signal intensity in the patellar tendon using three-dimensional T1-weighted MRI pulse sequences. DESIGN AND PATIENTS: Sixty patients were examined with a 1.0 T scanner (15 mT/m gradient strength) using a quadrature coil. Three pulse sequences were applied in the sagittal plane: PD turbo spin echo (PD-TSE), 3D T1-weighted gradient echo with fat suppression (3D-T1-FFE-FS) and 3D T1-weighted echo planar imaging with fat suppression (3D-T1-EPI-FS). The high signal intensity areas were measured in their maximum length. The angle of the patellar tendon relative to the main field position was measured in the same slice. In eight patients with anterior knee pain, and in 11 with no anterior knee pain, a fourth T2-weighted TSE pulse sequence (T2-TSE) was obtained to rule out patellar tendinitis. RESULTS: The correlation of the high signal intensity areas with the relative position of the tendon was found to be significant with the 3D sequences (P = 0.03 for 3D-T1-FFE-FS and P = 0.003 for 3D-T1-EPI-FS). The length of the high signal intensity area in the tendon was 5.4 mm with 3D-T1-FFE-FS, 4.9 mm with 3D-T1-EPI-FS and 3.1 mm with PD-TSE images. No patellar tendinitis was demonstrated on the T2-TSE images. CONCLUSION: The magic angle effect is commonly observed in the 3D based T1-weighted pulse sequences with fat suppression. The presence of the above sign must be recognized by radiologists, so that misdiagnosis of patellar tendinitis is avoided.

Comparison of echo planar imaging, gradient echo and fast spin echo MR scans of knee menisci.

In order to reduce the acquisition time, we compared a three-dimensional multi-shot echo-planar imaging (EPI) sequence with fat-suppression with two widely used sequences, the fat-suppressed gradient echo (GRE) and the proton-density weighted turbo spin-echo (FSE) in imaging the menisci of the knee. Sixty patients with various indications were studied prospectively with MRI. The menisci were imaged in the sagittal plane with all three sequences using a 1T MR scanner with 15mT/m gradients. The signal-to-noise ratio (SNR) of bone (b), cartilage (c), and meniscus (m) as well as contrast-to-noise ratio (CNR) and relative contrast (ReCon) between menisci and cartilage and between bone and cartilage were measured. A qualitative analysis was performed on grading of meniscal pathology (0-IV). The imaging accuracy of meniscal pathology was assessed compared to arthroscopy in 13 patients. The EPI provided the highest SNR in cartilage and meniscus (p<0.001), the highest CNR and the highest ReCon between bone and cartilage (p< or =0.001). MR grading of meniscal abnormalities showed overestimation compared to GRE and FSE. The EPI sequence could not be included in the routine protocol in imaging the menisci since the overestimation of meniscal abnormalities could lead to unnecessary arthroscopy.

Malignant fibrous histiocytoma of the spine causing spinal neural foramen widening.

A case with a clinical picture of a chronic low back pain radiating to both lumbar regions caused by malignant fibrous histiocytoma is reported. Radiological, surgical and histopathological findings and treatment of this rare case are discussed.

Single-shot turbo spin-echo MR myelography: comparison with 3D-turbo spin-echo MR myelography and T2-turbo spin-echo at 1 T.

In order to reduce the acquisition time, we compared the single-shot-TSE-MR myelography (MRm) and 3D-TSE-MRm. The T2-TSE sequence was the standard of reference. Fifty patients with low back pain, sciatica or cervical radiculopathy were examined at 1.0 T. The shortest AP diameter of the spinal canal, signal-to-noise ratio (SNR) for CSF and cord, contrast-to-noise ratio (CNR) and relative contrast (ReCon) between CSF and cord were calculated. No statistically significant difference was found between the three sequences with regard to the AP diameter of the spinal canal. A significant difference was found in: (i) SNRcord; (ii) SNRCSF; (iii) SS-TSE-MRm (showed the highest CNR) and (iv) SS-TSE-MRm (showed higher ReCon compared to 3D-TSE-MRm). In conclusion, SS-TSE-MRm can be used alternatively to 3D-TSE-MRm reducing the acquisition time down to only 8 s per image.

Unusual causes of spinal foraminal widening.

Spinal neural foraminal widening is usually caused by benign lesions, most commonly neurofibromas. Rare lesions can also cause spinal neural foraminal widening. Computed tomography and/or MRI are the modalities of choice for studying the spinal foraminal widening. The present pictorial review describes six rare lesions, namely a lateral thoracic meningocele, a malignant fibrous histiocytoma, a tuberculous abscess, an osteoblastoma, a chondrosarcoma and a malignant tumour of the lung which caused spinal neural foraminal widening.

Dimensions of the lumbar spinal canal: variations and correlations with somatometric parameters using CT.

The aim of this study was to investigate the correlation of vertebral dimensions with somatometric parameters in patients without clinical symptoms and radiological signs of central lumbar spinal stenosis. One hundred patients presenting with low back pain or sciatica were studied with CT. In each of the L3, L4 and L5 vertebra three slices were taken with the following measurements: 1. Slice through the intervertebral disc: (a) spinal canal area; (b) interarticular diameter; (c) interligamentous diameter. 2. Slice below the vertebral arcus: (a) dural sac area; (b) vertebral body area. 3. Pediculolaminar level: (a) anteroposterior diameter and interpedicular diameter of the spinal canal; (b) spinal canal area; (c) width of the lateral recesses. The Jones-Thomson index was also estimated. The results of the present study showed that there is a statistically significant correlation of height, weight and age with various vertebral indices. The conventional, widely accepted, anteroposterior diameter of 11.5 mm of the lumbar spinal canal is independent of somatometric parameters, and it is the only constant measurement for the estimation of lumbar spinal stenosis with a single value. The present study suggests that there are variations of the dimensions of the lumbar spinal canal and correlations with height, weight and age of the patient.