Can conservative treatment be effective for thoracolumbar injuries patients with TLICS scores of 4 or 5? An analysis of initial radiological findings and clinical risk factors for treatment failure.

BACKGROUND: This study aimed to assess the outcomes of conservative management in patients with thoracolumbar fractures classified with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4 or 5, and to analyze initial imaging findings and clinical risk factors associated with treatment failure. METHODS: In this retrospective analysis, patients with thoracolumbar fractures and a TLICS score of 4 or 5, determined through MRI from January 2017 to December 2020, were included. Patients undergoing conservative treatment were categorized into two groups: Group 1 (treatment success) and Group 2 (treatment failure), based on initial and 6-month follow-up outcomes. Clinical data were compared between the two groups. Initial radiological assessments included three kyphosis measurements (Cobb angle, Gardner angle, and sagittal index [SI]), anterior and posterior wall height, and central canal compromise (CC). Additionally, risk factors contributing to treatment failure were analyzed. RESULTS: The conservative treatment group comprised 84 patients (mean age, 60.25 ± 15.53; range 22-85; 42 men), with 57 in Group 1 and 27 in Group 2. Group 2 exhibited a higher proportion of women, older age, and lower bone mass density (p = 0.001-0.005). Initial imaging findings in Group 2 revealed significantly greater values for Cobb angle, SI, and CC (p = 0.001-0.045 or < 0.001; with cutoff values of 18.2, 12.8, and 7.8%, respectively), and lower anterior wall height (p = 0.001), demonstrating good to excellent interobserver agreement (0.72-0.99, p < 0.001). Furthermore, osteoporosis was identified as a significant risk factor (odds ratio = 5.64, p = 0.008). CONCLUSION: Among patients with TLICS scores of 4 or 5, those experiencing conservative treatment failure exhibited unfavorable initial radiological findings, a higher proportion of women, advanced age, and osteoporosis. Additionally, osteoporosis emerged as a significant risk factor for treatment failure.

Deep Learning-Assisted Quantitative Measurement of Thoracolumbar Fracture Features on Lateral Radiographs.

OBJECTIVE: This study aimed to develop and validate a deep learning (DL) algorithm for the quantitative measurement of thoracolumbar (TL) fracture features, and to evaluate its efficacy across varying levels of clinical expertise. METHODS: Using the pretrained Mask Region-Based Convolutional Neural Networks model, originally developed for vertebral body segmentation and fracture detection, we fine-tuned the model and added a new module for measuring fracture metrics-compression rate (CR), Cobb angle (CA), Gardner angle (GA), and sagittal index (SI)-from lumbar spine lateral radiographs. These metrics were derived from six-point labeling by 3 radiologists, forming the ground truth (GT). Training utilized 1,000 nonfractured and 318 fractured radiographs, while validations employed 213 internal and 200 external fractured radiographs. The accuracy of the DL algorithm in quantifying fracture features was evaluated against GT using the intraclass correlation coefficient. Additionally, 4 readers with varying expertise levels, including trainees and an attending spine surgeon, performed measurements with and without DL assistance, and their results were compared to GT and the DL model. RESULTS: The DL algorithm demonstrated good to excellent agreement with GT for CR, CA, GA, and SI in both internal (0.860, 0.944, 0.932, and 0.779, respectively) and external (0.836, 0.940, 0.916, and 0.815, respectively) validations. DL-assisted measurements significantly improved most measurement values, particularly for trainees. CONCLUSION: The DL algorithm was validated as an accurate tool for quantifying TL fracture features using radiographs. DL-assisted measurement is expected to expedite the diagnostic process and enhance reliability, particularly benefiting less experienced clinicians.

Neurosarcoidosis involving cervical nerve root with unusual MRI findings: a case report and systematic literature review.

BACKGROUND: Neurosarcoidosis is rare, and among its manifestations, nerve root involvement has been reported in only a few cases. Therefore, magnetic resonance imaging (MRI) findings of neurosarcoidosis, particularly those involving nerve roots, are scarce in the literature. METHODS: We presented the case of neurosarcoidosis involving cervical nerve roots and cranial nerves, alongside a systematic literature review. RESULTS: A 28-year-old female suddenly developed right facial numbness as well as left upper extremity and left hand pain. Initial brain and spine MRI showed a bulging mass of T2 iso-to-high signal intensity in the left Meckel's cave/trigeminal nerve, as well as diffuse enlargement of the right C6 and C7 nerve roots. Follow-up MRI at 2 months revealed a reduction in the size of the initial lesion and the appearance of new similar lesions on the contralateral side (right Meckel's cave, left C3-C8 nerve roots). In particular, the lesions involving the nerve roots demonstrated central enlargement along the nerve roots, without involvement of the adjacent spinal cord. All these lesions exhibited enhancement, leading to the differentiation between sarcoidosis and lymphoma. Sarcoidosis was subsequently confirmed through biopsy of a hilar lymph node. CONCLUSIONS: This report presents a distinctive MRI feature of neurosarcoidosis involving spinal nerve roots, representing the first of its kind, and describes the evolution of MRI findings throughout the clinical course.

Histiocytic sarcoma mimicking localized tenosynovial giant cell tumor in the pediatric foot: A rare case report with MRI Findings.

We present a rare case of histiocytic sarcoma (HS) occurring in the foot of a 12-year-old male, initially misdiagnosed as localized tenosynovial giant cell tumor (TSGCT). HS is an exceptionally uncommon hematologic malignant neoplasm, with its occurrence in children and extranodal sites being even rarer. To our knowledge, this is the first reported case of extranodal HS in the foot, emphasizing comprehensive MRI findings. Initially, the patient was diagnosed with TSGCT based on histological results following surgical resection. However, after recurrence and subsequent surgical resection, histological and immunochemical analyses led to a revised diagnosis of HS. This report focuses on the MRI findings of HS, highlighting the distinctions from localized TSGCT. While both conditions share histopathological similarities, immunohistochemical tests are crucial for accurate diagnosis. The report underscores the importance of differentiating HS for appropriate treatment.

Analysis of clinical factors and ultrasound features associated with COVID-19 vaccine-related axillary lymphadenopathy: A large group study.

PURPOSE: To investigate factors that distinguish COVID-19 vaccine-related axillary lymphadenopathy from malignancy or other etiologies. METHODS: From June 2021 to April 2022, 3859 consecutive female patients had breast and axillary ultrasound (US) at our institution. After exclusions, 592 patients were included in the study. We retrospectively reviewed clinical history and US features of enlarged axillary lymph nodes. Assessed clinical factors included age, vaccination type, dose and vaccination date, and ultrasound features included cortical thickness, shape, marginal irregularity, focal cortical thickening, fatty hilum, and number and anatomic location of enlarged lymph nodes. The seven US features were used to score the severity of lymphadenopathy. Binary logistic models and independent two-sample t-tests were used for statistical analysis. RESULTS: Among 592 patients (mean age 49.3 ± 10.3 years), 406(68.6%), 90(15.2%), 42(7.1), 4(0.7%) and 50(8.4%) patients received Pfizer, AstraZeneca, Moderna, Janssen and cross inoculation of more than one type, respectively. 185(31.3%), 376(63.5%) and 31(5.2%) patients received a first, second and third dose, respectively. The interval between vaccination and US was 30.9 ± 21.5 days. US showed axillary lymphadenopathy (LAP) in 113 patients (19.1%). Clinical factors associated with LAP were age younger than 50 years, mRNA vaccine, first dose and shorter interval(P < 0.05). US features associated with LAP were mean cortical thickness of 4.6 ± 1.63 mm, oval shape (70.8%), smooth margin (53.1%), focal cortical thickening (62.8%) and preserved fatty hilum (84.1%). Using our scoring method, the mean overall score for vaccine-related LAP was 2.45 ± 1.51 points. CONCLUSION: Awareness of influencing factors and sonographic features can help differentiate COVID-19 vaccine-related adenopathy from other etiologies.

Deep learning system for automated detection of posterior ligamentous complex injury in patients with thoracolumbar fracture on MRI.

This study aimed to develop a deep learning (DL) algorithm for automated detection and localization of posterior ligamentous complex (PLC) injury in patients with acute thoracolumbar (TL) fracture on magnetic resonance imaging (MRI) and evaluate its diagnostic performance. In this retrospective multicenter study, using midline sagittal T2-weighted image with fracture (± PLC injury), a training dataset and internal and external validation sets of 300, 100, and 100 patients, were constructed with equal numbers of injured and normal PLCs. The DL algorithm was developed through two steps (Attention U-net and Inception-ResNet-V2). We evaluate the diagnostic performance for PLC injury between the DL algorithm and radiologists with different levels of experience. The area under the curves (AUCs) generated by the DL algorithm were 0.928, 0.916 for internal and external validations, and by two radiologists for observer performance test were 0.930, 0.830, respectively. Although no significant difference was found in diagnosing PLC injury between the DL algorithm and radiologists, the DL algorithm exhibited a trend of higher AUC than the radiology trainee. Notably, the radiology trainee's diagnostic performance significantly improved with DL algorithm assistance. Therefore, the DL algorithm exhibited high diagnostic performance in detecting PLC injuries in acute TL fractures.

High-Resolution Finger MRI: What Should You Look for in Trauma of the Fingers?

The fingers are among the most commonly injured structures in traumatic injuries resulting from sports and work. Finger injuries encompass a broad spectrum of injuries to bone and soft tissues, including tendons, ligaments, and cartilage. The high resolution of 3T MRI with dedicated surface coils allows for optimal assessment of the intricate soft tissue structures of the fingers. There have been several reports on detailed MRI features of the basic anatomy and common pathological findings of the finger and hand. Understanding the normal anatomy and familiarization with common traumatic lesions of the ligaments, tendons, and pulleys of the fingers on high-resolution MRI will allow radiologists to perform accurate preoperative evaluations of traumatic hand lesions. The purpose of this study is to review the normal hand anatomy and common traumatic lesions of the finger on high-resolution MRI and correlate them with surgical findings.

Novel MRI signs of ruptured disc in the cervical spine with intraoperative comparisons.

OBJECTIVES: To evaluate the diagnostic performance of two novel MRI signs for extruded disc (ED) and uncontained ED (ruptured disc, RD) in the cervical spine using intraoperative findings as reference. METHODS: This retrospective study included patients who underwent cervical spine MRI and surgery for disc pathology with intraoperative confirmation of RD from September 1, 2016, to January 31, 2021. Two radiologists determined whether the disc was extruded or ruptured with and without the aid of two novel MRI signs suggesting RD (sign 1: blurred margin of the disc; sign 2: mushroom-shaped disc). The diagnostic performance was analyzed using surgical findings as reference. Intra- and interobserver agreements were measured for each MRI sign. RESULTS: A total of 91 patients totaling 131 discs were enrolled (mean age: 56.02 ± 12.93; range: 26-88; 62 men and 29 women), of whom 62 were surgically confirmed with RD. When the diagnosis was based exclusively on existing ED definitions, ED was diagnosed with 62.9-79.0% sensitivity and 80.2% accuracy, whereas RD was diagnosed with 35.5-45.2% sensitivity and 67.9-71.0% accuracy. However, when the two novel MRI signs were used as an aid in the diagnosis, ED was diagnosed with 95.2-96.8% sensitivity and 84.0-88.5% accuracy, while RD was diagnosed with 95.2-96.8% sensitivity and 84.0-89.3% accuracy. Intra- and interobserver agreement was substantial (k = 00.77-0.86, 0.69-0.79, respectively, p < 0.001). CONCLUSIONS: The detection of two novel MRI signs on preoperative MRI can lead to a more accurate RD diagnosis. KEY POINTS: • The diagnostic sensitivity of MRI for cervical ruptured disc is very low (about 35-45 %) using the standardized definition of lumbar disc nomenclature. • Two novel MRI signs can lead to a more accurate diagnosis of the surgically confirmed ruptured disc in the cervical spine. • These two novel MRI signs showed substantial intra-and interobserver reliabilities.

Utility of Preoperative Shear-Wave Elastography of the Supraspinatus Muscle for Predicting Successful Rotator Cuff Repair: A Prospective Observational Study With MRI Correlation.

BACKGROUND. After rotator cuff tear, properties of the torn muscle predict failed surgical repair. OBJECTIVE. The purpose of our study was to explore the utility of preoperative shear-wave elastography (SWE) measurements of the supraspinatus muscle to predict successful rotator cuff repair, including comparison with MRI-based measures. METHODS. This prospective study included 74 patients (37 men, 37 women; mean age, 63.9 ± 10.0 [SD] years) who underwent rotator cuff repair between May 2019 and January 2021. Patients underwent preoperative clinical shoulder MRI and investigational shoulder ultrasound including SWE using shear modulus. The mean elasticity values of the supraspinatus and trapezius muscles were measured, and the elasticity ratio (i.e., ratio of mean elasticity of supraspinatus muscle to mean elasticity of trapezius muscle) was calculated. The muscular fatty infiltration score (1-3 scale) was recorded on gray-scale ultrasound. On MRI, muscular fatty infiltration was assessed by Goutallier grade (0-4 scale), and muscular atrophy was assessed by the occupation ratio (ratio of cross-sectional areas of supraspinatus muscle and supraspinatus fossa) and by the muscle atrophy grade (0-3 scale). After rotator cuff repair, the surgeon classified procedures as achieving sufficient (n = 60) or insufficient (n = 14) repair. RESULTS. Patients with insufficient repair, versus those with sufficient repair, more commonly exhibited a large (3-5 cm) tear (100.0% vs 50.0%). Patients with insufficient, versus sufficient, repair exhibited higher mean Goutallier grade (3.8 ± 0.4 vs 1.9 ± 1.1), mean muscle atrophy grade (2.0 ± 0.8 vs 0.5 ± 0.7), mean supraspinatus elasticity (44.15 ± 8.06 vs 30.84 ± 7.89 kPa), mean elasticity ratio (3.66 ± 0.66 vs 1.83 ± 0.58), and mean gray-scale fatty infiltration grade (2.86 ± 0.36 vs 1.63 ± 0.66) and showed lower mean occupation ratio (0.3 ± 0.1 vs 0.6 ± 0.1) (all, p < .001). AUC for predicting insufficient repair was 0.945 for Goutallier grade, 0.961 for occupation ratio, 0.900 for muscle atrophy grade, 0.874 for mean elasticity, 0.971 for elasticity ratio, and 0.912 for gray-scale fatty infiltration grade. Elasticity ratio (cutoff ≥ 2.51) achieved sensitivity of 100.0% and specificity of 90.0% for insufficient repair. At multivariable analysis including tear size, the three MRI measures, elasticity ratio, and gray-scale fatty infiltration grade, the only independent predictors of insufficient repair were muscle atrophy grade of 2-3 (odds ratio [OR] = 9.3) and elasticity ratio (OR = 15.7). CONCLUSION. SWE-derived elasticity is higher in patients with insufficient rotator cuff repair; the elasticity ratio predicts insufficient repair independent of tear size and muscle characteristics. CLINICAL IMPACT. Preoperative SWE may serve as a prognostic marker in patients with rotator cuff tear.

Acute to Subacute Spinal Cord Infarction Mimicking Acute Multiple Sclerosis: Usefulness of Diffusion-weighted MRI for Diagnosis.

BACKGROUND: Spinal Cord Infarction (SCI) is difficult to diagnose because of its rarity, unknown etiology, and unestablished diagnostic criteria. Additionally, the timeline of SCI has not been studied in detail, as few studies using Diffusion-Weighted Image (DWI) sequences of the spine of a small target population have been previously conducted. CASE STUDY: A 56-year-old male with underlying arrhythmia suddenly developed visual field defects on the right side, pain in the left upper extremity, and a tingling sensation in the left hand. Brain Magnetic resonance imaging (MRI) revealed acute to subacute stages of multifocal brain infarction. On additional cervical spinal MRI, it showed atypical MRI findings of SCI, considered late acute to early subacute phase, which were similar to those seen in the acute phase of multiple sclerosis (MS). Additional DWI revealed restricted diffusion. From these findings, it could be inferred that the patient's SCI occurred at the same time as the multifocal brain infarctions caused by atrial fibrillation. CONCLUSION: A DWI sequence of spine MRI could be helpful in the diagnosis of acute to subacute phase SCI and in differentiating with acute MS.

COVID-19 vaccine-related axillary lymphadenopathy in breast cancer patients: Case series with a review of literature.

PURPOSE: Lymphadenopathy (LAP) after COVID-19 vaccination in patients with a diagnosis of cancer has been challenging. We analyzed imaging and clinical features from early cases of axillary LAP in six COVID-19 vaccine recipients with a history of breast cancer. METHOD: Among the patients with a history of breast cancer and recent COVID-19 vaccine administration, six patients who showed isolated axillary LAP were gathered. Radiologic features were reviewed from breast ultrasound, chest computed tomography, and breast magnetic resonance imaging. Clinical and pathological information were obtained for analysis. RESULTS: The interval between ultrasound detection of LAP and last COVID-19 vaccine administration ranged from 14 to 28 days (mean 21.67 days). Round shape of the lymph node and irregular cortex were noted in 2 and 0 cases, respectively. Mean maximum cortical thickness, length to width ratio and interval aggravation in maximum cortical thickening were 4.2 mm, 1.34, and 2.81-fold with cut-off value of 3 mm, 1.5, 2.0-fold, respectively. CONCLUSION: We observed axillary LAP ipsilateral to a recent vaccine administration persisting longer than what the Centers for Disease Control and Prevention announced. In our patients, COVID-19 vaccine-related LAP tended to show increased cortical thickness without cortical irregularity. Oncologist as well as radiologist should be familiar with the fact that COVID-19 vaccines, regardless of vaccine type or dosage, can frequently cause ipsilateral axillary LAP, showing some suspicious features more often than others, and can persist longer than anticipated so that both over- and underdiagnosis can be avoided. We report our observations in six patients and provide an exhaustive review of the published literature.

Effect of co-administration of atelocollagen and hyaluronic acid on rotator cuff healing.

BACKGROUND: This study aimed to evaluate the co-administration effect of atelocollagen combined with hyaluronic acid (HA) injections for treatment of full-thickness rotator cuff tear (RCT). METHODS: Eighty patients who underwent arthroscopic rotator cuff repair for full-thickness RCT from March 2018 to November 2019 were enrolled. The patients were randomly allocated to the following groups: combined atelocollagen and HA injection (group I, n=28), only HA injection (group II, n=26), and no injection (group III, n=26). Clinical outcomes were assessed at 3, 6, and 12 months after surgery using the American Shoulder and Elbow Surgeons score, visual analog scale pain score, functional scores (pain visual analog scale, function visual analog score), and range of motion. Magnetic resonance imaging was performed 12 months after surgery to evaluate rotator cuff integrity. RESULTS: Preoperative demographic data and postoperative clinical outcomes did not differ significantly among the three groups (p>0.05). However, in group I, the number of steroid injections after surgery was significantly lower than that in the other groups (p=0.011). The retear rate on follow-up magnetic resonance imaging was significantly higher in group II (9.5%, n=2) and group III (13.6%, n=3) than in group I (0%) (p=0.021). CONCLUSIONS: Co-administration of atelocollagen and HA improves healing of the rotator cuff and increases the integrity of the rotator cuff repair site. This study provides encouraging evidence for use of combined atelocollagen-HA injections to treat patients with full-thickness RCT.

Gray Ramus Communicans Nerve Block for Acute Pain Control in Vertebral Compression Fracture.

Background and Objectives: The current options for acute pain control of vertebral compression fracture include hard brace, vertebroplasty, early surgery, and analgesic injection. We hypothesize that the gray ramus communicans nerve block (GRNB) controls the acute pain experienced during vertebral compression fractures. This study assessed the time course of pain control after injection and evaluated the risk factors affecting pain control failure. Materials and methods: Sixty-three patients (24 male, 66.19 ± 15.17 y) with a thoracolumbar vertebral fracture at the T10-L5 spine, who presented to our hospital from November 2018 to October 2019, were included in this retrospective cohort study. GRNB was performed within 1 week of the trauma. The patients were followed up on days 3, 14, 30, 90, and 180 and assessed with the serial visual analog scale (VAS, resting and motion), Oswestry Low Back Disability (ODI) questionnaire, and Roland-Morris Disability Questionnaire (RDQ). The failure group was defined by the need for an additional block or cement injection after a single GRNB. The failure group's risk factors, such as body mass index, initial thoracolumbar injury classification and severity score, Kummel's disease, age, bone marrow density (BMD), and underlying disease, were analyzed. Results: The motion VAS score improved from preoperative to three months post-procedure, but the resting VAS was affected by the procedure for only three days. The quality of life index improved at postoperative six months. A lower BMD was the only risk that affected treatment failure in the logistic regression analysis (p = 0.0038). Conclusion: The effect of GRNB was maintained even at three months after trauma based on motion VAS results. The only risk factor identified for GRNB failure was lower BMD.

A modified MRI protocol for the increased detection of sacrococcygeal fractures in patients with thoracolumbar junction fractures.

This study aimed to identify concurrent thoracolumbar junction (TLJ) and sacrococcygeal (SC) fractures using a modified MRI protocol and analyze the risk factors associated with tandem fractures. We retrospectively investigated patients with MRI-confirmed TLJ fractures from January 2017 to March 2020. Patients were divided into two study groups: study 1 with a modified MRI protocol and study 2 with a routine protocol. The modified protocol included an extended field of view of sagittal scans in L-spine MRI covering the full SC spine. In study 1, frequency of concurrent TLJ and SC fractures was investigated. And we analyzed risk factors and compared CT and MRI for detecting SC fractures. In study 2, co-occurrence of both fractures was investigated. A total of 176 and 399 patients with TLJ fractures were enrolled in study 1 and 2, then SC fractures were identified in 53 (30.14%) and 36 patients (9.02%), respectively. An axial loading trauma mechanism was a significant risk factor (Odds ratio 7.0, p < 0.001), and MRI was more sensitive than CT in detecting SC fractures (p < 0.002). Thus, a modified MRI protocol was useful to detect the high occurrence of SC fractures in TLJ fractures, which concurrent fractures increased by an axial loading mechanism.

Subscapularis (SSC) tendon tears: diagnostic performance and reliability of magnetic resonance arthrography (MRA) with arthroscopic correlation and comparison with clinical tests.

OBJECTIVE: To evaluate the diagnostic performance and reliability of magnetic resonance of arthrography (MRA) in diagnosis of subscapularis (SSC) tendon tears between two reviewers with varying levels of experience, and compare the results with clinical tests. MATERIALS AND METHODS: SSC tendons were retrospectively evaluated in a total of 272 patients with arthroscopic confirmations. A total of 548 shoulder MRAs were evaluated by two musculoskeletal radiologists, and SSC tendon pathologies were classified into three groups: intact tendon (n = 149), partial-thickness tear (n = 92), or full-thickness tear (n = 31). Diagnostic performance was determined using arthroscopy as gold standard and compared with results of four clinical tests. Intra- and inter-observer reliabilities of two reviewers were evaluated using kappa statistics. RESULTS: For full-thickness tears, mean values of sensitivity, specificity, and accuracy of reviewer 1/reviewer 2 were 71.0%/87.1%, 97.3%/98.3%, and 94.4%/95.5%, respectively. For partial-thickness tears, mean values of sensitivity, specificity, and accuracy were 72.8%/73.4%, 78.3%/81.2%, and 76.5%/78.5%, respectively. Intra- and inter-observer reliabilities for both reviewers were good to very good (k = 0.85/0.93, p < 0.001; k = 0.74-0.89, p < 0.001). For all clinical tests, while specificity was very high, sensitivity was very low and the overall accuracy was also low. CONCLUSION: MRA showed high diagnostic performance for the diagnosis of SSC tendon tears, especially full-thickness tears, with good inter- and intra-observer reliabilities, regardless of the level of experience of the reviewer.

Comparison of Hook Plate Fixation Versus Arthroscopic Coracoclavicular Fixation Using Multiple Soft Anchor Knots for the Treatment of Acute High-Grade Acromioclavicular Joint Dislocations.

PURPOSE: To compare the clinical and radiologic outcomes of arthroscopically assisted coracoclavicular (CC) fixation using multiple soft anchor knots versus hook plate fixation in patients with acute high-grade Rockwood type III and V acromioclavicular (AC) joint dislocations. METHODS: This retrospective study included 22 patients with acute Rockwood type III and V AC joint dislocations who underwent arthroscopic fixation or hook plate fixation surgery between February 2016 and March 2018. Patients were categorized into 2 groups: arthroscopically assisted CC fixation using multiple soft anchor knots group (AR, n = 12) and hook plate fixation group (HO, n = 10). We measured the CC distances (CCDs) and CCD ratio at 6 months, 1 year, and last follow-up postoperatively to compare the radiologic results between the groups. Clinical outcomes were assessed at 1 year postoperatively and at the last follow-up using the Visual Analog Scale, American Shoulder and Elbow Surgeons (ASES) scores, and Shoulder Pain and Disability Index (SPADI) scores, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Magnetic resonance imaging after hook plate removal was used to evaluate the healing ligaments and tendon-bone interface. RESULTS: The patients in the AR group had better ASES, SPADI, and Quick DASH scores than the patients in the HO group at 1 year postoperatively and at last follow-up. The CCD and CCD ratio were significantly better in the AR group than in the HO group at the last follow-up period (P = .007/0.029). Magnetic resonance imaging findings showed grade I in 60% of patients in the AR group and grade III in 60% of patients in the HO group. AC joint arthritic change was observed in 40% of the HO group. CONCLUSIONS: The CC fixation method using multiple soft anchor knots showed satisfactory results and had superior CC ligament healing ability and maintenance of CCD than hook fixation. LEVEL OF EVIDENCE: Level III, retrospective therapeutic comparative investigation.

Idiopathic Hypertrophic Spinal Pachymeningitis with Spinal Cord Lesion: A Case Report.

Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare, diffuse inflammatory fibrosis of the dura mater that can lead to spinal cord compression. Though the optimal treatment is controversial, some reports recommend decompressive surgery and postoperative steroid therapy. However, we encountered a case of pachymeningitis that worsened after decompressive surgery. A 79-year-old woman presented with gait disturbance and bilateral lower extremity weakness that began 6 months prior. She had radiating pain on the C5 and T1 dermatomes and clumsiness in both hands. Magnetic resonance imaging (MRI) revealed diffuse thickening of the posterior longitudinal ligament of C6 to T4/5 and ligamentum flavum of C3/4 to T4/5, causing central canal stenosis and compressive myelopathy. She underwent posterior decompressive laminectomy from C4 to T1 total (T2 subtotal) and cervicothoracic screw fixation. During surgery, we found severe adhesion of the posterior longitudinal ligament and ligamentum flavum to the dura mater. Chronic inflammation with fibrosis and lymphoplasmacytic infiltration were present. After surgery, the patient's motor weakness worsened. Despite steroid treatment, her symptom severity fluctuated. Follow-up MRI obtained 3 months postoperation revealed high signal intensity from C5 to T2, possibly indicating aggravated compressive myelopathy. Thus, in this case, decompressive surgery and steroid therapy were detrimental.

Correlations between the Clinical and Ultrasonographic Parameters of Congenital Muscular Torticollis without a Sternocleidomastoid Mass.

OBJECTIVE: To determine whether ultrasonography at initial presentation can help assess the clinical severity of congenital muscular torticollis (CMT) in infants without a sternocleidomastoid muscle (SCM) mass. MATERIALS AND METHODS: This retrospective study included 71 infants aged less than 12 months (4.1 ± 2.3 months) with non-mass CMT. The clinical severity was divided into three grades (groups 1-3) based on the degree of lateral head bending or cervical rotation. The difference (SCM-D) and ratio (SCM-R) between the maximal thickness of the affected and non-affected SCMs were obtained using transverse and longitudinal ultrasonography. The sonographic echotexture and echogenicity of the involved SCM were reviewed. RESULTS: A significant difference was observed in the SCM-D (0.42 ± 0.30 mm in group 1; 0.74 ± 0.50 mm in group 2; 1.14 ± 0.85 mm in group 3; p = 0.002) and SCM-R (1.069 ± 0.067 in group 1; 1.129 ± 0.087 in group 2; 1.204 ± 0.150 in group 3; p = 0.001) among the groups when measured along the longitudinal but not along the transverse ultrasonography plane. The areas under the curves of the SCM-R and SCM-D measured by longitudinal ultrasonography were 0.731 (p < 0.001) and 0.731 (p < 0.001) for group 1 versus groups 2-3. The proportions of heterogeneous echotexture or hyperechogenicity in the involved SCM did not differ significantly among the three clinical groups (all p > 0.05). CONCLUSION: Ultrasonography can aid in assessing the clinical severity of CMT in infants without an SCM mass at the time of initial diagnosis. The SCM-R and SCM-D helped grade the clinical severity when obtained by longitudinal scan.

Spinal extradural arteriovenous fistula after lumbar epidural injection: CT angiographic diagnosis using 3D-volume rendering.

Spinal extradural arteriovenous fistulas (SEDAVFs) are a rare form of spinal arteriovenous fistulas, the etiology of which has not been completely elucidated. To our knowledge, this is the first reported case of SEDAVF that may have been caused by a spinal procedure. This report describes a 50-year-old female patient who presented with an SEDAVF at the L3/4 level that developed 3 years after a transforaminal epidural block due to disc extrusion, after which she underwent no other operation or trauma. From routine spine magnetic resonance imaging, disc sequestration was considered more likely than vascular malformation. However, on lumbar CT angiography (CTA) and three-dimensional volume rendering images (3D-VRI), the lesion showed good association with arteries of the aortic branches, allowing us to confirm the exact diagnosis of the lesion as SEDAVF. A limitation of 3D-VRI reconstruction is the difficulty in separate visualization of the vertebral body and blood vessels. On follow-up CTA, 3D dual-energy computed tomography (DECT) depicted smaller vascular structures and showed their anatomical relationships to the bone. While spinal angiography has been traditionally known as the gold standard for SEDAVF diagnosis, CTA with 3D-VRI, especially obtained by DECT, allows clinicians to make an accurate diagnosis and treatment plan that are difficult to judge by routine MRI.

Threshold-based quantification of fatty degeneration in the supraspinatus muscle on MRI as an alternative method to Goutallier classification and single-voxel MR spectroscopy.

BACKGROUND: Conventional fat quantification methods for rotator cuff muscles have various limitations, such as inconsistent reliabilities of the Goutallier grades and need for advanced techniques in quantitative MRI sequences. We aimed to examine a threshold-based fat quantification method in the supraspinatus muscle on standard T1-weighted MR images and compare the threshold-based method with Goutallier grades and MR spectroscopy. METHODS: We retrospectively examined 38 symptomatic patients, who underwent T1 and T2-weighted fast spin-echo MR imaging and a single voxel spin-echo MR spectroscopy. The supraspinatus muscle and fossa were manually segmented in T1-weighted sagittal images and clustering-based thresholding was applied to quantify the fat fractions in the segmented areas using custom MATLAB software. Threshold-based fat fractions were compared with the Goutallier grades and MR spectroscopy fat/water ratios. A one-way analysis of variance and Pearson correlation were tested in the MATLAB software. RESULTS: Inter-observer reliability of threshold-based fat fractions for the supraspinatus muscle and fossa were 0.977 and 0.990 respectively, whereas the reliability of the Goutallier grading was 0.798. Threshold-based fat fractions in the supraspinatus fossa were significantly different between various Goutallier grades (one-way ANOVA, p < 0.001). Threshold-based fat fractions in the supraspinatus muscle strongly correlated with the MR spectroscopy fat/water ratio (Pearson correlation R-square = 0.83). CONCLUSIONS: Threshold-based fat quantification on standard T1-weighted MR images was highly reliable and produced comparable results to conventional Goutallier grades and MR spectroscopy fat/water ratios and could serve as an alternative method for accurate fat quantification in rotator cuff muscles.