Blunt traumatic posterior cord syndrome.

INTRODUCTION: Posterior cord syndrome (PCS) is rare and insufficiently assessed in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). CASE PRESENTATION: A 39-year-old male was involved in a motorcycle collision and presented with paresthesia of the entire body, neck pain, subjective right arm weakness, and loss of position sense in all extremities. Imaging of the cervical spine revealed fractures of the upper cervical spine including a teardrop fracture and hangman fracture. Patient underwent anterior cervical interbody fusion and plating and halo orthosis. He ultimately regained near full function. Follow-up imaging clearly depicted the traumatic lesion to the level of the posterior spinal cord. DISCUSSION: PCS is uncommon, but may be underdiagnosed. We would like to emphasize the importance of a full neurological exam in order to properly diagnose and manage patients with PCS. Our case is unique since we were able to anatomically delineate the focus of spinal cord injury to the posterior column on follow up MRI at 10 months. Therefore, a delayed MRI obtained sub-acutely may facilitate the anatomical diagnosis of PCS.

Effect of Extrinsic Warming of Low-Osmolality CT Contrast Media (Iohexol 350) on Extravasations and Patient Reaction Rates: A Retrospective Study.

BACKGROUND. Extrinsic warming of iodinated CT contrast media to body temperature reduces viscosity and injection pressures. However, studies examining the effect of extrinsic warming on clinical adverse events are limited in number and provide conflicting results. Therefore, consensus practice recommendations have been sparse. OBJECTIVE. The purpose of this study is to compare rates of extravasation, allergic and allergiclike reactions, and physiologic reactions between iohexol 350 mg I/mL warmed to body temperature (37°C) versus this agent maintained at room temperature. METHODS. This retrospective study compared adult patients who received CT examinations using IV iohexol 350 that had either been warmed to body temperature or maintained at room temperature. At our institution, contrast media had historically been warmed to body temperature before a protocol change unrelated to this investigation. Information on the patient and CT examination was extracted from the electronic medical record. Adverse events, including extravasations, allergic and allergiclike reactions, and physiologic reactions, were compared between groups. RESULTS. A total of 3939 patients received contrast media warmed to body temperature before the protocol change; 3933 patients received contrast media at room temperature after the protocol change. The body temperature group experienced 11 (0.28%; 95% CI, 0.14-0.50%) adverse events, all extravasations; the allergic and allergic-like reaction rate was 0.00% (97.5% CI, 0.00-0.09%). The room temperature group experienced 17 (0.43%; 95% CI, 0.25-0.69%) adverse events: 13 (0.33%; 95% CI, 0.17-0.56%) extravasations and four (0.10%; 95% CI, 0.03-0.26%) allergic and allergiclike reactions. No physiologic reaction occurred in either group. The two groups were not different in terms of overall reaction rate (p = .19), extravasation rate (p = .69), allergic and allergiclike reaction rate (p = .06), or physiologic reaction rate (p > .99). Logistic regression adjusting for patient and CT characteristics (age, sex, conventional CT vs CTA, contrast media volume, injection location) showed no significant association of patient group and adverse reaction rate (odds ratio, 2.19; 95% CI, 0.68-7.00). Multivariable regression modeling showed an excess of 0.27 adverse events per 100 patients within the room temperature group, which is below a 0.6% noninferiority margin. CONCLUSION. The data suggest that maintaining iohexol 350 at room temperature is noninferior to warming the agent to body temperature before injection. CLINICAL IMPACT. The resources involved to prewarm iohexol 350 before injection may not be warranted.

Location of Traumatic Cranial Epidural Hematoma Correlates with the Source of Hemorrhage: A 12-Year Surgical Review.

BACKGROUND: Epidural hematoma (EDH) can result in a catastrophic outcome of traumatic brain injury. Current management guidelines do not consider the source of hemorrhage in decision making. The purpose of this study was to examine the relationship between EDH location and the source of hemorrhage. METHODS: We report retrospectively reviewed, prospectively obtained surgical data of patients with acute traumatic cranial EDH treated between 2007 and 2018. Computed tomography (CT) scans were used to categorize EDH location as lateral or medial. The source of hemorrhage was identified intraoperatively by a single surgeon. RESULTS: Overall, of 92 evacuated EDHs (in 87 patients), 71 (77.2%) were in the lateral location. Arterial bleeding was the cause of EDH in 63.4% of the lateral EDHs and 9.2% of the medial EDHs (P < 0.0001). In the cases where surgery was done primarily to treat EDH, 65.3% had an arterial bleed source (P < 0.0001). In those treated for primary reasons other than EDH evacuation, 75% had a venous bleed source (P = 0.002). CONCLUSIONS: The location of EDH correlates with the source of hemorrhage. The decision to operate on EDH may be influenced by this factor.

Natural History of a Patient with Sacral Chordoma: Case Report and Literature Review.

BACKGROUND: Chordomas are rare, slow-growing, locally aggressive, malignant tumors of the spine. Chordomas are conventionally treated with surgical resection with or without radiation. There is an absence of literature documenting the natural history of a primary sacral chordoma. CASE DESCRIPTION: A 65-year-old man presented with rectal pain, constipation, urinary and fecal incontinence, S1 radiculopathy, and a palpable rectal mass. A needle biopsy confirmed the pathologic diagnosis of sacral chordoma. The patient declined to have surgery because of the surgical risks involved. He was managed conservatively with supportive care only. The patient was routinely followed in clinic and had a subjective and objective excellent quality of life with adequate pain management. Meanwhile, his neurologic status did not deteriorate. During follow-up, some posterolateral aspects of the chordoma regressed. However, the bulk of the lesion continued to slowly progress. The patient survived for 7.5 years. He eventually succumbed to urosepsis and new-onset peritoneal metastasis. CONCLUSIONS: To our knowledge, the patient is the only documented case in the literature of an untreated biopsy-proven sacral chordoma. The patient's tumor was intended for resection, and therefore comparable with data from treated chordomas. The patient's survival is similar to the median survival in treated chordomas. The patient's survival was despite negative prognosticators, such as advanced age of the patient and high sacral location above S2.

Risk Factors for Late Screening Mammography.

BACKGROUND: Breast cancer has the highest incidence of cancers in women in the United States. Previous research has shown that screening mammography contributes to reduced breast cancer mortality. This study aimed to clarify why late screening might occur in an at-risk population. MATERIALS AND METHODS: This study was a prospective cross-sectional study including 758 patients presenting to our radiology department for routine screening mammography who completed a 30-question survey regarding personal characteristics and mammography history. Univariate and multivariate logistic regression were performed to determine whether survey responses correlated with late screening. RESULTS: Of the 758 patients, 184 (24%) were noncompliant with screening mammography guidelines. Risk factors for late screening included younger age (P = 0.001), white race/ethnicity (P = 0.03), self-reported lack of financial means or health insurance (P = 0.005), lack of satisfaction with a previous mammogram experience (P = 0.001), inadequate mammography education by a physician (P = 0.001), and lack of awareness/comprehension of screening mammography guidelines (P = 0.002). CONCLUSION: Many factors contribute to late screening mammography. Although some are outside physician control, others can be influenced: patient education regarding screening mammography guidelines, and patient satisfaction with the mammography experience. This study highlights the importance of communication with and education of patients.

Epidural venous plexus engorgement due to inferior vena cava thrombosis resulting in cauda equina syndrome: Case report and literature review.

BACKGROUND: Epidural venous plexus congestion at L5-S1 due to inferior vena cava (IVC) thrombosis led to an acute cauda equina syndrome (CES). Laminectomy to rule out an epidural abscess, allowing for resection of the dilated veins, led to immediate symptom resolution. CASE DESCRIPTION: A 47-year-old male presented with acute urinary retention and left greater than right lower extremity paresis of 2 weeks duration. Magnetic resonance imaging (MRI) revealed a contrast-enhancing space-occupying anterior epidural L5-S1 level lesion resulting in cauda equina compression. As the patient was septic, he underwent an emergency laminectomy for a presumed epidural abscess. Intraoperative findings, however, documented a markedly dilated epidural venous plexus secondary to a newly diagnosed IVC thrombus. One day postoperatively, the patient was symptom-free and neurologically intact. CONCLUSIONS: Here we report a patient who uniquely presented with a CES characterized by acute paraparesis. This was attributed to a massively engorged anterior lumbar epidural venous plexus attributed to newly diagnosed IVC thrombus.

Computed tomography localization of the appendix in the pediatric population relative to the lumbar spine.

BACKGROUND: Computed tomography (CT) is commonly used to evaluate suspected acute appendicitis. Although very effective, CT uses ionizing radiation, exposing patients to an increased risk of cancer. OBJECTIVE: This study assessed the potential for decreasing the field of view of the CT (and therefore the dose to the patient) in the evaluation of suspected acute appendicitis in children. MATERIALS AND METHODS: This study was a retrospective review of prospectively collected data from 212 consecutive patients who underwent CT for suspected acute appendicitis. The most superior aspect of the appendix with respect to vertebral bodies was recorded. Age, gender and diagnosis (negative, acute appendicitis or alternative diagnosis) were noted. RESULTS: The appendix was visualized in 190 of 212 subjects (89.6%). Overall, all visualized appendixes were located at or below the level of L1. Sixty-three of the subjects (29.7%) were diagnosed with acute appendicitis via CT imaging. All appendixes in patients with acute appendicitis were located at or below the level of the L3 vertebral body, predominating at the level of L5. Six subjects (3.1%) received alternative diagnoses, including pneumonia, pyelonephritis, small bowel obstruction and infected urachal cyst. There were no differences in appendix location with regard to diagnosis, gender, or age (P=0.664, 0.748 and 0.705, respectively). CONCLUSION: CT field of view may be decreased to the level of L1 or L3 superiorly, decreasing radiation dose without affecting the rate of appendix visualization.