Usefulness of direct-conversion flat-panel detector system as a quality assurance tool for high-dose-rate 192Ir source.

The routine quality assurance (QA) procedure for a high-dose-rate (HDR) 192Ir radioactive source is an important task to provide appropriate brachytherapy. Traditionally, it has been difficult to obtain good quality images using the 192Ir source due to irradiation from the high-energy gamma rays. However, a direct-conversion flat-panel detector (d-FPD) has made it possible to confirm the localization and configuration of the 192Ir source. The purpose of the present study was to evaluate positional and temporal accuracy of the 192Ir source using a d-FPD system, and the usefulness of d-FPD as a QA tool. As a weekly verification of source positional accuracy test, we obtained 192Ir core imaging by single-shot radiography for three different positions (1300/1400/1500 mm) of a check ruler. To acquire images for measurement of the 192Ir source movement distance with varying interval steps (2.5/5.0/10.0 mm) and temporal accuracy, we used the high-speed image acquisition technique and digital subtraction. For accuracy of the 192Ir source dwell time, sequential images were obtained using various dwell times ranging from 0.5 to 30.0 sec, and the acquired number of image frames was assessed. Analysis of the data was performed using the measurement analysis function of the d-FPD system. Although there were slight weekly variations in source positional accuracy, the measured positional errors were less than 1.0 mm. For source temporal accuracy, the temporal errors were less than 1.0%, and the correlation between acquired frames and programmed time showed excellent linearity (R2 = 1). All 192Ir core images were acquired clearly without image halation, and the data were obtained quantitatively. All data were successfully stored in the picture archiving and communication system (PACS) for time-series analysis. The d-FPD is considered useful as the QA tool for the 192Ir source.

COVID-19 Masked by Pyogenic Lumbar Discitis and Bacteremia: A Case Report.

CASE: A 65-year-old man experienced backache, and 9 days later, he developed cellulitis in his left foot. On the 20th day, his body temperature was 37°C, and he had intermittent and shallow cough. On the 29th day, he was diagnosed with pyogenic lumbar discitis and bacteremia. Computed tomography examinations showed no evidence of pneumonia, but his cough persisted, and an elevated d-dimer level was observed. Finally, he tested positive for coronavirus disease 2019 (COVID-19). CONCLUSIONS: This case shows possible associations among COVID-19, venous thrombosis, cellulitis, and bacteremia. Other infections may coexist with COVID-19 and mask it.

Percutaneous transthoracic fenestration of an intramedullary neurenteric cyst in the thoracic spine with intraoperative magnetic resonance image navigation and thoracoscopy.

Neurenteric cysts are rare congenital cysts typically located in the anterior cervical or thoracic spinal canal. The authors report on their experience with the successful treatment of a midthoracic neurenteric cyst in an 8-year-old boy. Percutaneous fenestration via a transthoracic, transvertebral approach with combined thorascopy and intraoperative MR imaging guidance was used, and the cyst showed lasting shrinkage. The authors discuss this minimally invasive technique and its limitations.

Application of superb micro-vascular imaging (SMI) in obstetrics.

Superb Micro-vascular Imaging (SMI; Toshiba Medical Systems, Tokyo) is a new blood flow imaging technique that employs a unique algorithm to minimize motion artifacts by eliminating signals based on analysis of tissue movement. Compared to conventional blood flow imaging such as color and power Doppler imaging, SMI significantly reduces motion artifacts and can visualize low-velocity blood flow in small vessels. In the present report, the clinical value and future potential of SMI in obstetrics have been demonstrated for the first time. We believe this new blood flow imaging technique is acceptable for obstetricians for the purpose of perinatal clinical assessments.

Magnetic resonance imaging-guided percutaneous fenestration of a cervical intradural cyst. Case report.

The authors describe the case of a high cervical, intradural extramedullary cyst located anterior to the spinal cord in a 13-year-old boy. The lesion was fenestrated percutaneously by using real-time magnetic resonance (MR) imaging guidance and a local anesthetic agent. The patient's symptom, severe exercise-induced headache, immediately resolved after treatment. Nine months later, complete disappearance of the cyst was confirmed on MR imaging and computerized tomography myelography. Magnetic resonance imageing-guided fenestration can be considered a minimally invasive option for intradural cystic lesions.

Long-term clinical outcome of sacral chondrosarcoma treated by total en bloc sacrectomy and reconstruction of lumbosacral and pelvic ring using intraoperative extracorporeal irradiated autologous tumor-bearing sacrum: a case report with 10 years follow-up.

BACKGROUND CONTEXT: Primary malignant tumors of the sacrum are rare. Chondrosarcoma is one of the common malignant tumors arising from the sacrum. Chondrosarcoma is often invasive, and there is a high propensity for local recurrence. Surgical resection is often the only effective treatment; however, the treatment of malignant sacral tumors can be challenging, both because of the anatomy of the spinopelvic complex and the frequently large tumor size. PURPOSE: We report a case of sacral chondrosarcoma that was successfully treated by total en bloc sacrectomy and reconstruction of the lumbosacral and pelvic ring using intraoperative extracorporeal irradiated autologous tumor-bearing sacrum. STUDY DESIGN: A case report with 10 years follow-up. METHODS: A 51-year-old man presented with right lower leg pain. Plain radiographs and computed tomography (CT) showed an osteolytic lesion at the sacrum that extended to the sacroiliac joint. Magnetic resonance imaging demonstrated that the tumor mass was localized from S1 to S2 with an epidural lesion at L5-S1 disc level. Histopathologic evaluation by open biopsy revealed that the lesion was chondrosarcoma. Total en bloc sacrectomy of the tumor-bearing sacrum was performed. The removed tumor-bearing sacrum was extracorporeally irradiated at 200 Gy during the operation and returned to the original position as a bone graft and fixed with instruments thereafter. RESULTS: We needed two revision surgeries during the first 3 years because of the implant failures; however, 10 years after the initial surgery, CT revealed that the irradiated sacrum had remodeled into living bone and integrated with surrounding iliac bone without radiological evidence of tumor recurrence. The patient ambulates without any support and there was no clinical and radiological evidence of tumor recurrence. CONCLUSIONS: The advantages of our method include the availability of high dose of radiation because of extracorporeal irradiation, excellent fit between graft and host bone, reduction of the dead space, no immunological rejection, no need for a bone bank, availability of the sacrum not only for the augmentation of the large defect but also for the scaffold for the other bone grafts. Our report is of only one case; however, we consider that it could be one option for the treatment of sacral malignant bone tumors, such as chondrosarcoma.

Development of the Japanese version of the Fibromyalgia Impact Questionnaire (JFIQ): psychometric assessments of reliability and validity.

AIM: To perform a psychometric assessment of the Japanese version of the Fibromyalgia Impact Questionnaire (JFIQ). METHODS: Data for the psychometric assessment were collected from Japanese fibromyalgia (FM) patients who visited a clinic. Analyses were performed to examine the reliability and validity of the JFIQ. RESULTS: A total of 56 patients were included in the analysis. There was no remarkable floor or ceiling effect for the JFIQ item or total scores. In the analysis of reproducibility, the interclass correlation coefficients of each item score and total score ranged from 0.61 to 0.95. Cronbach's alpha coefficient was 0.92. For the concurrent validity, the total score and most of the item scores correlated to every domain of Short Form-36 or Beck Depression Inventory-II to a moderate or great extent. The results of the known-group comparisons indicated that the total score tended to increase with the increase in severity of FM and pain (P-values for trend < 0.05). CONCLUSION: This psychometric assessment demonstrated good reliability and validity of the JFIQ for use with Japanese FM patients. In the future, we expect that this questionnaire will be used in clinical studies and medical practice, and will be beneficial in the development of new therapies as well as for the comprehensive evaluation of patients' conditions in Japan.

Percutaneous aspiration of spinal terminal ventricle cysts using real-time magnetic resonance imaging and navigation.

STUDY DESIGN: Clinical case series. OBJECTIVE: To present a new innovative treatment option for cysts of the terminal ventricle. SUMMARY OF BACKGROUND DATA: Invasive surgery including laminectomy and cyst fenestration has been the sole reported method of treatment for this rare pathology. METHODS: Four cases of symptomatic cyst of the terminal ventricle of the spinal cord were treated by percutaneous aspiration using real-time guidance with magnetic resonance imaging (MRI) and optically-tracking navigation. RESULTS: Three patients were treated successfully by this percutaneous method, and for 1 patient the treatment was converted to conventional surgery after a single unsuccessful trial of percutaneous puncture. All patients were relieved of their symptoms without any complication. Follow-up MRI revealed continued shrinkage of the cysts after both surgery and MRI-guided percutaneous fenestration. CONCLUSION: MRI-navigated percutaneous aspiration can be a minimally-invasive treatment option for symptomatic cysts of the terminal ventricle, and therefore, can be indicated before more invasive surgery might be scheduled.

Respiratory dysfunction in patients with chronic-onset cervical myelopathy.

STUDY DESIGN: A retrospective study. OBJECTIVE To clarify the characteristics of respiratory dysfunction associated with chronic-onset cervical myelopathy. SUMMARY OF BACKGROUND DATA: In acute cervical cord injury, respiratory dysfunction, especially vital capacity (VC), is impaired, which causes respiratory complications. No comprehensive study has been published about respiratory dysfunction in patients with chronic-onset myelopathy. METHODS: Eighty-four consecutive patients without history of respiratory disease who underwent surgery for cervical myelopathy were studied. The control group consisted of 84 age-matched patients with lumbar degenerative diseases. Parameters of spirometry, arterial blood gas, height of the diaphragm, and the score for neurologic impairment were analyzed before and after surgery. RESULTS: Percent VC (%VC) was significantly lower in the study group than in the control group. In patients with cranial cord lesions and multilevel cord lesions, %VC was lower than in those with a caudal lesion and a single-level lesion, respectively. Percent VC correlated with the preoperative neurologic score in the study group. In patients having the lesion at or above C4, %VC improved after surgery, whereas in those with a lower lesion, %VC had not decreased before surgery, and no further improvement was obtained. CONCLUSIONS: In patients with chronic-onset cervical myelopathy, %VC significantly decreases when they have more cranial or multilevel lesions. Percent VC also correlates with the preoperative neurologic score and improves with surgical treatment in patients with more cranial cord lesions. Respiratory dysfunction should be taken into consideration as a part of neurologic impairment in chronic-onset cervical myelopathy.

Surgical treatment of idiopathic scoliosis in adults: an age-related analysis of outcome.

STUDY DESIGN: A retrospective outcome study was conducted. OBJECTIVE: To analyze the clinical and radiographic outcome of surgical treatment for idiopathic scoliosis in patients treated at the age of 20 years or older. SUMMARY OF BACKGROUND DATA: Idiopathic scoliosis continues to pose problems in many patients after adolescence. Surgical treatment of idiopathic scoliosis in adults still is a challenging subject, but no outcome analysis in terms of different age groups had been performed. METHODS: In this study, 58 adult patients with idiopathic scoliosis who underwent surgery using Cotrel-Dubousset instrumentation were followed up for 2 to 7 years, and the results were studied clinically and radiographically. RESULTS: The prevalence of pain that requires specific treatment decreased from 16% to 5%, and the pain improvement was reliably obtained in the older patients. Radiographically, the mean rate of Cobb angle correction was 53% for both the thoracic and lumbar curves, whereas it decreased age dependently, especially in relation to the thoracic curve. The sagittal plane correction generally was satisfactory in patients younger than 50 years, but appropriate lumbar lordosis was difficult to maintain after the age of 50 years. Frontal and sagittal balance often was difficult to achieve in patients older than 50 years. CONCLUSIONS: This study clarified specific characteristics and problems in the surgical treatment of adult idiopathic scoliosis according to different age groups. Although pain was the most important indication for surgery in patients older than 40 years, it was improved reliably by surgery in most of these patients. On the other hand, the radiographic results tended to be less satisfactory in the older patients in an age-dependent manner. These results provide useful information concerning the indications and strategies of adult scoliosis surgery.

Evaluation of standard nucleotomy for lumbar disc herniation using the Love method: results of follow-up studies after more than 10 years.

A retrospective analysis of long-term follow-up results more than 10 years after a standard nucleotomy for lumbar disc herniation with the Love method was done to determine the effectiveness of this procedure. Nucleotomy according to Love was the standard treatment for lumbar disc herniation before the various minimally invasive alternatives were recently introduced. Without long-term follow-up analysis of Love operations, evidence-based evaluation of those new methods is impossible. We believe that the standard nucleotomy procedure should now be evaluated precisely. In this study we present a comparison of 1-year follow-up results to the results more than 10 years after lumbar nucleotomy. Seventy-six consecutive patients who had undergone lumbar nucleotomy were identified. It was possible to assess 54 (71.1%) of the cases more than 10 years after surgery. The initial and final outcomes were assessed using the MacNab classification and the Japanese Orthopaedic Association (JOA) score. With the MacNab classification a successful outcome 1 year after surgery was achieved in 87.0% of the cases. At the final follow-up, this result was reduced to 74.1%. Seven patients required a second operation and patients under 21 years of age were at risk for reoperation. Patient overall satisfaction with the results of the standard nucleotomy was high. The disc height of the operation site significantly decreased after surgery; nevertheless, this did not affect the clinical outcome. A standard lumbar nucleotomy according to Love is a safe and reliable method of treating selected patients with lumbar disc herniations.

Degenerative intraspinal cyst of the cervical spine: case report and literature review.

STUDY DESIGN: A case report and a literature review are presented. OBJECTIVE: To describe and review the clinical presentations, characteristic findings from imaging studies, and treatment of synovial and ganglion cysts arising within the cervical spinal canal. SUMMARY OF BACKGROUND DATA: Synovial and ganglion cysts in the cervical spine are rare. To the authors' knowledge, 24 sporadic cases in all, designated by various terms, have been reported in the literature. METHODS: Three cases of synovial and ganglion cysts in the cervical spine are reported as well as a review of the literature. RESULTS: Characteristic findings from imaging studies included a fluid-containing extradural lesion demonstrated on magnetic resonance images and gas content in the lesion demonstrated on ordinary or sagittally reconstructed computed tomography images. A laminectomy with removal of the cyst was the treatment of choice in most cases. CONCLUSIONS: Neither communication with an adjacent facet joint nor histopathology of the cyst wall provides a persuasive basis for differentiating ganglion, synovial cyst, and cyst arising from the ligaments. To accommodate the varied presentations, the authors propose a comprehensive term for these lesions: "degenerative intraspinal cyst."