Diagnostic features of sciatica without lumbar nerve root compression.

STUDY DESIGN: Retrospective case series review of patients showing sciatica without radiographic evidence of nerve root compression. OBJECTIVE: To elucidate clinical features of sciatica caused by extralumbar spinal lesions. SUMMARY OF BACKGROUND DATA: Sciatica caused by extralumbar spinal lesions has been reported sporadically. Given the paucity of case series studies, however, the pathology and clinical features of such sciatica remain not fully understood. METHODS: Sixty-one patients who presented with persistent sciatica were examined with lumbar magnetic resonance (MR) imaging. Of these, the records of patients showing no detectable nerve root compression in MR images were reviewed with respect to demographics, neurologic status, further diagnostic procedures, treatments, and treatment outcomes. RESULTS: Of 61 patients, 10 (16.4%) showed sciatica and a lack of nerve root compression in the lumbar MR imaging. In demographics, there was female sex dominance (9 patients) and right side preference (9 patients). Eight patients exhibited sensory disturbance beyond a single dermatome. Piriformis syndrome was diagnosed in 3 patients and 5 patients were considered to have sacral plexus pathologies associated with gynecologic conditions such as ectopic endometriosis, ovarian cyst, and pregnancy. A review of the literature also supported the right side preference in sciatica associated with gynecologic conditions. CONCLUSIONS: Piriformis syndrome and gynecologic conditions account for most cases of extralumbar spinal sciatica. Female sex, right side involvement, and overlapping sensory disturbance are suggestive of extralumbar spinal sciatica associated with gynecologic conditions.

Debridement arthroplasty for primary osteoarthritis of the elbow. Surgical technique.

BACKGROUND: Formal and more aggressive debridement procedures have been described for the treatment of advanced primary osteoarthritis of the elbow. However, the literature contains little information on the results of long-term follow-up. The purpose of this study was to evaluate outcomes at an average of ten years after debridement arthroplasties performed through a posteromedial approach. METHODS: Thirty-three elbows with primary osteoarthritis in thirty-two patients treated with debridement arthroplasty were available for clinical follow-up evaluation. Through a posteromedial approach, the flexor-pronator muscle origin was reflected from the medial epicondyle and the joint was opened, preserving the anterior oblique bundle of the medial collateral ligament. The ulnar nerve was decompressed in all patients. Osteophytes were removed from the anterior, medial, and posterior sides of the elbow joint. In nine elbows, osteophytes from the lateral compartment were removed through an additional lateral approach. The mean age at the time of the operation was fifty years. The mean duration of follow-up was 121 months, and nineteen elbows were followed for more than ten years. RESULTS: The mean preoperative limitation of extension of 31 degrees was reduced to 24 degrees , and the mean preoperative flexion of 101 degrees improved to 118 degrees (p < 0.001). The mean arc of movement improved by 24 degrees . The mean Japanese Orthopaedic Association elbow score was 83 points at the latest follow-up evaluation compared with 60 points preoperatively (p < 0.001). Of twenty-five patients who had performed heavy manual work, nineteen (76%) returned to their previous job or an equivalent job. At the latest examination of the nineteen elbows followed for more than ten years, the limitation of extension was found to have increased by 7 degrees compared with the limitation noted at one year (p < 0.009); the mean arc of flexion had remained the same. Three elbows required a reoperation. Overall, 85% of the elbows were satisfactory to the patients. CONCLUSIONS: Debridement arthroplasty through a posteromedial approach can provide stable and reliable long-term results with regard to relief of pain, gains in range of motion, and the patient's ability to return to his or her previous occupation. In our series, a modest loss of extension was observed at ten years, whereas the arc of flexion remained consistent.

Orthography effect on brain activities in the working memory process for phonologically ambiguous syllables: a functional magnetic resonance imaging study using Japanese speakers.

English /l/ and /r/ sounds are not distinctive for Japanese speakers and they are loosely associated with corresponding graphemes. The purpose of this study was to investigate the brain activities in the memory process for the graphemes containing 'l' and 'r' in Japanese speakers. Two functional magnetic resonance imaging (at 1.5 T) experiments was conducted using syllable working memory tasks. The task using 'l' and 'r' syllables was coupled with either task using 'b' and 'n' syllables (l/r versus b/n block-designed experiment), or 'd' and 'n' syllables (l/r versus d/n block-designed experiment). The results revealed that the l/r working memory tasks induced augmented activation specifically in the right middle frontal gyrus (BA9, 46) and the right superior parietal lobule (BA7), compared with the b/n or d/n tasks. The results indicate that a visually-biased memory process (i.e. excessive visual rehearsal or monitoring) was executed for phonologically ambiguous syllables. Significant activation in the left inferior frontal gyrus was not observed only in the b/n task, probably because articulatory contrast between /b/ and /n/ sounds was highly clear for Japanese speakers.

Preliminary study of tagged MR image velocimetry in a replica of an intracranial aneurysm.

Flow dynamics in intracranial aneurysms and their adjacent parent vessels play important roles in the development and rupture of intracranial aneurysms. Combined with tagged MR imaging and the use of particle image velocimetry software, tagged MR image velocimetry reveals flow vectors, vorticity, and shear strains at each location in the aneurysm replica every 9 milliseconds. This technique is a promising and noninvasive technique for assessing hemodynamics in intracranial aneurysms.

Débridement arthroplasty for primary osteoarthritis of the elbow.

BACKGROUND: Formal and more aggressive débridement procedures have been described for the treatment of advanced primary osteoarthritis of the elbow. However, the literature contains little information on the results of long-term follow-up. The purpose of this study was to evaluate outcomes at an average of ten years after débridement arthroplasties performed through a posteromedial approach. METHODS: Thirty-three elbows with primary osteoarthritis in thirty-two patients treated with débridement arthroplasty were available for clinical follow-up evaluation. Through a posteromedial approach, the flexor-pronator muscle origin was reflected from the medial epicondyle and the joint was opened, preserving the anterior oblique bundle of the medial collateral ligament. The ulnar nerve was decompressed in all patients. Osteophytes were removed from the anterior, medial, and posterior sides of the elbow joint. In nine elbows, osteophytes from the lateral compartment were removed through an additional lateral approach. The mean age at the time of the operation was fifty years. The mean duration of follow-up was 121 months, and nineteen elbows were followed for more than ten years. RESULTS: The mean preoperative limitation of extension of 31 degrees was reduced to 24 degrees, and the mean preoperative flexion of 101 degrees improved to 118 degrees (p < 0.001). The mean arc of movement improved by 24 degrees. The mean Japanese Orthopaedic Association elbow score was 83 points at the latest follow-up evaluation compared with 60 points preoperatively (p < 0.001). Of twenty-five patients who had performed heavy manual work, nineteen (76%) returned to their previous job or an equivalent job. At the latest examination of the nineteen elbows followed for more than ten years, the limitation of extension was found to have increased by 7 degrees compared with the limitation noted at one year (p < 0.009); the mean arc of flexion had remained the same. Three elbows required a reoperation. Overall, 85% of the elbows were satisfactory to the patients. CONCLUSIONS: Débridement arthroplasty through a posteromedial approach can provide stable and reliable long-term results with regard to relief of pain, gains in range of motion, and the patient's ability to return to his or her previous occupation. In our series, a modest loss of extension was observed at ten years, whereas the arc of flexion remained consistent.

Manipulo-spatial processing of ideographic characters in left-handers: observation in fMRI.

It has been suggested that left-handers have a cerebral ambilaterality for language representation. Specifically, the use of the right hand for writing may have a specific effect on the cerebral organization in left-handers. In an investigation of the relationship between motor and visual language procedures, functional magnetic resonance imaging at three tesla was conducted during stroke counting of kanji (Japanese ideographic characters) in six left-handers who usually write with their right hand. Two types of stimulus presentation, phonography-displayed and kanji-displayed, were employed to examine the different neural pathways used for processing kanji. Each stimulus presentation involved two motor conditions: one allowed finger movements for tracing the characters, while the other disallowed finger movements. The tasks induced activation in the primary motor area, the premotor area, the supplementary motor area, and the anterior cingulate gyrus as well as the parietal and occipital lobes (Brodmann's area 7/39/19). The activated areas in both the movement-allowed and movement-disallowed conditions were almost identical except for the primary motor area. These results clearly contrasted with those of a previous study of right-handers which showed that right-handed volunteers demonstrated decreased activation in the premotor area and the dorsal pathway during the movement-allowed condition. This discrepancy may be attributable to a difference in cerebral organization for language processing. Specifically, in left-handers, the visuospatial procedure for kanji and the motor procedure for tracing the kanji may be ambilaterally distributed in both hemispheres, whereas in right-handers these procedures may be predominantly lateralized in the left hemisphere.

The lateral collateral ligament complex and related muscles act as a dynamic stabilizer as well as a static supporting structure at the elbow joint: an anatomical and experimental study.

Among 71 osteoligamentous elbow joint specimens from Japanese subjects, 66% of the lateral ulnar collateral ligaments (LUCLs) were in an incomplete form, such as a fibrous intermuscular septum lying between the anconeus, supinator and extensors, and terminated on the annular ligament. The 'typical' complete ligament, extending from the lateral epicondyle and over the radial collateral ligament (RCL) to the crista spinatoris, appeared in only 20% of the elbows examined. This observation suggests that, in Japanese subjects, the LUCL is not usually a simple ligamentous static stabilizer, but acts as a dynamic stabilizer, together with its related muscles. In addition, when the elbow was flexed by more than 90 degrees, the distance between the lateral epicondyle and the radial head became almost 1.5 mm larger than the distance from the epicondyle to the annular ligament. We therefore consider that, in the overflexed position, the radial head moves slightly distal while the length of the RCL remains almost constant. This morphometrical observation suggests that the annular ligament needs to be supported by the LUCL-muscle complex from the distal side, as well as by the RCL from the proximal side. This extended definition of the lateral collateral ligament complex and its associated muscular function is discussed.

[Interventonal radiology in the splanchnic arteries].

We present a review of interventional radiology in the splanchnic arteries, focusing on what has been achieved and the remaining challenges. Embolization is currently the treatment of choice for hemorrhagic events due to anastomotic leakage after intestinal anastomosis, although occasional association with liver necrosis poses a hazardous problem yet to be overcome. For splanchnic artery aneurysms, we should recognize that we are not, in reality, well informed about their natural history. The indications for the embolization of aneurysms is limited depending on the morphology of the aneurysm and surrounding vessels. Rotational angiography and other recently developed imaging techniques can help analyze the vascular anatomy of every lesion in decision making on the appropriate treatment for each patient when choosing between embolization and surgical obliteration. Partial splenic artery embolization for hypersplenism has been highly evaluated since the 1980s, although treatment indication should be carefully studied for patients with severe liver dysfunction. For acute mesenteric artery occlusion, local fibrinolysis should always be backed up by or combined with surgical treatment, and the treatment outcome is still sometimes dismal, suggesting one of the boundaries of modern medicine.

Piriformis syndrome resulting from a rare anatomic variation.

STUDY DESIGN: Case report. OBJECTIVES: We report a rare case of piriformis syndrome accompanying anatomic variation in the piriformis muscle and sciatic nerve. SUMMARY OF BACKGROUND DATA: Beaton classified anatomic variation in the piriformis muscle and sciatic nerve into 6 types based on cadaver studies. There has been no report in the English literature of surgical treatment for a case of piriformis syndrome accompanying Beaton type d anatomic variation. METHODS: A patient with sciatica showing no nerve root compression in lumbar MRI underwent pelvic MRI and perineurography of the sciatic nerve followed by CT. The findings in these images suggested piriformis syndrome accompanying anatomic variation of the piriformis muscle and sciatic nerve. Surgical treatment was performed. RESULTS: Surgical exploration of the piriformis muscle revealed Beaton type d anatomic variation. Both anterior and posterior lobes of the piriformis muscle were resected. The pain in the leg had completely disappeared after surgery. CONCLUSIONS: This is a very rare case of surgically treated piriformis syndrome resulting from type d anatomic variation in Beaton's classification. Pelvic MRI and perineurography of the sciatic nerve were useful for diagnosis in this case.

Underutilization of antiosteoporotic drugs by orthopedic surgeons for prevention of a secondary osteoporotic fracture.

BACKGROUND: Despite the availability of effective treatment and well-publicized treatment guidelines for preventing osteoporotic fractures, there are significant gaps in implementing the recommendations, and it is unknown how many patients are treated for prevention of secondary osteoporotic fractures. In this study, we investigate what percentage of osteoporosis patients were treated with antiosteoporotic drugs after osteoporotic fractures of the hip, wrist, and proximal humerus, and we discuss here the need for improvement in the treatment of osteoporosis following fracture. METHODS: We studied 422 patients with osteoporotic fractures, 91 men and 331 women, with an average age of 77.1 years (range, 52-102 years). The 422 cases consisted of 299 hip fractures, 97 distal radius fractures, and 26 proximal humerus fractures. All patients underwent surgical intervention. The variables were examined to ascertain whether osteoporosis patients were medicated with antiosteoporotic drugs at postfracture. RESULTS: Fifty-five (13%) of the 422 patients received antiosteoporotic medication at postfracture. Pharmaceutical treatment was given in 44 cases (14.7%) of hip fractures, 8 cases (8.2%) of distal radius fractures, and 3 cases (11.5%) of proximal humerus fractures. Thirty-one (7.3% of total) of the 55 patients were taking the same medication pre- and postfracture. Seven (1.7%) of the 55 were administered a different drug compared to before the fracture, and 17 (4%) started to take an antiosteoporotic drug for the first time subsequent to the fracture. CONCLUSIONS: The present rate of treatment is insufficient given the high risk of secondary fractures and the availability of appropriate drugs that would reduce that risk.

Magnetic resonance imaging findings of refractory tennis elbows and their relationship to surgical treatment.

Treatment of tennis elbow is a problem. We performed magnetic resonance imaging (MRI) examinations of 11 elbows in 11 patients who were referred to us with refractory tennis elbow. Of the 11 elbows, 6 showed a high signal intensity focus on MRI T2 images in the tendon of the extensor carpi radialis brevis at the lateral epicondyle. The other 5 elbows showed various abnormal findings on MRI. The mean age of the 6 patients with a high T2 signal focus was 52.0 years, and the mean morbidity period was 25 months. We performed enucleation of the granulation focus through a surgical approach without detachment of the tendon origin of the extensor carpi radialis brevis. Pain was relieved and elbow function recovered in all 6 cases. This study demonstrates that MRI is an important decision-making tool in the surgical treatment of this condition. Enucleation of the granulation focus with high T2 signal has proved to be effective in 6 selected cases.

Successful transcatheter arterial embolization of an inferior pancreaticoduodenal artery aneurysm associated with celiac axis stenosis.

A case of inferior pancreaticoduodenal artery (IPDA) aneurysm associated with celiac axis stenosis was successfully treated using only transcatheter arterial embolization (TAE). A 57-year-old woman was urgently referred to our hospital with sudden abdominal pain; computed tomography revealed retroperitoneal hematoma due to bleeding from an aneurysm around the superior mesenteric artery (SMA). Selective angiography into the SMA showed an aneurysm derived from the IPDA posterior branch; the IPDA anterior branch was intact and contrast medium flowed into the common hepatic artery territory through the pancreatic arcade because of celiac axis stenosis. We subsequently performed TAE on the lesion. Arteriography after TAE showed that the aneurysm had disappeared and that the IPDA anterior branch was intact. She had no aneurysm recurrence for about two years after the treatment. We believe that TAE is effective even for a PDA aneurysm with celiac axis stenosis or occlusion. However, it is important to perform embolization precisely and over a long period.

Variation in insertion of the abductor digiti minimi: an anatomic study.

We dissected 70 cadaver hands to examine the anatomy of the insertion of the abductor digiti minimi (ADM). The insertion had 2 forms. In 58 hands the insertion of the ADM was divided into 2 tendinous portions: one attached the base of the proximal phalanx (bone insertion) and the other attached the extensor aponeurosis (extensor insertion). In 12 hands the bone insertion existed solely. The mean length and width of the bone insertion were 10.6 +/- 3.1 and 4.0 +/- 0.9 mm and those of the extensor insertion were 18.5 +/- 4.0 and 2.1 +/- 1.1 mm, respectively. The mean proportion of the width of the extensor insertion to that of whole tendon was 31% (range, 0% to 50%). These observations show greater variation in the insertional anatomy of the ADM than reported previously.

Simultaneous radial closing wedge and ulnar shortening osteotomies for distal radius malunion.

PURPOSE: Closing wedge osteotomies are an attractive treatment option for distal radius malunion in patients with osteopenia; however, they require an ulnar head resection to accommodate closure of corrective osteotomy and to address the issue of ulnocarpal abutment. The literature contains little information on concomitant ulnar shortening osteotomy despite a physiologic solution. We report the functional and radiographic outcomes of 5 patients treated for symptomatic distal radius malunion with simultaneous radial closing wedge and ulnar shortening osteotomies. METHODS: All 5 patients were women aged 52 to 69 years (average, 61 years). Four patients had extra-articular radius fractures with dorsal angulation (20-22 degrees ) and shortening (3-7/mm); the other had the fracture with volar angulation (24 degrees ) and shortening (11 mm). Through a volar approach an appropriate amount of bone wedge was removed from the distal radius. A small volar T-plate was used to secure the osteotomized bone fragment. Six to 11 mm of ulnar shortening osteotomy was performed by using transverse osteotomy and compression plating technique with an AO compression device. RESULTS: In all 5 wrists healing of radial and ulnar osteotomies occurred less than 3 months after surgery. There were no postsurgical complications. Postsurgical radiographs showed that the volar tilt angle of the radius was reduced to normal range (range, 8-15 degrees ) in all wrists. The ulnar variance was 0 mm in 4 wrists and 2 mm in 1 wrist. There were significant improvements in pain, function, and range of motion at an average follow-up evaluation of 17 months. The average grip strength as a percentage of the opposite side improved from 30% before to 73% after surgery. CONCLUSIONS: This study showed that closing wedge osteotomy of the radius concomitant with ulnar shortening osteotomy is technically and functionally adequate. Our procedure is indicated for patients with osteopenia for whom opening wedge osteotomy of the radius is inadequate.

One-bone forearm reconstruction using vascularized fibular graft for massive forearm soft-tissue and bone defect: case report.

The authors report a case of recurrent malignant fibrous histiocytoma with extensive bone- and soft-tissue involvement, successfully treated with one-bone forearm reconstruction using a vascularized fibular graft and multiple tendon transfer. Twenty-four months after surgery, elbow and hand functions were maintained, and the patient had no disturbance of hand function in daily activity, although rotation of the forearm was sacrificed. No local recurrence or metastasis was noted. The procedure is a useful reconstructive option for complex tissue defects following wide excision of sarcoma of the forearm.

Laminar configuration of the transverse carpal ligament.

We investigated the laminar configuration of the transverse carpal ligament, using 77 hands from 44 donated cadavers. According to the running directions and attachments of the fiber bundles composing the ligament, we identified four basic bundle patterns: proximal transverse, distal transverse, radial oblique, and ulnar oblique. Although these patterns often coexisted and the bundles were somewhat intermingled, a specific pattern was very evident in several laminae. Laminae with the distal transverse bundle pattern were the thickest and were reinforced by additional fibers which originated from the palmar aponeurosis and were deeply inserted into the lamina. Based on the laminar configurations of the superficial and deep layers and their composite fiber bundles, we classified the ligaments into four types. Type I, in which distal transverse and ulnar oblique laminae predominated in every layer, was the most common (44.2%), while another large group (41.6%) exhibited type II ligaments, comprising distal transverse and ulnar oblique laminae in the superficial layer and proximal transverse and radial oblique laminae in the deep layer. Thus, in almost half of the patients (type II), the strong distal transverse lamina is likely to be excised during the final step of endoscopic carpal tunnel release because of its superficial localization. This could be a major reason for the frequent occurrence of incomplete release. Moreover, the almost universal superficial ulnar oblique bundle pattern (observed in type I, II, and III ligaments), predisposes to scarring, which may cause radial shifting of the ulnar neurovascular bundle and may affect the palmar branch of the median nerve. We conclude that the interindividual variability seen in the results of endoscopic carpal tunnel release, including minor complications, depends partly on configurational variations in the laminar arrangement of the transverse carpal ligament.

Tumor enhancement using Mn-metalloporphyrin in mice: magnetic resonance imaging and histopathologic correlation.

PURPOSE: To determine the signal enhancement characteristics of tumors after administration of a metalloporphyrin derivative, HOP-9P (13, 17-bis (1-carboxypropionyl) carbamoylethyl-3, 8-bis (1-phenylpropyloxyethyl)-2, 7, 12, 18-tetramethyl-porphyrinato manganese (III)) and to determine whether HOP-9P is tumor-necrosis specific. MATERIALS AND METHODS: Ten C3H/He mice bearing a SCC VII tumor in the right flank were examined using T1-weighted conventional spin echo magnetic resonance (MR) imaging before contrast injection, and five minutes, one hour, and 24 hours after intravenous administration of 0.1 mmol/kg of HOP-9P. Following the imaging schedule, the mice were sacrificed, and sectioned in the same axial planes as the MR images. Based on an MR imaging-histopathologic correlation, mean signal intensities were measured, and signal-to-noise ratios (SNR) were calculated for both pure viable component and admixture of necrotic and viable component of the tumor. RESULTS: Mean SNR of the pure viable component peaked at one hour (35.0 +/- 3.8) and maintained that level until 24 hours (34.6 +/- 3.6). Mean SNR of the admixture of necrotic and viable component peaked at 24 hours (44.3 +/- 12.1). CONCLUSION: Although different enhancement patterns were seen between the pure viable component and the admixture of necrotic and viable component, HOP-9P enhanced both of the two components.

Assessment of a potential tumor-seeking manganese metalloporphyrin contrast agent in a mouse model.

The performance of a newly developed potential tumor-seeking magnetic resonance (MR) contrast agent alpha-Aqua-13,17-bis(1-carboxypropionyl) carbamoylethyl-3,8-bis(1-phenethyloxyethyl)-beta-hydroxy-2,7,12,18-tetramethyl-porphyrinato manganese (III) (HOP-8P) was tested using a mouse model. Tumor-bearing (SCC-VII) mice were imaged using a 1.5T MR imager before and after intravenous administration of 0.1 mmol/kg of HOP-8P. A biodistribution analysis was performed using an optical emission spectrometer. Significant enhancement of the transplanted tumor was observed in MR images 24 h after intravenous injection of HOP-8P. The biodistribution assessment of manganese also correlated with the results of the imaging study. During the 24-h period following contrast administration, HOP-8P was consistently cleared from the circulation, liver, kidneys, and muscle; however, it was progressively accumulated within the tumor. HOP-8P is a promising tumor-seeking metalloporphyrin MR contrast agent with a wide imaging window.