Differences in MRI measurements of lateral recesses and foramina in degenerative lumbar segments in upright versus decubitus symptomatic patients.

OBJECTIVE: To evaluate differences in measurements of the lateral recesses and foramina in degenerative lumbar segments on MR images in symptomatic patients obtained with the patient standing versus lying down and to analyze the relationship between possible differences and patients' symptoms. MATERIAL AND METHODS: We studied 207 disc levels in 175 patients aged between 17 and 75 years (median: 47 years) with low back pain. All patients underwent MRI in the decubitus position with their legs extended, followed by MRI in the standing position. We calculated the difference in the measurements of the lateral recesses (in mm) and in the foramina (area in mm2 and smallest diameter in mm) obtained in the two positions. To eliminate the effects of possible errors in measurement, we selected cases in which the difference between the measurements obtained in the two positions was ≥10%; we used Student's t-tests for paired samples to analyze the entire group and subgroups of patients according to age, sex, grade of disc degeneration, and postural predominance of symptoms. RESULTS: Overall, the measurements of the spaces were lower when patients were standing. For the lateral recesses, we observed differences ≥10% in 68 (33%) right recesses and in 65 (31.5%) left recesses; when patients were standing, decreases were much more common than increases (26% vs. 7%, respectively, on the right side and 24% vs. 7.5%, respectively, on the left side; p < 0.005). For the foramina, decreases in both the area and in the smallest diameter were also more common than increases when patients were standing: on the right side, areas decreased in 23% and increased in 4%, and smallest diameters decreased in 20% and increased 6%; on the left side, areas decreased in 24% and increased in 4%, and smallest diameters decreased in 17% and increased in 8% (p < 0.005). Considering the group of patients in whom the postural predominance of symptoms was known, we found significant differences in patients whose symptoms occurred predominantly or exclusively when standing, but not in the small group of patients whose symptoms occurred predominantly while lying. We found no differences between sexes in the changes in measurements of the recesses or foramina with standing. The differences between the measurements obtained in different positions were significant in patients aged >40 years, but not in younger groups of patients. Differences in relation to the grade of disc degeneration were significant only in intermediate grades (groups 3-6 in the Griffith classification system). CONCLUSION: MRI obtained with patients standing can show decreases in the lateral recesses and foramina related to the predominance of symptoms while standing, especially in patients aged >40 years with Griffith disc degeneration grade 3-6, thus providing additional information in the study of patients who have low back pain when standing in whom the findings on conventional studies are inconclusive or discrepant with their symptoms. Further studies are necessary to help better define the value of upright MRI studies for degenerative lumbar disease.

Differences in MRI measurements of lateral recesses and foramina in degenerative lumbar segments in upright versus decubitus symptomatic patients. / Cambios en recesos laterales y forámenes en segmentos degenerativos lumbares de pacientes sintomáticos estudiados mediante resonancia magnética en decúbito y bipedestación.

OBJECTIVE: To evaluate differences in measurements of the lateral recesses and foramina in degenerative lumbar segments on MR images in symptomatic patients obtained with the patient standing versus lying down and to analyze the relationship between possible differences and patients' symptoms. MATERIAL AND METHODS: We studied 207 disc levels in 175 patients aged between 17 and 75 years (median: 47 years) with low back pain. All patients underwent MRI in the decubitus position with their legs extended, followed by MRI in the standing position. We calculated the difference in the measurements of the lateral recesses (in mm) and in the foramina (area in mm2 and smallest diameter in mm) obtained in the two positions. To eliminate the effects of possible errors in measurement, we selected cases in which the difference between the measurements obtained in the two positions was ≥10%; we used Student's t-tests for paired samples to analyze the entire group and subgroups of patients according to age, sex, grade of disc degeneration, and postural predominance of symptoms. RESULTS: Overall, the measurements of the spaces were lower when patients were standing. For the lateral recesses, we observed differences ≥10% in 68 (33%) right recesses and in 65 (31.5%) left recesses; when patients were standing, decreases were much more common than increases (26% vs. 7%, respectively, on the right side and 24% vs. 7.5%, respectively, on the left side; p<0.005). For the foramina, decreases in both the area and in the smallest diameter were also more common than increases when patients were standing: on the right side, areas decreased in 23% and increased in 4%, and smallest diameters decreased in 20% and increased 6%; on the left side, areas decreased in 24% and increased in 4%, and smallest diameters decreased in 17% and increased in 8% (p<0.005). Considering the group of patients in whom the postural predominance of symptoms was known, we found significant differences in patients whose symptoms occurred predominantly or exclusively when standing, but not in the small group of patients whose symptoms occurred predominantly while lying. We found no differences between sexes in the changes in measurements of the recesses or foramina with standing. The differences between the measurements obtained in different positions were significant in patients aged>40 years, but not in younger groups of patients. Differences in relation to the grade of disc degeneration were significant only in intermediate grades (groups 3-6 in the Griffith classification system). CONCLUSION: MRI obtained with patients standing can show decreases in the lateral recesses and foramina related to the predominance of symptoms while standing, especially in patients aged>40 years with Griffith disc degeneration grade 3 to 6, thus providing additional information in the study of patients who have low back pain when standing in whom the findings on conventional studies are inconclusive or discrepant with their symptoms. Further studies are necessary to help better define the value of upright MRI studies for degenerative lumbar disease.

[Tumor thrombosis of the left renal vein and inferior vena cava secondary to renal cell carcinoma. Findings with ultrasonography, Echo-Doppler, and computerized tomography]. / Trombosis tumoral de la vena renal izquierda y vena cava inferior secundaria a carcinoma de células renales. Hallazgos en ecografía, ECO-doppler y tomografía computerizada.

Renal cell carcinoma represents a 2.5-3% of all neoplastic processes, usually seen un patients older than 50 years. 60-75% are resectable at diagnosis, representing local or metastatic advanced disease the rest of them. This tumor tends to spread intravascularly, leading to tumoral thrombosis within the inferior caval vein (ICV) and renal vein 4-10% and 21-35% of cases, respectively. As the only effective treatment is surgical resection, preoperative determining of the thrombus extension is crucial. Thus, an accurate radiological study including ultrasound, doppler sonography, computed tomography and/or Magnetic Resonance, is key for these patients. We present a 49 year-old patient with renal cell carcinoma and associated tumoral thrombosis in inferior caval vein and left renal vein; we provide the most significant figures, explaining its most characteristic radiological findings.

Trombosis tumoral de la vena renal izquierda y vena cava inferior secundaria a carcinoma de células renales. Hallazgos en ecografía, eco-doppler y tomografía computerizada / Tumoral thrombosis in both left renal vein and lower cava vein secondary to renal cell carcinoma. Ultrasonography, eco-doppler and computerized tomography findings

El carcinoma de células renales representa un 2,5-3 por ciento de todos los cánceres, siendo más frecuente en pacientes mayores de 50 años. De ellos, el 60-75 por ciento son resecables al momento del diagnóstico, presentando el resto de los casos enfermedad avanzada local o metastásica. Este tumor tiende a extenderse intravascularmente, produciendo trombosis tumoral en la vena cava inferior y vena renal en un 4-10 por ciento y 2135 por ciento de los casos, respectivamente. Dado que el único tratamiento efectivo es la resección quirúrgica, resulta prioritario determinar la extensión de la trombosis tumoral previamente a la cirugía. Por tanto, en estos pacientes es fundamental un cuidadoso estudio radiológico que incluya, al menos, ecografía, eco-doppler, TC y/o RM abdominal. Presentamos el caso de un paciente de 49 años con carcinoma renal y trombosis tumoral secundaria de la vena renal izquierda y de la VCI, aportando las imágenes más significativas y comentando sus principales hallazgos radiológicos (AU)