Interferon-alpha2a reduces MRI disease activity in relapsing-remitting multiple sclerosis. Norwegian Study Group on Interferon-alpha in Multiple Sclerosis.

OBJECTIVE: To evaluate the efficacy and safety of interferon-alpha2a (IFN-alpha2a) in relapsing-remitting MS (RRMS). BACKGROUND: Several immune-modulating therapy regimens of IFN-alpha have shown varying results in MS. A recent pilot study suggested benefits from IFN-alpha2a. METHODS: Ninety-seven patients were randomized to receive subcutaneous injections of placebo (33 patients) or 4.5 million international units (mIU) (32 patients) or 9.0 mIU (32 patients) of IFN-alpha2a three times weekly for 6 months, with a further 6 months of follow-up. Monthly gadodiamide-enhanced MRI was the primary method of evaluating efficacy. RESULTS: IFN-alpha2a treatment resulted in fewer new MRI lesions during the treatment period (p < 0.003). The probability of no new lesions during treatment was >2.5 times higher with 9.0 mIU IFN-alpha2a than with placebo (p < 0.005). The median number of lesions at the end of treatment was lower with IFN-alpha2a treatment than with placebo (p = 0.0004), but the difference disappeared during follow-up. The total number of lesions (mean) increased by 4.78 with placebo, 0.86 with 4.5 mIU IFN-alpha2a, and 0.28 with 9.0 mIU IFN-alpha2a during treatment (p = 0.030). No treatment effect on exacerbation rate, progression of disability, or quality of life was detected. Nine patients discontinued treatment, five because of adverse events. CONCLUSIONS: IFN-alpha2a treatment significantly reduced disease activity as measured by MRI, but the efficacy disappeared within 6 months after discontinuation of treatment. A long-term study of more patients using disability as a primary outcome measure is needed to evaluate the clinical impact.

Diagnosis of vertebral fractures. A comparison of conventional radiography, conventional tomography, and computed axial tomography.

Thirty patients with acute thoracic, lumbar, or thoracolumbar fractures, dislocations, or fracture-dislocations were evaluated with standard radiographs, conventional polytomography, and computerized axial tomography. The resulting ninety studies were coded, randomized, and independently interpreted by three radiologists. The diagnostic accuracy of the interpretations based on the computerized tomography scans combined with standard radiographs equaled that of the interpretations based on just the tomograms in the evaluation of fractures of posterior elements. In addition, computerized tomography was superior to the other methods in demonstrating impingement on the neural canal as well as injuries to other organ systems. Also, when compared with conventional polytomography, computerized tomography could be completed with less risk to the patient (no changes in position and ten times less radiation). We concluded that computerized tomography should replace conventional polytomography as the initial study to augment standard radiographs in the assessment of thoracic and lumbar fractures. Conventional polytomography should be reserved for patients in whom precise evaluation of the pars interarticularis is deemed necessary.

Lumbar spinal stenosis: conservative or surgical management?: A prospective 10-year study.

STUDY DESIGN: A cohort of 100 patients with symptomatic lumbar spinal stenosis, characterized in a previous article, were given surgical or conservative treatment and followed for 10 years. OBJECTIVES: To identify the short- and long-term results after surgical and conservative treatment, and to determine whether clinical or radiologic predictors for the treatment result can be defined. SUMMARY OF BACKGROUND DATA: Surgical decompression has been considered the rational treatment. However, clinical experience indicates that many patients do well with conservative treatment. METHODS: In this study, 19 patients with severe symptoms were selected for surgical treatment and 50 patients with moderate symptoms for conservative treatment, whereas 31 patients were randomized between the conservative (n = 18) and surgical (n = 13) treatment groups. Pain was decisive for the choice of treatment group. All patients were observed for 10 years by clinical evaluation and questionnaires. The results, evaluated by patient and physician, were rated as excellent, fair, unchanged, or worse. RESULTS: After a period of 3 months, relief of pain had occurred in most patients. Some had relief earlier, whereas for others it took 1 year. After a period of 4 years, excellent or fair results were found in half of the patients selected for conservative treatment, and in four fifths of the patients selected for surgery. Patients with an unsatisfactory result from conservative treatment were offered delayed surgery after 3 to 27 months (median, 3.5 months). The treatment result of delayed surgery was essentially similar to that of the initial group. The treatment result for the patients randomized for surgical treatment was considerably better than for the patients randomized for conservative treatment. Clinically significant deterioration of symptoms during the final 6 years of the follow-up period was not observed. Patients with multilevel afflictions, surgically treated or not, did not have a poorer outcome than those with single-level afflictions. Clinical or radiologic predictors for the final outcome were not found. There were no dropouts, except for 14 deaths. CONCLUSIONS: The outcome was most favorable for surgical treatment. However, an initial conservative approach seems advisable for many patients because those with an unsatisfactory result can be treated surgically later with a good outcome.

Lumbar spinal stenosis. Clinical and radiologic features.

STUDY DESIGN: A prospective, randomized study of patients with symptomatic lumbar spinal stenosis. OBJECTIVES: Evaluation of clinical and radiologic characteristics and relationship. SUMMARY OF BACKGROUND DATA: The diagnosis of lumbar spinal stenosis is frequently used and represents a wide variety of patients with more or less well-defined spinal disorders. METHODS: One hundred patients who met inclusion criteria were consecutively selected from a neurology department and examined clinically and radiologically with plain radiography, myelography, and computed tomographic imaging. RESULTS: Duration of complaints was long, and multilevel, bilateral afflictions were common. The dominanting symptoms were sciatica, neurogenic claudication, and low back pain. The clinical findings were modest. Narrowness in the spinal canal was demonstrated radiologically with signs of compression on nerve roots, centrally and/or laterally. The radiologic findings were more extensive than expected from the clinical symptoms and signs. In most patients the sagittal diameter of the spinal canal increased on flexion and decreased on extension of the spine. An exception was demonstrated in 33 patients where extension increased the diameter, usually at one level. Radiologic subgroups of stenosis were found, but their clinical relationship could hardly be identified. No definite association between the degree of narrowing and clinical symptoms was found. CONCLUSIONS: A clinical picture is demonstrated in 100 patients with symptomatic lumbar spinal stenosis. Different types of stenosis are found radiologically, but their clinical relationships are not identified. The radiologic changes were more extensive than expected from the clinical picture, and the degree of narrowing did not correspond to the degree of clinical affliction.

The clinical value of dynamic magnetic resonance imaging in normal and incontinent women--a preliminary study on micturition.

In this preliminary study in nine volunteers and nine women with genuine stress incontinence (GSI) dynamic magnetic resonance imaging (MRI) was used to study the voiding phase in the sitting position after physiological filling of the bladder by urine. The MRI technique has been documented as being useful for this purpose, but in this small group of women it was not possible to determine any specific difference in the voiding pattern between the volunteers and the G

Dural ectasia in Marfan syndrome: a case control study.

BACKGROUND AND PURPOSE: Dural ectasia (DE) is one of the major criteria of Marfan syndrome (MFS). Our aim was to establish the prevalence of DE in an adult population fulfilling the Ghent criteria for MFS and to assess definitions of DE. MATERIALS AND METHODS: One hundred five adults with suspected MFS were included. MR imaging at 1.5T was performed unless contraindicated; then CT was obtained. Lumbosacral anteroposterior vertebral body diameters (VBD) and dural sac diameters (DSD) were measured. Dural sac ratios (DSR = DSD/VBD) at levels L3 through S1 were calculated. Anterior meningoceles, herniations of nerve root sleeves, and scalloping were characterized. One hundred one sex- and age-matched patients were included as controls. RESULTS: We identified 3 patient groups: 1) fulfilling Ghent criteria independent of DE (n = 73), 2); fulfilling Ghent criteria dependent on DE (n = 14), and 3); and suspected MFS, not fulfilling Ghent criteria (n = 18). DE was found in 86% of group 1. At levels L4-S1, mean DSRs were significantly higher in group 1 than in group 3 and controls (P < .001). Herniations of the nerve root sleeves were present in 73% in group 1 versus 1% in controls. Anterior meningoceles were found in 37% and 14% in groups 1 and 2, respectively, but not in group 3 or controls. CONCLUSIONS: The diagnosis of DE on MR imaging or CT should be based on the presence of at least 1 of the following criteria: anterior meningoceles or nerve root sleeve herniation, DSD at S1 or below larger than DSD at L4, and DSR at S1 >0.59.

[Discography]. / Diskografi.

Discography means imaging of the intervertebral discs by intradiscal contrast injections. Discography with a combined CT/discography allows a more detailed classification of annular disruption and degeneration. Combined with a pain response registration, discography can be of value in the diagnosis of chronic low back pain with signs of sciatica in cases where other x-ray modalities have failed to explain the source of pain. Among 20 discography examinations there was a correlation between radicular symptoms and annular disruption with contrast leakage to the epidural space, and disc protrusion on CT scanning.

Septic complications to sphenoidal sinus infection.

Sphenoid sinusitis is an uncommon infection, but an early diagnosis and appropriate treatment is important because of its serious complications. We report 4 patients (28, 28, 37 and 28 years old) admitted to a department of infectious diseases with meningitis, sepsis and orbital cellulitis as complications of acute sphenoidal cavity infection. The cases illustrate the value of computed tomography (CT) scan of the sphenoid sinus in the evaluation of patients with clinical features suspicious of sphenoid sinusitis.

MR findings in cases of suspected impacted fracture of the femoral neck.

PURPOSE: To evaluate MR imaging of the hip in patients with a clinically suspected impacted fracture of the femoral neck in cases where conventional plain films show negative or equivocal findings. MATERIAL AND METHODS: Twenty-seven such patients were prospectively examined by MR imaging with a 1.0 T unit, within 24 hours of admittance to hospital. A coronal T1-weighted turbo spin-echo sequence (n = 27), and a coronal STIR sequence (n = 25) or a coronal T2-weighted turbo spin-echo fat saturation sequence (n = 2) were used. The evaluations were made by 2 radiologists with experience in musculoskeletal radiology. RESULTS: There were 6 patients with a pertrochanteric fracture, 2 without and 4 with slight displacement. Five patients had an impacted fracture of the femoral neck, and 3 had a fracture of the superior pubic bone. Of 2 patients with advanced arthrosis, 1 had an impacted femoral neck fracture and the other a nondisplaced intertrochanteric fracture. There was 1 patient who had sustained a nondisplaced acetabular fracture with increased joint fluid and muscle contusions. Three patients had muscle contusions only. Two patients had bone marrow contusions only, while 2 others with advanced coxarthrosis had increased joint fluid only. Three patients showed normal findings. Our findings led to emergency surgery in 13 cases, and conservative measures directed to the specific MR findings in 14 patients. CONCLUSION: MR imaging should be the first modality of choice in examining patients with a clinically suspected impacted fracture of the femoral neck where conventional films show negative or equivocal findings.

[Vertebral fractures in osteoporosis--silent fractures of clinical importance]. / Vertebrale frakturer ved osteoporose--skjulte brudd med stor betydning.

Vertebral fractures are a common concern in patients with low bone mass. Even though less than half of these fractures are symptomatous, they represent a major health problem. This article gives a survey of vertebral fractures in osteoporosis as a "silent epidemic". They are of clinical importance for two main reasons. First, several studies have demonstrated an association between vertebral fractures and morbidity and even mortality. Second, an osteoporotic vertebral fracture dramatically increases a persons risk of suffering from further osteoporotic fractures, also non-axial ones. Vertebral deformities represent the clinical end point of large interventional studies on osteoporosis, and is used as a definition of osteoporosis in epidemiological studies. Spinal radiographs provide vertebrae in all shapes, from normal via slight reduction of height to severely crushed. There is no commonly accepted definition of when a reduction in height is defined as a vertebral fracture. This lack of standardisation complicates interpretation and comparison of different studies. During the last decade, several well documented treatments reducing the risk of further fractures have come into use. This points to the importance of discovering a vertebral fracture, so that the patient can be diagnosed as having osteoporosis and given appropriate treatment.

Dynamic MRI of the pelvic floor muscles in an upright sitting position.

Since the pelvic floor muscles are situated inside the pelvis, the actual function is difficult to observe. Magnetic resonance imaging (MRI) is a new method that may prove to give additional information about pelvic floor muscle function during contraction. The purpose of the present study was to assess pelvic floor muscle function during contraction and straining in an upright sitting position by use of MRI. Sixteen women, nine continent and seven with urodynamically and clinically proven genuine stress incontinence participated in the study. MRI was performed in an open-configured GE Signa SP, 0.5 T Tesla magnet. With the participants sitting in an upright position on a pelvic RF-coil, sagittal, coronal and axial T1 weighted spin echo images of the pelvic floor were obtained. During contraction and straining a scan time of 2 seconds per image for 150-250 images, was performed in a mid-sagittal plane. The results showed that the mean inward lift during contraction was 10.8 mm (SD 6.0) for all women. During straining the mean downward movement was 19.1 mm (SD 7.4). The coccyx moved in a ventral, cranial direction during contraction and was pressed in a caudal, dorsal direction during straining. It is concluded that contraction of the pelvic floor muscles is concentric, moving the coccyx in a ventral, cranial direction. The movement measured by MRI in upright sitting position is less than that concluded after clinical observation in supine position. The coccyx is pressed dorsally during straining.

Cavernous hemangioma of the middle ear.

A case of an accidentally discovered, nonsymptomatic cavernous angioma of the middle ear in a 29-year-old white male Caucasian is presented together with a review of the relevant literature. The lesion is documented with computer tomography, light microscopy, and immunohistochemistry.

Arthrography of the knee joint with amipaque.

In a double-blind investigation, 30 knee arthrographies were performed by injection of either Amipaque 290 mg I/ml or Urografin 60% (292 mg I/ml). Both contrast media are well tolerated, and give excellent initial contrast quality, which deteriorates rapidly. This occurs more slowly with Amipaque, which has lower osmolality and causes less joint effusion.

Lumbar myelography with Omnipaque (iohexol).

Lumbar myelography with iohexol (Omnipaque) was performed in 103 consecutive adult patients with low back pain or sciatica. The patients were observed for 48 h with registration of possible adverse reactions. Mild or moderate transient side effects were recorded in 24 patients. No serious adverse reactions were noted, and EEG recorded in 25 patients showed no changes.

Functional imaging of the thoracic outlet syndrome in an open MR scanner.

Symptoms due to thoracic outlet syndrome may present only in abduction, a position that cannot be investigated in conventional MR scanners. Therefore, this study was initiated to test MRI in an open magnet as a method for diagnosis of thoracic outlet syndrome. Ten volunteers and 7 patients with a clinical suspicion of thoracic outlet syndrome were investigated at 0.5 T in an open MR scanner. Sagittal 3D SPGR acquisitions were made in 0 and 90 degrees abduction. In the patients, a similar data set was also obtained in maximal abduction. To assess compression, the minimum distance between the first rib and the clavicle, measured in a sagittal plane, was determined. In the neutral position, no significant difference was found between patients and controls. In 90 degrees abduction, the patients had significantly smaller distance between rib and clavicle than the controls (14 vs 29 mm; p < 0.01). On coronal reformatted images, the compression of the brachial plexus could often be visualised in abduction. Functional MR examination seems to be a useful diagnostic tool in thoracic outlet syndrome. Examination in abduction, which is feasible in an open scanner, is essential for the diagnosis.

A magnetic resonance imaging study of modifications to the infraclavicular brachial plexus block.

A previously described infraclavicular brachial plexus block may be modified by using a more lateral needle insertion point, while the patient abducts the arm 45 degrees or 90 degrees. In performing the modified block on patients abducting 45 degrees, we often had problems finding the cords of the brachial plexus. Therefore, we designed an anatomic study to describe the ability of the recommended needle direction to consistently reach the cords. Additionally, we assessed the risk of penetrating the pleura by the needle. Magnetic resonance images were obtained in 10 volunteers. From these images, a virtual reality model of each volunteer was created, allowing precise positioning of a simulated needle according to the modified block, without exposing the volunteers to actual needle placement. In both arm positions, the recommended needle angle of 45 degrees to the skin was too shallow to reach a defined target on the cords. Comparing the two arm positions, target precision and risk of contacting the pleura were more favorable with the greater arm abduction. We conclude that when the arm is abducted to 90 degrees, a 65 degrees -needle angle to the skin appears optimal for contacting the cords, still with a minimal risk of penetrating the pleura. However, this needs to be confirmed by a clinical study.

Magnetic resonance imaging demonstrates lack of precision in needle placement by the infraclavicular brachial plexus block described by Raj et al.

UNLABELLED: The infraclavicular brachial plexus block first described by Raj et al. was supposed to anesthetize all the main peripheral nerves of the brachial plexus without the risk of pneumothorax. However, in performing the block, we have had difficulties finding the nerves at the cord level. Therefore, we questioned whether the recommended needle direction (the "Raj line") guides the needle close enough to the cords. We therefore designed an anatomic study to answer this question and to assess the risks of entering the pleura and axillary vein. Ten volunteers were examined noninvasively in an open model magnetic resonance scanner. The Raj line deviated greatly from a defined location on the cords by a mean of 26 (range 14-39) mm, always caudad, and posterior to the target in nine cases. Further, the needle trajectory's shortest distance to the pleura was only 10 (0-27) mm, and in one case, it hit the pleura. Finally, the Raj line's distance to the axillary vein was also short, 11 (0-18) mm. We conclude that a modification of the method is necessary to guide the needle closer to the cords and further away from the pleura and the axillary vein. A more lateral needle insertion seems beneficial. IMPLICATIONS: Using a magnetic resonance scanner, the anatomical basis of Raj's infraclavicular method for brachial plexus blockade was examined in volunteers. The results show that the method should be modified to make it more precise and to provide less risk of complications.

Palatopharyngoglossoplasty in the treatment of patients with obstructive sleep apnea syndrome.

A new technique (palatopharyngoglossoplasty (PPGP)) has been developed for surgical treatment of patients with the obstructive sleep apnea syndrome (OSAS). In 20 operated patients 18 reported immediate marked improvement of daytime sleepiness, alertness and vigilance during the day, and of working capacity. However, polysomnography carried out pre- and postoperatively showed that only 10 patients were "cured", defined as 50% or more reduction in apnea/hypopnea index (AHI). Cephalometric analysis pre- and postoperatively indicated that nonresponders had a long and narrow posterior airway space, and we suggest that during sleep this part of the upper airway collapses before as well as after the operation. The discrepancy between the subjective improvement observed after PPGP and the postoperative reduction in AHI may be due to reduced/eliminated snoring and/or improvement in sleep quality after the operation.

[The intervention center at the Rikshospital. Experiences from the first year of activity]. / Intervensjonssenteret ved Rikshospitalet. Erfaringer fra ett års drift.

In order to co-ordinate and promote the development of new clinical applications by structuring collaboration and communication across traditional specialty boundaries, a first of its kind hospital department was opened at Rikshospitalet in June 1996. The Interventional Centre is a multidisciplinary centre for research and development, teaching and quality management of imaging-guided minimally invasive therapy, endoscopic surgery and interventional radiology. The department is a full fusion of state-of-the art operating theatre with an advanced radiology department and with fully up-to-date ultrasound and endoscopy facilities for integrated use in the treatment of the patient. The department is cross-disciplinary organised. A small staff of 14 persons are responsible for the day-to-day running of the centre. Specialists from other hospital departments work together with the centre's permanent staff to develop new procedures. During the first year, 19 research projects were started and a total of 510 procedures performed within the fields of Radiology, Neurosurgery, Gastroenterology, Cardiology, Cardiovascular surgery and Paediatric cardiology, and also within the fields of image processing and telecommunication.

[Percutaneous automated lumbar nucleotomy. Patient selection, practical performance and clinical results]. / Perkutan automatisert lumbal nukleotomi. Pasientutvelgelse, praktisk utførelse og kliniske resultater.

Percutaneous nucleotomy is designed to treat small and medium-sized contained disk hernias. It is offered to patients who have not responded to conservative treatment for three months or more. The nucleotomy procedure is well tolerated by a majority of patients and the rate of complications is low. The patients can be treated as out-patients. Among a total material of 130 patients, a primary good response to the treatment was observed in 81 (62%). However, owing to recurrencies the success rate had fallen to 52% at 12-39 months (mean 22 months) after nucleotomy. In selected patients with symptoms from one disk level only, and with no evidence of spinal stenosis, or of osteophyte formation or a narrowing of the disk space by more than 25%, the results were better. Here the success rate was 61% (70% in males and 50% in females).