Multi-focal Lytic Lesions in a Patient with Myelofibrosis: A Case Report.

Myelofibrosis is a rare disorder that is classified as one of the myeloproliferative disorders. This particular disorder results in the abnormal proliferation of hematopoietic stem cells in the bone marrow. In some cases, such as ours, pathologic fractures can occur due to skeletal manifestations. We report on a rare finding of rapidly progressive lytic lesions in multiple regions throughout the body. This presentation of myelofibrosis behaving in a metastatic-like fashion has not been previously described.

A practical radiographic visual estimation technique for the prediction of developmental narrowing of cervical spinal canal.

OBJECTIVES: To determine if visual spinal canal percentage of facet overlap could be used as a rapid visual pre-screening test to detect developmental bony spinal canal narrowing on lateral cervical radiographs. METHODS: Lateral cervical spine radiographs with radiology report documenting developmental narrowing of the spine canal were retrospectively identified. Cohort was supplemented with additional images without such documentation. Utilizing a radiology work station, one reader (Orthopaedics) calculated the Torg ratio at C3-C6. Two readers (Radiology, Primary Care Sports Medicine) visually estimated percentage (≥80, ≥90, 100%) of spinal canal overlaid by facet articulations C3-C6 for all cases independently. Statistical analysis included accuracy tests and kappa test for comparing the gold standard and inter-, intra-observer reliability, respectively. RESULTS: 96 lateral images were included; 25 had abnormal radiology reports. High specificity (range, 91-93%) and true negative predictive values (range, 88-93%) achieved consistent statistical significance for relationship between facet/canal overlap and Torg ratio for both combined and individual data points. Sensitivity values (range, 59-75%) showed a trend toward association, with statistical significance for only the C3 level at 80% overlap. Interobserver agreement was substantial. Intra-observer reliability was moderate to perfect. CONCLUSION: Visual estimation of percentage of facet overlap of the spinal canal is a valid tool to identify individuals with potential developmental narrowing of the spinal canal as a screening prompt to select which patients may need formal calculation utilizing accepted metrics. Advances in knowledge Visual estimation of percentage of facet overlap from lateral radiographs can predict developmental narrowing of cervical spinal canal.

Practicality of exchanging transparent 3D CT for radiography for pelvic fractures.

OBJECTIVE: We assess the utility of transparent 3D reconstructed CT images for evaluation of traumatic pelvic bony injuries compared to traditional radiographs. METHODS: Radiographs and 3D reconstructed CT were anonymized and randomized before review by 4 board certified physicians using a standardized questionnaire and compared to a gold-standard axial CT by a fifth board certified physician. RESULTS: 49 patients were included. We found significant agreement (K=[0.5-0.92], p<0.001) and comparable accuracy (K=[0.36-0.38], p<0.02) and ghost images of radiographs and transparent 3D reconstructed CT without a difference in confidence (p=0.38). CONCLUSION: Transparent 3D reconstructed CT images may be sufficient for pelvic trauma injury without the use of radiographs.

Examining the Potential Use of a Novel Radiographic Scoring System for Determining Surgical Intervention in Diabetic Charcot Arthropathy.

INTRODUCTION: Although Eichenholtz and the Schon systems are commonly used to evaluate foot Charcot arthropathy on radiographs, a novel system with expanded characterization may have added benefit. METHODS: Patients with Charcot arthropathy and foot radiographs were grouped in nonsurgical group 1 (imaging sets at minimum 2-year interval) and surgical group 2 (imaging preceding fusion and/or amputation). Radiographs were scored with Eichenholtz and Schon systems, and a novel scoring system (summation of 0-3 rank for bone density, distention/swelling, debris, disorganization, and dislocation/subluxation). Summative scores of the 2 groups were compared. Differences in scores of each system from serial images of group 1 were compared and average scores from each of the systems for preoperative imaging sets of group 2 were compared. RESULTS: A total of 111 patients were included (group 1, 19 patients; group 2, 92 patients). The novel system provided a broad numerical characterization of the radiographs (range 1-15). Summative scores of the novel system for groups 1 and 2 were statistically different with lower median score in the nonsurgical group (nonsurgical median score 6 vs surgical median score 9). Individual characteristic scores from 4 (distention, debris, disorganization, and dislocation) of 5 categories for the novel system were statistically different, with lower scores for the nonoperative group. The narrower numerical scores from the Eichenholtz and Schon systems did not yield statistically significant results. CONCLUSION: The novel scoring system provides a broad numerical description of radiographic findings in Charcot arthropathy of the foot and has potential advantage for surgical predictive value. LEVELS OF EVIDENCE: Level IV: Retrospective.

Team Approach: Treatment of Diabetic Foot Ulcer.

At any point in time, 3% to 4% of the 29.1 million diabetic patients in the United States (9.3% of the population) will have a foot ulcer. Diabetes-associated foot ulcers and infection lead to >70,000 lower-extremity amputations yearly in the United States. Between one-third and one-half of diabetic patients undergoing a major lower-extremity amputation will die within 2 years after the amputation. Multidisciplinary population health-management strategies have been developed to decrease the rate and magnitude of this important comorbidity in the diabetic population. The goal of the present review is to provide the reader with a framework for the development of a health-care-system strategy for addressing this complex patient population.

Erdheim Chester disease with appendicular skeletal, renal and pleural involvement responding to Zelboraf (BRAF inhibitor) treatment: case report.

Erdheim Chester disease is a rare non-Langerhans cell histiocytosis which may involve multiple organs including bone, soft tissue, lungs, cardiovascular system, kidneys (retroperitoneum), skin, and central nervous system. Bone involvement is most common followed by other organs. This case report describes a 58-year-old man who presented with progressive renal dysfunction presumed due to obstruction. The patient failed multiple urinary tract interventions, and clinical course was complicated by recurrent low-grade fevers, and bilateral knee pain. Advanced imaging and histopathological features on bone biopsy were consistent with Erdheim Chester disease. Molecular studies of tissue showed BRAF V600 mutation. This patient was treated with Zelboraf (vemurafenib) BRAF inhibitor with subsequent improvement in renal and pleural dysfunction as well as decreased histiocytic soft tissue masses on CT.

Is Cervical Sagittal Imbalance a Risk Factor for Adjacent Segment Pathomechanics After Multilevel Fusion?

STUDY DESIGN: A biomechanical study using human spine specimens. OBJECTIVE: The aim of this study was to assess whether the presence of cervical sagittal imbalance is an independent risk factor for increasing the mechanical burden on discs adjacent to cervical multilevel fusions. SUMMARY OF BACKGROUND DATA: The horizontal offset distance between the C2 plumbline and C7 vertebral body (C2-C7 Sagittal Vertical Axis (SVA)) or the angle made with vertical by a line connecting the C2 and C7 vertebral bodies (C2-C7 tilt angle) are used as radiographic measures to assess cervical sagittal balance. There is level III clinical evidence that sagittal imbalance caused by kyphotic fusions or global spinal sagittal malalignment may increase the risk of adjacent segment pathology. METHODS: Thirteen human cadaveric cervical spines (Occiput-T1; age: 50.6 years; range: 21-67) were tested first in the native intact state and then after instrumentation across C4-C6 to simulate in situ two-level fusion. Specimens were tested using a previously validated experimental model that allowed measurement of spinal response to prescribed imbalance. The effects of fusion on segmental angular alignments and intradiscal pressures in the C3-C4 and C6-C7 discs, above and below the fusion, were evaluated at different magnitudes of C2-C7 tilt angle (or C2-C7 SVA). RESULTS: When compared with the pre-fusion state, in situ fusion across C4-C6 segments required increased flexion angulation and resulted in increased intradiscal pressure at the C6-C7 disc below the fusion in order to accommodate the same increase in C2-C7 tilt angle or C2-C7 SVA (P < 0.05). The adjacent segment mechanical burden due to fusion became greater with increasing C2-C7 tilt angle or SVA. CONCLUSION: Cervical sagittal imbalance arising from regional and/or global spinal sagittal malalignment may play a role in exacerbating adjacent segment pathomechanics after multilevel fusion and should be considered during surgical planning. LEVEL OF EVIDENCE: N/A.

Systemic Lead Toxicity.

A 4-year-old girl with slow mentation had increasing knee tenderness and limping gait.

Three-Dimensional Computed Tomography-Based Specimen-Specific Kinematic Model for Ex Vivo Assessment of Lumbar Neuroforaminal Space.

STUDY DESIGN: Cadaveric study to accurately measure lumbar neuroforaminal area and height throughout the flexion-extension range of motion (ROM). OBJECTIVE: Create a new computed tomography (CT)-based specimen-specific model technique to provide insight on the effects of kinematics on lumbar neuroforamen morphology during flexion-extension ROM. SUMMARY OF BACKGROUND DATA: Nerve root compression is a key factor in symptomatic progression of degenerative disc disease because these changes directly affect neuroforaminal area. Traditional techniques to evaluate the neuroforamen suffer from poor accuracy, have inherent limitations, and fail to provide data throughout the ROM. METHODS: Six cadaveric specimens (L1-sacrum) were instrumented with radiopaque spheres and CT scanned. 3-Dimensional reconstructions were made of each vertebra and the sphere locations determined. During kinematic testing, the spheres were located in relation to optoelectronic targets attached to each vertebra. The result was a 3-dimensional representation of the specimen's CT reconstruction moving in response to experimental data. Bony contours of the L2-L3 and L4-L5 neuroforamen were digitized producing continuous neuroforaminal area and height data throughout the ROM. RESULTS: Neuroforaminal area and height linearly increased in flexion and decreased in extension. There was significant correlation between flexion-extension motion and percent change in area (L2-L3: 3.1%/deg, R = 0.94, L4-L5: 2.5%/deg, R = 0.90) and neuroforaminal height (L2-L3: 2.1%/deg, R = 0.95, L4-L5: 1.6%/deg, R = 0.93). Regression analysis showed that the ratio between neuroforaminal height and area is at least 1:1.5 such that a 100% increase in height is associated with an area increase of more than 150%. CONCLUSION: This is the first study to measure lumbar neuroforaminal area and height throughout flexion-extension ROM. The CT-based specimen-specific model technique can accurately evaluate the effect of kinematics on morphological features of the spine. The demonstrated increase in neuroforaminal dimension in flexion is consistent with treatment modalities used in clinical therapies to relieve radicular symptoms. LEVEL OF EVIDENCE: N/A.

Acute fibular sesamoid fracture: one part of the spectrum of sesamoid pathologies.

A 35-year-old male athlete presented with acute pain plantar to the hallux metatarsophalangeal joint following jumping to catch a basketball.

Magnetic resonance imaging of abnormal shoulder pain following influenza vaccination.

The influenza vaccine is increasingly available to the general public and mandated by many employers in the United States. The prevalence of post-vaccination complications is likely on the rise. Complications are well known to general clinicians, but are under-reported in the imaging literature. We present four cases of post-vaccination shoulder pain with magnetic resonance imaging (MRI) findings. An intrasubstance fluid-like signal in deep muscular and/or tendinous structures was the most common finding on MRI of these four cases. Focal bone marrow signal within the humeral head and inflammatory changes in the subacromial/subdeltoid bursa were also observed. The most likely reason for a humeral intraosseous edema-like signal was presumed injection of vaccine substance directly into osseous structures that might lead to focal osteitis. In the published literature, there is little emphasis on the imaging of local injection site complications accompanying influenza vaccination. We intended to increase familiarity of MRI findings in the setting of prolonged or severe clinical symptoms following influenza vaccination through the imaging findings of these four cases.

Imaging of the pediatric athlete: use and overuse.

This article highlights the unique patterns of sports-related injury of the upper extremity that radiologists are likely to encounter in children and adolescents. The injuries are classified as acute "use" injuries or chronic "overuse" injuries, and reviewed separately for the shoulder, elbow, and wrist. Recommendations for imaging strategies are provided and characteristic imaging findings are discussed and illustrated.

Magnetic resonance arthrography of the upper extremity.

Although magnetic resonance arthrography is not indicated for every clinical scenario, capsular distention can significantly improve visualization of intra-articular pathologic conditions. With attention to technique, intraarticular injection can be completed successfully with little patient discomfort. This article provides details of the technique for injection of the shoulder, the elbow, and the wrist for optimization of magnetic resonance imaging.