Paravertebral venous plexus distention (Batson's): an inciting etiologic agent in lumbar radiculopathy as observed by venous angiography.

Can the paravertebral plexus of veins adjacent to the spinal nerve root within the narrow confines of the lateral neural canal be a collateral generator of radicular pain when no other evidence of spinal pathology is evident? A patient with complaints of intractable lumbar radiculopathy and an otherwise unremarkable clinical neuromusculoskeletal examination, as well as normal imaging and electrodiagnostic studies, is reviewed with special reference to symptomatic and paravertebral venous responses to both a Valsalva maneuver and dipyridamole infusion as imaged by magnetic venous angiography.

Computed tomography-guided biopsy of the spine. A review of 103 patients.

STUDY DESIGN: A retrospective study of 103 computed tomography-guided biopsies of the spine. These represent a consecutive series of patients with spinal lesions or disorders observed over a 32-month period. OBJECTIVES: To determine the diagnostic accuracy and clinical usefulness of computed tomography-guided biopsies with respect to major influencing variables. SUMMARY OF BACKGROUND DATA: Computer tomographic-guided biopsy of the spine is considered a safe, accurate, and relatively inexpensive examination technique. A study comparing its diagnostic accuracy with respect to all the variables of age, gender, radiographic appearance, spinal level, tissue type, or pathologic diagnosis has not been done. METHODS: Biopsy specimens were sent for cytologic and histologic analysis. Bacteriologic studies were performed when clinically indicated. The biopsy results were analyzed for adequacy and diagnostic accuracy, i.e., the ability to generate a tissue sample adequate for pathologic examination and one that yields diagnostic information. RESULTS: The mean age of patients was 60 years, with a range of 4-91 years. The spines of 52 males and 51 females were studied. There were eight cervical, 28 thoracic, 53 lumbar, and 14 sacral lesions used as biopsy sites. The radiographic appearance of spinal lesions were lytic in 74 cases, blastic in four cases, and mixed in two cases. Tissues undergoing biopsy included bone (63 cases), soft tissue (35 cases), and mixed specimens (five cases). The pathologic examinations revealed 18 infections, 23 primary neoplasms, 34 metastases, and 19 normal tissues. An adequate specimen for pathologic examination was obtained in 90 biopsies (87%). A diagnosis was achieved in 67 of 94 patients (71%). Diagnostic rates obtained in thoracic level biopsies were lower than those from biopsies of other spinal levels (P = .007). CONCLUSION: Computed tomography-guided biopsy is an important tool in the evaluation of spinal lesions. A positive biopsy result may preclude the need for open surgical intervention. This study included one of the largest series of patients in the medical literature. In addition, it determined the diagnostic rates of this procedure with respect to the major influencing variables. Thoracic-level biopsies have a diagnostic rate that is significantly lower than that of other spinal levels. No significant correlation was found between diagnostic accuracy and age, gender, radiographic appearance, tissue type, or eventual diagnosis.

Spinal pedicle fixation. Confirmation of an image-based technique for screw placement.

Although many advances in the technique of pedicle screw insertion have been made, there still exist unacceptable rates of perforations through the pedicle cortex. Successful placement of a pedicle screw requires accurate identification of the entry point, correct transverse and sagittal plane angulation, safe preparation of a pilot hole, and appropriate depth of insertion. The authors propose that a technique of pedicle screw insertion using posteroanterior image intensification angled in the axis of the pedicle to define the entry point and guide insertion would improve the accuracy of this procedure. This study tests the accuracy of pedicle screw placement using this technique. Ninety pedicle screws were placed in human cadaveric lumbar spines. All specimens were then dissected and split longitudinally to assess accuracy of pedicle insertion by both visual and palpatory means. Five of 90 (5.5%) pedicle screws were found to have perforated the pedicle. Three of these were at L1, two of which were due to the transverse pedicle diameter being smaller than the screw diameter. Therefore, a 3.4% incidence of pedicle perforation due to malpositioning and a 2.1% incidence of pedicle perforation secondary to pedicle/screw size discrepancy was determined. This technique may lead to significant improvements over recently reported rates of pedicle screw perforations; however, this in vitro condition eliminated many potentially complicating factors that might be encountered in the clinical setting.

Intracranial gumma mimicking a tuber cinereum tumor.

The brain magnetic resonance (MR) and computed tomography (CT) finding in a 37-year-old patient with a history of persistent headache and secondary hypogonadism and with a strongly positive blood and cerebrospinal fluid (CSF) fluorescent treponemal antibody-absorption (FTA-ABS) test is reported. A focal enhancing mass was demonstrated involving the tuber cinereum. The mass was markedly reduced after the completion of a course of intravenous administration of penicillin G treatment. This case is interesting because of its rare incidence and unique neuroradiological findings.

Association of vertebral end plate fracture with pediatric lumbar intervertebral disk herniation: value of CT and MR imaging.

A retrospective review of the radiologic findings in 31 patients less than 21 years old who underwent laminotomy for lumbar disk herniation revealed six cases of associated avulsion fracture of the vertebral end plate, a prevalence of 19%. All fractures were found in the 14-17-year-old subgroup (six of 19), a prevalence of 32%. In four patients, plain radiographs did not reveal the fracture. Computed tomographic (CT) findings were diagnostic in all six cases. Magnetic resonance (MR) images, obtained in three patients, demonstrated the avulsed cortical fragment and what are assumed to be the attached Sharpey fibers. On sagittal MR images, these structures had a configuration with the appearance of a "Y" or "7". Four of these six patients underwent bilateral laminotomies. The need for more extensive surgical resection may not be apparent at plain radiography or myelography but can be predicted with CT and MR imaging.

Night pain associated with diminished cardiopulmonary compliance. A concomitant of lumbar spinal stenosis and degenerative spondylolisthesis.

Twenty patients admitted to hospital with congestive heart failure were evaluated for severe concomitant lumbosacral and leg pain. In each instance the discomfort was worse at night and progressively decreased with a resolution of the pulmonary edema. Neurologic and electromyographic examinations in all but four patients were normal with reflexes, strength and straight leg raising testing normal. An absent Achilles reflex was recognized in two, a diminished knee jerk reflex in one and in a third, weakness in the extensor hallucis longus. Lumbar spinal stenosis was identified in all of the patients with a concomitant degenerative spondylolisthesis present in nine instances and in an additional two a spondylolisthesis with interruption of the neural arch. It is theorized that diminished right heart compliance can induce a sufficient increase in venous volume and pressure within the paravertebral plexus of Batson to acutely exacerbate a chronic lumbar spinal stenosis. In support of this hypothesis, the multiple factors involved in the pathomechanics and physiology of lumbar radiculopathy, spinal stenosis and the role of the paravertebral plexus of veins are examined. Specifically, their response to altered volume and pressure gradients tending to induce venous "creep" as well to alterations in posture and diurnal cycles are reviewed.

Tc-99m glucoheptonate brain scintigraphy: a clinical comparison between one- and two-hour delayed images: concise communication.

Sixteen patients with known cerebral disease had one- and two-hour delayed brain scans following intravenous injection of 15 mCi of technetium-99m glucoheptonate. No abnormalities were seen on the two-hour images that were not detected on the one-hour delayed scan. There were two false negative scans. Of the 14 true positives, 10 were visualized equally well in the one-and two-hour delayed images, two were better seen on two-hour images, and two were better on one-hour scans. As no difference in lesion detection was found, consideration of reducing the post-dose delay time two hours to one seems warranted.

Use of a vaginal tampon in the diagnosis of vesicovaginal fistulae.

A technique for the demonstration of vesicovaginal fistula during excretory urography is described. The method consists of inserting a vaginal tampon prior to the administration of contrast material for excretory urography.