Magnetic resonance neurography in the diagnosis of neurological subtypes of thoracic outlet syndrome.

Neurological thoracic outlet syndrome (TOS) can be challenging to diagnose, particularly given its described subtypes of neurogenic TOS (NTOS) and disputed TOS (DTOS) that exhibit variable clinical presentations and etiologies. The diagnostic workup of TOS often includes magnetic resonance neurography (MRN) of the brachial plexus. Specific MRN imaging modifications for TOS evaluation are required to maximize spatial and contrast resolution to increase the conspicuity of nerve segments and their relationships to surrounding osseous structures. Dynamic assessment with arm positioning is used to evaluate outlet narrowing and compression of the plexus. Individual nerve segments are interrogated for their longitudinal and cross-sectional morphologies and signal characteristics. In patients with NTOS, MRN may reveal focal impingement of the C8/T1 nerve roots and/or lower trunk with accompanying abnormal T2-weighted signal hyperintensity. Predisposing anatomical entities include cervical ribs, rib synostoses, hypertrophic callous following clavicular fracture, remnant first thoracic rib from prior incomplete resection, and variable perineural scarring. In comparison, DTOS patients frequently demonstrate signal hyperintensity and enlargement of the mid plexus (trunk and division level), with narrowing of the costoclavicular interval. Following comprehensive diagnostic workup that frequently includes electrodiagnostic testing, patients are directed to different management pathways. Nonsurgical management is considered for all cases of DTOS; all patients with NTOS or DTOS who fail conservative treatment warrant referral for a surgical opinion. If surgery is pursued, MRN can be helpful in preoperative planning.

Combined femoral and acetabular version and synovitis are associated with dGEMRIC scores in people with femoroacetabular impingement (FAI) syndrome.

This study sought to explore, in people with symptoms, signs and imaging findings of femoroacetabular impingement (FAI syndrome): (1) whether more severe labral damage, synovitis, bone marrow lesions, or subchondral cysts assessed on magnetic resonance imaging (MRI) were associated with poorer cartilage health, and (2) whether abnormal femoral, acetabular, and/or combined femoral and acetabular versions were associated with poorer cartilage health. This cross-sectional study used baseline data from the 50 participants with FAI syndrome in the Australian FASHIoN trial (ACTRN12615001177549) with available dGEMRIC scans. Cartilage health was measured using delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) score sampled at the chondrolabral junction on three midsagittal slices, at one acetabular and one femoral head region of interest on each slice, and MRI features were assessed using the Hip Osteoarthritis MRI Score. Analyses were adjusted for alpha angle and body mass index, which are known to affect dGEMRIC score. Linear regression assessed the relationship with the dGEMRIC score of (i) selected MRI features, and (ii) femoral, acetabular, and combined femoral and acetabular versions. Hips with more severe synovitis had worse dGEMRIC scores (partial η2 = 0.167, p = 0.020), whereas other MRI features were not associated. A lower combined femoral and acetabular version was associated with a better dGEMRIC score (partial η2 = 0.164, p = 0.021), whereas isolated measures of femoral and acetabular version were not associated. In conclusion, worse synovitis was associated with poorer cartilage health, suggesting synovium and cartilage may be linked to the pathogenesis of FAI syndrome. A lower combined femoral and acetabular version appears to be protective of cartilage health at the chondrolabral junction.

Positive anterior margins in breast conserving surgery: Does it matter? A systematic review of the literature.

Positive margins are associated with an increased risk of ipsilateral breast tumor recurrence (IBTR); therefore re-excision of positive margins is recommended. Involvement of anatomically non-breast margins, such as anterior margins, has been associated to a lower risk of IBTR than radial margins. Although many surgeons do not re-excise positive anterior margins (PAM); there is no consensus regarding this approach. The objective of this study is to find evidence that assesses this practice. A systemic literature review was performed through six databases from January 1995 to July 2014. Studies that discussed anatomical location of involved margins in BCS were included. Six studies were identified evaluating PAM. One study reported a 2.5% rate of IBTR in patients with non-negative margins treated with radiotherapy (of which 23% had a PAM). Another study showed 4% of residual disease after re-excision of PAM, but did not report IBTR rates. A later observational study reported that 87.5% of positive anterior and posterior margins were re-excised. One survey from America and one from the UK showed that 47% and 71% of surgeons would not re-excise PAM, respectively. A later survey in the UK reported that 43.8% of surgeons would not re-excise PAM in DCIS, whilst 29.2% would not for invasive carcinoma. Common surgical practices to not re-excise PAM contradict current guidelines that recommend obtaining negative margins to reduce the risk of IBTR. However, there is little evidence detailing the relationship between PAM and IBTR rates. Low residual disease after re-excision of PAM supports the limited benefit of re-excise this margin; however further studies are required to evaluate this topic.