Cohort study of lumbar percutaneous chemonucleolysis using ethanol gel in sciatica refractory to conservative treatment.

PURPOSE: To investigate the efficacy of percutaneous chemonucleolysis using ethanol gel (PCEG) in alleviating radicular pain due to disc herniation after failure of conservative treatment. MATERIALS AND METHODS: After failure of conservative treatment, PCEG was performed under fluoroscopic guidance in 42 patients with sciatica >4/10 on a Visual Analog Scale (VAS) for at least 6 weeks and consistent disc herniation on MRI or CT <3 months. The VAS pain score was determined at baseline, then after 1 and 3 months. We assessed the influence of patient-related factors (age, gender, pain duration) and disc herniation-related factors (level, migration pattern, disc herniation-related spinal stenosis) on outcome of PCEG. RESULTS: Mean pain duration was 6.7 months. Pain intensity decreased by 44% and 62.6% after 1 and 3 months, respectively, versus baseline (P = 0.007). A mild improvement was noted by the rheumatologist in 30/42 (71.4%) and 36/42 (85.7%) patients after 1 and 3 months, respectively, and in 31/42 (73.8%) and 33/42 (78.6%) patients by self-evaluation. Patients who failed PCEG were significantly older (49.8 vs. 37.3 years, P = 0.03). None of the other variables studied were significantly associated with pain relief. CONCLUSION: PCEG may significantly improve disc-related radicular pain refractory to conservative treatment. KEY POINTS: • Percutaneous chemonucleolysis using ethanol gel (PCEG) is feasible on an outpatient basis. • PCEG improves disc-related radicular pain refractory to conservative treatment. • PCEG is feasible on an outpatient basis. • Failure of PCEG does not interfere with subsequent spinal surgery.

Bone marrow involvement in Gaucher disease at MRI : what long-term evolution can we expect under enzyme replacement therapy?

PURPOSE: To study the long-term evolution of the bone marrow burden (BMB) score at MRI in patients with Gaucher disease (GD) under enzyme replacement therapy (ERT). MATERIAL AND METHODS: Forty patients treated for GD were retrospectively studied in a referral centre. BMB scores were assessed on spine and femur MR examinations performed between January 2003 and June 2014. The long-term evolution of the BMB scores was analyzed using a linear mixed model. RESULTS: A total of 121 MRI examinations were performed during the study period with a mean follow-up of 7.1 years ± 5.6, an average rate of 3.1 MR examinations ± 1.7 per patient and an interval of 2.3 years ± 1.1 between examinations. Patients had received ERT during 12 years on average ± 6.7. The trend of BMB scores with time decreased significantly by 15% (P = 0.008) during the total study period and 39% (P = 0.01) during the first 5 years of treatment. No changes in BMB scores were observed after five years of treatment. CONCLUSION: In Gaucher patients, the trend of MRI BMB scores with time decreased significantly under ERT the first 5 years of treatment before a long-term stabilization. KEY POINTS: • Bone marrow infiltration of Gaucher patients responds to enzyme replacement therapy • MRI BMB score decreases mainly during the first five years of treatment • MRI BMB score tends to stabilize after five years of treatment • MR examinations could be limited after five years of treatment.

Has the percutaneous vertebroplasty a role to prevent progression or local recurrence in spinal metastases of breast cancer?

OBJECTIVE: To evaluate the effectiveness of percutaneous vertebroplasty (PV) on the prevention of progression or local recurrence in patients with spinal metastases from breast cancer. MATERIALS AND METHODS: Retrospective study on 55 patients between 27-78 years of age (mean age: 55 years) treated for metastatic breast cancer in the same institution (Curie institute, Paris, France), who underwent percutaneous vertebroplasty (PV) (number of vertebrae treated=137) for spinal metastases from January 2000 to December 2009 at the Pitié-Salpêtrière hospital. Statistical correlation between the local tumor progression/recurrence, and the presence of an epidural or a paravertebral metastatic extension at diagnosis, the rate of cement filling the lesion (<50%, ≥50% but incomplete, complete/almost complete) and radiotherapy was evaluated using Chi(2) and Fisher's exact test. RESULTS: The rate of local tumor progression/recurrence of the vertebrae treated by vertebroplasty was 14% (19/137). No statistically significant correlation between either the rate of cement filling of the lesion, or the presence of an epidural or paravertebral metastatic extension, and progression/local recurrence after vertebroplasty was found. No influence of radiotherapy in preventing local progression/recurrence was noted. Distant new bone metastases were observed in 47 out of 55 patients (86%). CONCLUSION: The low rate of local tumor progression/recurrence after a vertebroplasty may support the hypothesis of an antitumor effect of the cement.

Is pain duration associated with morphologic changes of osteoid osteomas at CT?

PURPOSE: To assess the morphologic changes of osteoid osteomas on computed tomographic (CT) scans in association with pain duration. MATERIALS AND METHODS: Institutional review board approval was obtained. Informed consent was waived. From January 2008 to December 2012, 235 patients were treated with interstitial laser ablation at the Hôpital Lariboisière. Ninety-six patients with histopathologically proven osteoid osteomas, complete clinical files, and CT data were studied retrospectively. The following variables were assessed: age, sex, bone location, bone segment, location of the osteoid osteoma in relation to the native cortex, nidus area, nidus calcification area and attenuation at CT, and nidus mineralization ratio (percentage of the calcification area over the total nidus area). Analysis of variance, Kaplan-Meier method, and Cox multivariate regression model were used for statistical analyses. RESULTS: The study sample consisted of 96 patients, 68 of whom were male (71%) and 28 of whom were female (29%) (ratio of male to female patients, 2.4:1). Mean age ± standard deviation was 22.2 years ± 10.4 (range, 4-54 years; median, 18.5 years). The patients' age and nidus mineralization ratio increased significantly with pain duration (hazard ratio, 0.975 [P = .031] and 0.193 [P = .007], respectively). No significant association was found between pain duration and other variables, including the nidus area. In long bones, diaphyseal osteoid osteomas were significantly less mineralized than those in other locations (P = .009). CONCLUSION: The nidus mineralization ratio of osteoid osteomas increases significantly with pain duration and may be a marker of tumor age. Diaphyseal osteoid osteomas demonstrate a lower ratio of nidus mineralization. At the onset of symptoms, older patients experience pain for a longer period before treatment.

Atypical vertebral Paget's disease.

A 40-year-old Mauritanian man consulted for back pain. A computed tomography of the spine showed patchy sclerosis of the fifth and seventh thoracic vertebral bodies with normal neural arch of T5 and sclerosis and hypertrophy of the neural arch of T7, as well as diffuse sclerosis of the T11 vertebral body with a normal neural arch. At MRI, low signal-intensity on T1-weighted images and high signal-intensity on T2-weighted images involved the whole T5 and T7 vertebrae and the vertebral body of T11. Working diagnoses included metastatic disease and lymphoma, and a biopsy of T7 and then T11 was carried out. Both showed pathological findings very suggestive of Paget's disease. Since CT is usually the more specific radiological examination in vertebral Paget's disease, we thought it could be useful to report this atypical CT presentation (patchy sclerosis of the vertebral body without diffuse bone texture changes and isolated involvement of the vertebral body) of vertebral Paget's disease.

A ganglion of the patellar tendon in patellar tendon-lateral femoral condyle friction syndrome.

Intratendinous ganglia are rare. We report the case of a sedentary woman with chronic mechanical anterolateral pain of the knee and an extensive ganglion of the patellar tendon as indicated on magnetic resonance (MR) and ultrasound (US) examinations. There was evidence of a high-riding patella, patellar malalignment and patellar tendon-lateral femoral condyle friction syndrome with significantly close contact between the patellar tendon and the lateral facet of the femoral trochlea. The ultrasound-guided aspiration of the ganglion enabled a localized injection of an anti-inflammatory drug (cortivazol) and the cytopathological examination of the fluid, which confirmed the diagnosis. Clinical improvement was maintained with knee rehabilitation and was satisfactory at follow-up after 1 year. To our knowledge, we report the first case of a ganglion of the patellar tendon subsequent to patellar tendon-lateral femoral condyle friction syndrome. We found that this case was illustrative of mucoid degeneration in connective tissue due to chronic repetitive microtraumas. Additionally, this case provided the opportunity to discuss the management of this condition in a sedentary individual with a high-riding patella and patellar malalignment.

Influence of meniscus on cartilage and subchondral bone features of knees from older individuals: A cadaver study.

OBJECTIVE: Cartilage and subchondral bone form a functional unit. Here, we aimed to examine the effect of meniscus coverage on the characteristics of this unit in knees of older individuals. METHODS: We assessed the hyaline cartilage, subchondral cortical plate (SCP), and subchondral trabecular bone in areas covered or uncovered by the meniscus from normal cadaver knees (without degeneration). Bone cores harvested from the medial tibial plateau at locations uncovered (central), partially covered (posterior), and completely covered (peripheral) by the meniscus were imaged by micro-CT. The following were measured on images: cartilage volume (Cart.Vol, mm3) and thickness (Cart.Th, mm); SCP thickness (SCP.Th, µm) and porosity (SCP.Por, %); bone volume to total volume fraction (BV/TV, %); trabecular thickness (Tb.Th, µm), spacing (Tb.Sp, µm), and number (Tb.N, 1/mm); structure model index (SMI); trabecular pattern factor (Tb.Pf); and degree of anisotropy (DA). RESULTS: Among the 28 specimens studied (18 females) from individuals with mean age 82.8±10.2 years, cartilage and SCP were thicker at the central site uncovered by the meniscus than the posterior and peripheral sites, and Cart.Vol was greater. SCP.Por was highest in posterior samples. In the upper 1-5 mm of subchondral bone, central samples were characterized by higher values for BV/TV, Tb.N, Tb.Th, and connectivity (Tb.Pf), a more plate-like trabecular structure and lower anisotropy than with other samples. Deeper down, at 6-10 mm, the differences were slightly higher for Tb.Th centrally, DA peripherally and SMI posteriorly. CONCLUSIONS: The coverage or not by meniscus in the knee of older individuals is significantly associated with Cart.Th, SCP.Th, SCP.Por and trabecular microarchitectural parameters in the most superficial 5 mm and to a lesser extent the deepest area of subchondral trabecular bone. These results suggest an effect of differences in local loading conditions. In subchondral bone uncovered by the meniscus, the trabecular architecture resembles that of highly loaded areas.

Impact of osteoid osteomas of the hip on the size and fatty infiltration of the thigh muscles.

We aimed to assess the impact of osteoid osteomas of the hip on the size and fatty infiltration of the muscle thigh in 42 patients. The thigh circumference, cross-sectional areas, and fatty atrophy of four anterior muscles were assessed on magnetic resonance axial T1-weighted images. A significant fatty atrophy was found in the studied muscles of the ipsilateral thigh except for the rectus femoris. No significant association was demonstrated with pain duration suggesting that muscle atrophy may rather be related to the locoregional inflammation than subsequent to the disuse of the limb.

Vertebral involvement in Paget's disease: morphological classification of CT and MR appearances.

Vertebral Paget's disease produces a large panel of radiologic appearances sometimes atypical and pseudotumoral. Classical classifications of bone alterations based on pathophysiological hypotheses do not always match the imaging findings. This article will review the computed tomography (CT) and magnetic resonance imaging (MRI) features of Paget's disease of the spine with special emphasis on morphological findings that differentiate Paget's disease from tumors. Combined CT and MRI analyses usually provide the diagnosis of Paget's disease.

Chondrocalcinosis of femoro-tibial and proximal tibio-fibular joints in cadaveric specimens: a high-resolution CT imaging study of the calcification distribution.

OBJECTIVES: To analyze calcium deposits by computed tomography (CT) in femoro-tibial compartments and proximal tibio-fibular joints; to assess the relationship with CT-assessed osteoarthritis (OA). METHODS: 68 (34 pairs) cadaveric knees (mean age of 84) were scanned at high resolution CT. Menisci and hyaline cartilage calcifications in the femoro-tibial and proximal tibio-fibular joints were analyzed. OA was CT-assessed by the Kellgren and Lawrence score. Gross appearance of OA was evaluated on 29 left knees after dissection and India ink staining of tibial plateaus. RESULTS: In femoro-tibial joints, meniscal calcifications (MC) and hyaline cartilage calcifications (HCC) were detected in 23(34%) and 14(21%) knees respectively. Calcifications mainly involved the three meniscal segments and were mainly observed in all thirds of the femoro-tibial compartments. In proximal tibio-fibular joints, HCC were detected in 19(28%) knees. The association HCC-MC in femoro-tibial joints and between calcifications in femoro-tibial and proximal tibio-fibular joints was strong (p<0.0001). Femoro-tibial and proximal tibio-fibular CT-assessed OA were respectively found in 23(34%) and 19(28%) knees. HCC were significantly associated with femoro-tibial OA (p = 0.04) while MC were not (p = 0.34). OA macroscopic evaluation showed a mean surface of cartilage lesions of 35% (range 0.13-0.55). No significant difference was demonstrated regarding the CT-detection of MC, HCC or CT-assessed OA. CONCLUSIONS: This is the first study to report a strong association of chondrocalcinosis between femoro-tibial and tibio-fibular joints in addition to a strong association between MC and HCC in femoro-tibial compartments. No significant relationship between chondrocalcinosis and OA was demonstrated.

Plantar fibromatosis may adopt the brain gyriform pattern of a low-grade fibromyxoid sarcoma.

We report the case of a 42-year-old man with histologically proven plantar fibromatosis (Ledderhose disease) demonstrating an uncommon brain gyriform pattern at MRI, so far exclusively described in the low-grade fibromyxoid sarcoma (LGFMS). An acoustic posterior enhancement at ultrasound, a high intensity on T2w and post-contrast T1wMR images were unusual and related to a high tumor cellularity at histology with no myxoid tissue. The juxtaposition of areas of high and low cellularity (with more fibrous material) in a multilobulated mass built a brain gyriform pattern at MR, similar to what was so far described exclusively in LGFMS. This case demonstrates that the brain gyriform pattern may also be observed in other soft tissue fibrous tumors with no myxoid material but with high cellularity areas alternating with fibrous zones of low cellularity.

Tibial hyperostosis: a diagnostic approach.

Tibial hyperostosis may be encountered in musculoskeletal imaging, incidentally or during the investigation of a leg pain. Hyperostosis involves the exuberant production of osseous tissue and results in cortical, periosteal and/or endosteal thickening of the bone. As a long bone with thick cortices, the tibia has a significant probability of being affected by ubiquitous bone diseases. As a tubular long bone, the tibia is likely to be involved in extensive infectious conditions such as osteomyelitis. As a bone of the lower limb, the tibia undergoes high stresses and may be affected by decrease in bone strength or repetitive submaximal stress. The tibia is also particularly involved in some bone sclerosing dysplasias and Paget's disease. In this work, we aim at highlighting the main conditions leading to tibial hyperostosis and try to provide key elements to narrow down the several diagnostic possibilities. Osteoid osteomas, fatigue or insufficiency fractures, infectious conditions, vascular lesions, sclerosing bone dysplasias and Paget's disease represent the main challenging diagnoses to discuss.