High Signal Intensity Changes Research Articles

Comparison of clinical outcomes between sequestered cervical disk herniation and non-sequestered cervical disk herniation after anterior cervical decompression and fusion: a cohort study

BackgroundThe advantages of anterior cervical decompression and fusion (ACDF) were well published, while research on postoperative results in different subtypes of cervical disk herniation (CDH) still remains blank. This study aimed to explore the surgical outcome between sequestration and other types in CDH.MethodsThis retrospective cohort study enrolled 108 patients treated with ACDF in our hospital. The participants were divided into two groups according to the existence of a sequestered disk. The Visual analog scale score, the Japanese Orthopedics Association (JOA) score and the Neck disability index score were used to evaluate postoperative outcome.ResultsSignificant improvements were observed in both groups at every viewpoint (P < 0.001). The mean JOA was 15.04 ± 1.26 in the sequestered disk group and 14.45 ± 1.43 in the non-sequestered disk group two months after the operation (P = 0.026 < 0.05). The improvement in JOA at two months after ACDF showed a significant difference: 46.58% ± 39.17% in the sequestered disk group and 33.39% ± 28.82% in the non-sequestered disk group (P = 0.047 < 0.05). Thirty-two patients in the sequestered disk group (64%) and 19 patients in the non-sequestered disk group (32.76%) presented with high signal intensity of the spinal cord on preoperative cervical T2-weighted MRI (P < 0.001).ConclusionsPatients with sequestered cervical disks seemed to have a higher degree of symptom improvement two months after ACDF. CDH with a sequestered disk appears to be more likely to cause high signal intensity changes in the compressed cervical spine on T2-weighted MRI. We prefer early positive surgery in patients with sequestered cervical disks from the clinical point of view.

Improving Diagnostic Performance of MRI for Temporal Lobe Epilepsy With Deep Learning-Based Image Reconstruction in Patients With Suspected Focal Epilepsy.

To evaluate the diagnostic performance and image quality of 1.5-mm slice thickness MRI with deep learning-based image reconstruction (1.5-mm MRI + DLR) compared to routine 3-mm slice thickness MRI (routine MRI) and 1.5-mm slice thickness MRI without DLR (1.5-mm MRI without DLR) for evaluating temporal lobe epilepsy (TLE). This retrospective study included 117 MR image sets comprising 1.5-mm MRI + DLR, 1.5-mm MRI without DLR, and routine MRI from 117 consecutive patients (mean age, 41 years; 61 female; 34 patients with TLE and 83 without TLE). Two neuroradiologists evaluated the presence of hippocampal or temporal lobe lesions, volume loss, signal abnormalities, loss of internal structure of the hippocampus, and lesion conspicuity in the temporal lobe. Reference standards for TLE were independently constructed by neurologists using clinical and radiological findings. Subjective image quality, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were analyzed. Performance in diagnosing TLE, lesion findings, and image quality were compared among the three protocols. The pooled sensitivity of 1.5-mm MRI + DLR (91.2%) for diagnosing TLE was higher than that of routine MRI (72.1%, P < 0.001). In the subgroup analysis, 1.5-mm MRI + DLR showed higher sensitivity for hippocampal lesions than routine MRI (92.7% vs. 75.0%, P = 0.001), with improved depiction of hippocampal T2 high signal intensity change (P = 0.016) and loss of internal structure (P < 0.001). However, the pooled specificity of 1.5-mm MRI + DLR (76.5%) was lower than that of routine MRI (89.2%, P = 0.004). Compared with 1.5-mm MRI without DLR, 1.5-mm MRI + DLR resulted in significantly improved pooled accuracy (91.2% vs. 73.1%, P = 0.010), image quality, SNR, and CNR (all, P < 0.001). The use of 1.5-mm MRI + DLR enhanced the performance of MRI in diagnosing TLE, particularly in hippocampal evaluation, because of improved depiction of hippocampal abnormalities and enhanced image quality.

Prevalence and distribution of Schmorl node and endplate signal change, and correlation with disc degeneration in a population-based cohort: the Wakayama Spine Study.

Degenerative spinal conditions, including disc degeneration (DD), Schmorl nodes (SN), and endplate signal changes (ESC), are pervasive age-associated phenomena that critically affect spinal health. Despite their prevalence, a comprehensive exploration of their distribution and correlations is lacking. This study examined the prevalence, distribution, and correlation of DD, SN, and ESC across the entire spine in a population-based cohort. The Wakayama Spine Study included 975 participants (324 men, mean age 67.2years; 651 women, mean age 66.0years). Magnetic resonance imaging (MRI) was used to evaluate the intervertebral space from C2/3 to L5/S1. DD was classified using Pfirrmann's system, ESC was identified by diffuse high-intensity signal changes on the endplates, and SN was defined as a herniation pit with a hypointense signal. We assessed the prevalence and distribution of SN, ESC, and DD across the entire spine. The correlations among these factors were examined. Prevalence of ≥ 1 SN over the entire spine was 71% in men and 77% in women, while prevalence of ≥ 1 ESC was 57.9% in men and 56.3% in women. The prevalence of ESC and SN in the thoracic region was the highest among the three regions in both sexes.Positive linear correlations were observed between the number ofSN and DD (r = 0.41, p < 0.001) and the number ofESC and DD (r = 0.40, p < 0.001), but weak correlations were found between the number ofSN and ESC (r = 0.29, p < 0.001). The prevalence and distribution of SN and ESC over the entire spine were observed, and correlations between SN, ESC, and DD were established. This population-based cohort study provides a comprehensive analysis of these factors.

Anatomical features of plantar fasciitis in various age cohorts: Based on magnetic resonance imaging.

Due to the lack of further studies on the influence of age factors on plantar fasciitis, this study evaluates the characteristic observation points of magnetic resonance imaging in various age cohorts of patients with plantar fasciitis to help diagnosis. A retrospective analysis of 160 cases of plantar fasciitis patients and normal subjects (who have the disease unrelated to plantar fasciitis) who have undergone an MRI examination in our institution. The two groups were separately divided into young adult subjects (36 to 44years old), middle age adult subjects (45 to 59years old), and older adult subjects (60 to 79years old). Data was gathered regarding plantar fascia thickness, the coronal length of the plantar fascia at the calcaneal origin, the signal intensity of plantar fascia and surrounding structures, and the presence or absence of plantar calcaneal spurs, all of which were assessed objectively by the investigators. There were statistical differences in the thickness of plantar fascia between two groups of three age cohorts (Older adult patients: 0.59 ± 0.09cm; Middle age adult patients: 0.49 ± 0.09cm; Young adult patients: 0.47 ± 0.05cm) (all p < 0.001). In addition, there were also statistical differences in the high signal intensity changes of the plantar fascia and surrounding soft tissues between two groups of three age cohorts (all p < 0.001). In older adult plantar fasciitis patients, with regard to plantar calcaneal spur discovery, there was a statistical difference between the two groups (Chi-square = 12.799. df = 1. p < 0.001). In plantar fasciitis cases where a diagnosis is difficult, abnormalities in the soft tissue surrounding the plantar fascia in patients of low age are noteworthy. In older adult patients, the discovery of plantar calcaneal spurs with abnormal thickening of plantar fascia deserves attention, and abnormal MRI findings are more manifest. But the final diagnosis should be based on the medical history. Level 3.

Whole-body MRI in children aged 6–18 years. Reliability of identifying and grading high signal intensity changes within bone marrow

BackgroundWhole-body magnetic resonance imaging (MRI) is increasingly being used in children, however, to date there are no studies addressing the reliability of the findings.ObjectiveTo examine intra- and interobserver reliability of a scoring system for assessment of high signal areas within the bone marrow, as visualized on T2-weighted, fat-saturated images.Materials and methodsNinety-six whole-body MRIs (1.5 T) in 78 healthy volunteers (mean age: 11.5 years) and 18 children with chronic nonbacterial osteomyelitis (mean age: 12.4 years) were included. Coronal water-only Dixon T2-weighted images were used to score the left lower extremity/pelvis for high signal intensity areas, intensity (0–2 scale), extension (0–4 scale) and shape and contour in a blinded fashion by two pairs of radiologists.ResultsFor the pelvis, grading of bone marrow signal showed moderate to good intra- and interobserver agreement with kappa values of 0.51–0.94 and 0.41–0.87, respectively. Corresponding figures for the femur were 0.61–0.68 within and 0.32–0.61 between observers, and for the tibia 0.60–0.72 and 0.51–0.73. Agreement for assessing extension was moderate to good both within and between observers for the pelvis (k = 0.52–0.85 and 0.35–0.80), for the femur (0.52–0.67 and 0.51–0.60) and for the tibia (k = 0.59–0.69 and 0.47–0.63) except for the femur metaphysis/diaphysis, with interobserver kappa values of 0.29–0.30. Scoring of shape was moderate to good within observers, but in general poorer between observers, with kappa values of 0.40–0.73 and 0.18–0.69, respectively. For contour, the corresponding figures were 0.35–0.62 and 0.09–0.54, respectively.ConclusionMRI grading of intensity and extension of high signal intensity areas within the bone marrow of pelvis and lower limb performs well and thus can be used interchangeably by different observers, while assessment of shape and contour is reliable for the same observer but is less reliable between observers. This should be considered when performing clinical trials.

K-line (−) in the neck-flexed position negatively affects surgical outcome of expansive open-door laminoplasty for cervical spondylotic myelopathy

BackgroundThe K-line in the neck-flexed position (FK-line) on radiography reflects dynamic factors and cervical alignment. Although the FK-line has been reported to affect the neurological recovery after muscle-preserving selective laminectomy for cervical spondylotic myelopathy (CSM), its influence on surgical outcomes after expansive open-door laminoplasty (ELAP) has not been investigated. MethodsWe reviewed the surgical outcomes in 81 patients with multilevel CSM who underwent C4–C6 ELAP combined with C3 and C7 partial laminectomy using a laminoplasty plate and were followed up for at least 2 years. We defined the K-line (−) as some portion of a bony spur or the vertebral body crossing the FK-line, whereas the FK-line (+) was defined as that never crossing the FK-line. Patients were divided into the FK-line (+) (n = 61) and FK-line (−) groups (n = 20), and the surgical outcomes were compared between the groups. A multivariate analysis was performed to identify the factors that influenced the neurological outcomes. ResultsThe FK-line (−) group had a smaller C2–C7 angle, smaller C7 slope, greater postoperative increase in the C2–C7 sagittal vertical axis, greater kyphosis in cervical flexion and less lordosis in cervical extension, and higher incidence of postoperative residual spinal cord compression. The preoperative-to-postoperative changes in the Japanese Orthopedic Association (JOA) score and JOA score recovery rate (RR) were lower in the FK-line (−) group. The multiple linear regression analysis revealed that the K-line (−) (β = −0.327, P = 0.011) and high signal intensity (SI) changes on T2-weighted imaging (WI) combined with the low SI changes on T1-WI in the spinal cord (β = −0.320, P = 0.013) negatively affected the JOA score RR. ConclusionsThe FK-line can be used for patients with CSM as a simple indicator of neurological outcomes after ELAP.

The relationship between high-signal intensity changes in the glenohumeral joint capsule on MRI and clinical shoulder symptoms

Background/objectiveHigh-signal intensity changes in the glenohumeral joint capsule on T2-and proton density-weighted magnetic resonance imaging are known as characteristic finding that is often observed in patients with frozen shoulder. We investigated the associations between high-signal intensity changes in the joint capsule on magnetic resonance imaging and the presence of rotator cuff tears and shoulder symptoms in patients with shoulder pain. MethodsThe medical records of 230 patients with shoulder pain who underwent magnetic resonance imaging at our hospital were reviewed. Patients were divided into three groups according to the presence and/or degree of rotator cuff tears (none, partial, or complete). The frequency of high-signal intensity changes in the joint capsule and its relationship with shoulder symptoms and the severity of rotator cuff tears were assessed. By quantitatively evaluating the intensity on MRI, the ratio between the joint capsule and the long head of the biceps (HSIC ratio) was calculated and compared with 15 healthy subjects. ResultsHigh-signal intensity changes were diagnosed in 165 (72%) patients, and it was significantly associated with night pain and range of motion limitation (p < 0.01). High-signal intensity changes were present in 66 patients (70%) with no rotator cuff tears, in 69 (71%) with partial rotator cuff tears, and in 36 (80%) with complete rotator cuff tears, without differences in their occurrence (p = 0.60), but were significantly associated with night pain in all the groups (p < 0.01) without differences in tear severity (p = 0.63). The ratio in the high-signal intensity changes (HSIC) positive group was approximately six times higher than that in the HSIC-negative and control groups (P < 0.01). Multivariate logistic regression analysis revealed that night pain is significantly associated with high-signal intensity changes (p < 0.01). ConclusionShoulder pain is a common and reliable clinical finding in patients with high–signal intensity changes, regardless of the presence and/or degree of rotator cuff tears, Such changes may indicate night pain and range of motion limitation in patients.

Bone Marrow Edema, Clinical Significance, and Treatment Options: A Review.

Bone marrow edema (BME) is a descriptive term used to describe high-signal intensity changes detected on magnetic resonance fluid-sensitive sequences that could be attributed to a number of underlying pathologies. Regardless of the cause, physiologic remodeling of the subchondral bone can be limited because of ongoing joint forces, increased focalization of stress, and reduced healing capacity of the subchondral bone. BME is a known prognostic factor associated with pain, dysfunction, and progressive cartilage damage. This review summarizes the current known causes of BMEs, theories related to histopathological changes, and current treatment options including novel biologic surgical options.

Magnetic resonance imaging of lower extremity muscles and isokinetic strength in foot dorsiflexors in patients with prior polio

The thigh and lower leg of six patients with prior polio were examined using magnetic resonance imaging (MRI), and the strength of their weak foot dorsiflexors was measured isokinetically. Spinecho images of the lower extremities were visually evaluated on a semi-quantitative four-point scale, and T1 and T2 relaxation times of the lower leg anterior compartment were analysed. There were prominent MRI signs of randomly distributed muscle degeneration. The high signal intensity changes in the affected muscles on T1-weighted images and T1 and T2 values indicated replacement of muscle fibres with fat and the accumulation of tissue water, respectively. MRI findings were compared with isokinetic strength in foot dorsiflexor muscles. Foot dorsiflexor peak torque values at 30 deg/s ranged from 6 to 29 Nm. There was no significant correlation between MRI visual scoring, T1 and T2 relaxation times and peak torque values at 30 deg/s. However, the most severe MRI changes with visual scoring and T2 relaxation times were observed in the patients with the most pronounced muscle weakness.

Roles of neuroimage in toxic encephalopathy induced by 1, 2-Dichloroethane

ObjectivesToxic encephalopathy induced by exposure to 1,2-dichloroethane(1,2-DCE) may result in central nervous system (CNS) abnormalities. The study was to describe the clinical and neuroimaging features in toxic encephalopathy induced by 1, 2-DCE. Patients and MethodsThe study evaluates six patients with clinical symptoms and neuroimaging who are exposed to 1, 2-DCE, including medical and neurologic examination, CT imaging, proton MR spectroscopy (MRS), Diffusion weighted MR (DW MR) and T1-and T2-weighted MR imaging. Results: All patients who had been exposed to DCE subsequently had seizures or symptoms of intracranial hypertension,including headache, nausea, and vomiting. CT findings: All lesions appeared as low density and bilateral symmetry. The lesions appeared in white matter of cerebral hemisphere diffusely, bilateral cerebellar dentate nuclei, thalamus and globus pallidus. MRI features: All lesions showed high signal intensity on T2WI. Cerebral sulci swelling and compressed or occluded ventricles were seen on CT and MRI. DW MR images obtained at b = 1000s/mm2 revealed symmetrical high signal intensity changes. The apparent diffusion coefficient (ADC) values of lesions were decreased. MR spectroscopic findings established the spectral patterns: increased choline-containing compounds and decreased N-acetylaspartate. ConclusionThe clinical symptoms of intracranial hypertension and the features of CT and MR imagings are useful for early diagnosis and prompt treatment in toxic encephalopathy.

Decompressive craniectomy for herpes simplex encephalitis complicated by frank intracerebral hemorrhage: a case report and review of the literature

BackgroundHerpes simplex encephalitis is the most common type of sporadic encephalitis worldwide. Frank intracerebral hemorrhage complicating the disease course in herpes simplex encephalitis patients is rare, especially cases where surgical decompression is necessary. Here, we report a previously healthy female with herpes simplex encephalitis who underwent surgical decompression due to temporal lobe hemorrhage.Case presentationA previously healthy 34-year-old Korean female presented with fever, myalgia and severe headache. Brain MRI showed a high T2 signal intensity change and diffuse swelling of the right temporal lobe. Polymerase chain reaction testing of the cerebrospinal fluid confirmed the presence of herpes simplex virus 1. The patient was admitted for close observation and intravenous acyclovir. On hospital day 3, she had a sudden onset of vomiting and severe headache. Brain CT showed frank temporal lobe hemorrhage. Despite aggressive medical treatment, she became increasingly drowsy. Ultimately, she underwent emergency right decompressive craniectomy, expansile duraplasty and intracranial pressure monitor insertion. The patient recovered fully without any neurological deficits or neuropsychological problems. She was discharged after completion of 2 weeks of acyclovir and returned 2 months later for cranioplasty.ConclusionsPatients with severe herpes simplex encephalitis complicated by intracerebral hemorrhage or malignant cerebral edema should undergo aggressive medical treatment. Surgical decompression should also be actively considered in these severe cases to prevent further neurological deterioration.

Clinical relation among dural adhesion, dural ossification, and dural laceration in the removal of ossification of the ligamentum flavum

Background ContextDural laceration frequently occurs during surgery in patients with ossification of the ligamentum flavum (OLF), mainly because of dural adhesion (DA) and dural ossification (DO) between the ligamentum flavum and the dura mater. However, the radiological predictive factors of DA in OLF have rarely been reported. PurposeThe objective of this study was to determine the preoperative radiological signs for predicting intraoperative DA in OLF by using preoperative magnetic resonance imaging (MRI) and computed tomography (CT). Study DesignThis is a retrospective study. Patient SampleThis study included 182 patients who underwent decompressive laminectomy and OLF removal from 2005 to 2014. Outcome MeasureDemographic data, preoperative neurologic status, surgical procedure and results, and intraoperative and postoperative complications were analyzed. Clinical outcome was assessed with the Japanese Orthopaedic Association score. Materials and MethodsDepending on the morphologic appearance of OLF in preoperative radiographs, we aimed to investigate the prevalence of intraoperative DA and DO. We used the following factors of representative classifications: (1) surface appearance, (2) “double-layer” or “tram-track” sign, (3) cross-sectional area of the stenosed level, (4) Sato classification as axial classification, (5) Kuh classification as sagittal classification, and (6) high–signal-intensity change on T2-weighted MRI. ResultsIntraoperative evidence of DA was observed in 52 patients (29%), and DO was observed in 23 patients (13%). Twenty-seven patients (15%) had dural laceration during surgery. Statistically, DA was closely associated with the non-uniform type of surface appearance (odds ratio 5.396, p=.001) and with the presence of either a double-layer sign or a tram-track sign (odds ratio 11.525, p<.001). In the preoperative CT and MRI, 21 out of 23 patients with DO showed a “double-layer sign” or a “tram-track sign.” ConclusionsThis study identified two predictive factors of DA in OLF, which were the non-uniform surface appearance and the presence of a double-layer sign or a tram-track sign. The presence of DO in OLF was closely associated with a double-layer sign or a tram-track sign in the preoperative radiological images.

Simultaneous Reconstruction of the Medial and Lateral Collateral Ligaments for Chronic Combined Ligament Injuries of the Ankle

Background: Objective data on chronic injuries of the medial collateral ligament (MCL) of the ankle are scarce. Chronic MCL injuries are frequently associated with lateral collateral ligament (LCL) injuries. For patients with chronic combined MCL and LCL injuries, the authors have performed simultaneous surgery of the 2 ligaments. Hypothesis: Simultaneous surgery of the 2 ligaments may be effectively used to treat chronic combined MCL and LCL injuries. Study Design: Case series; Level of evidence, 4. Methods: Surgical outcomes were evaluated in 29 consecutive patients presenting with chronic MCL and LCL injuries (30 ankles; 15 men and 14 women; mean age, 31 years; 13 competitive and 10 recreational athletes). Preoperative and postoperative clinical outcomes were measured with the Karlsson score and the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score. The patients underwent preoperative and postoperative functional measurements and a radiological examination. In addition, preoperative magnetic resonance imaging (MRI) results, arthroscopic findings, and histology of the MCL were evaluated. Results: Preoperatively, the deep fibers of the MCL did not appear striated in 29 ankles, and high-intensity signal changes were observed in 23 ankles on T2-weighted or gradient echo MRI. MCL ruptures were confirmed with arthroscopic surgery. Medial impingement lesions and focal chondral lesions were confirmed in 10 and 21 ankles, respectively. Histology of the reconstructed MCL showed dense collagen fibers with vessels. The mean postoperative follow-up period was 30 months (range, 24-52 months). There was a significant change between preoperative and postoperative Karlsson scores (69.0 vs 96.1 points, respectively; P < .0001) and JSSF scores (69.8 vs 94.5 points, respectively; P < .0001). On varus and valgus stress radiography, the postoperative talar tilt angle was significantly lower than the preoperative angle. Postoperative anterior displacement on stress radiography was significantly lower than preoperative anterior displacement. Postoperatively, all 23 athletes returned to their preinjury level of sports participation. Conclusion: MCL insufficiency resulted from medial ankle instability and medial impingement lesions. Outcomes in the patients indicated that MCL reconstruction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined MCL and LCL injuries of the ankle.

Whole-body MRI and diffusion MRI

Metastatic bone disease is a common manifestation of advanced cancers with a very high prevalence in breast, prostate and lung cancers. In order to effectively manage patients with metastatic bony disease it is essential to have consistent, reproducible and validated methods for detecting and assessing the response to therapy. In response assessments, confident categorization of response is needed to enable therapeutic strategies to be tailored to individual patient’s benefit. Commonly used methods such as x-rays, bone and CT scans do not always enable the positive assessment of therapeutic benefit to be made but instead provide an evaluation of progression, which then guides therapy decisions in the clinic. Whole body MRI incorporating DW imaging (WB-DWI) has emerged as a promising bone marrow assessment tool [1] for detection [2,3] and therapy monitoring of bone metastases [4]. On WB-DWI, lytic/infiltrative skeletal metastases appear as focal or diffuse areas of high-signal intensity on high b-values on a background of lower signal intensity of the normal bone marrow [4,5]. Metastasis detection with DWI should be done with anatomical MRI [1,4,5]; a recent meta-analysis demonstrated high sensitivity of WB-DWI to detect metastases at the expense of specificity [2]. Causes for false-positive findings on WB-DWI include bone marrow oedema, vertebral haemangioma, isolated bone marrow islands and bone marrow hyperplasia. False-negative findings occur when there are low levels of bone marrow infiltration or when background bone marrow hyperplasia obscures metastases. Detection of skeletal metastases may be impaired in areas of body movement and the visibility of skull base infiltrations is impaired because of the adjacent high signal of the brain. False-negative findings also include treated malignant disease and sclerotic deposits. WB-DWI when combined with emerging “wet” biomarkers can improve the classification of therapy response in patients with metastatic bone disease. Both high b-value image signal intensity and ADC value changes are needed for therapeutic assessments [4,5]. A range of imaging findings can be seen depending on the type of therapy and duration of treatment [4]. Morphologic and diffusion MRI therapy response criteria need to be tested in prospective studies in order to address current, unmet clinical and pharmaceutical needs for reliable measures of tumor response in metastatic bone disease [5].

Prognostic factors for cervical spondylotic amyotrophy: are signs of spinal cord involvement associated with the neurological prognosis?

The purpose of this study was to clarify the prognostic factors for cervical spondylotic amyotrophy (CSA). The authors retrospectively reviewed the medical records of 47 consecutive patients with CSA in whom the presence/absence of the pyramidal tract sign was noted. We analyzed whether the age, sex, presence of diabetes mellitus, medication (vitamin B12), type of the most atrophic and impaired muscle, the muscle strength at the presentation, the presence of the pyramidal tract sign, magnetic resonance imaging (MRI) findings, including the presence and number of T2 high signal intensity areas (T2 HIA) in the spinal cord and the conversion to surgery were associated with the recovery of muscle strength in the patients. In addition, we also investigated whether the duration of symptoms before surgery and the type of surgery were associated with the recovery of muscle strength in patients who required conversion to surgical treatment. The presence of T2 HIA on MRI (P=0.002), the number of T2 HIA on MRI (P=0.002) and conversion to surgery (P=0.015) were found to be significantly associated with a poorer recovery at the observational final follow-up. Further, the presence of the pyramidal tract sign (P=0.043) was significantly associated with a poor recovery at the final follow-up after surgery. The presence of a high signal intensity change on T2-weighted MRI and the pyramidal tract sign can be used as prognostic factors for patients with CSA.

Prognostic value of changes in spinal cord signal intensity on magnetic resonance imaging in patients with cervical compressive myelopathy

Background contextSignal intensity on preoperative cervical magnetic resonance imaging (MRI) of the spinal cord has been shown to be a potential predictor of outcome of surgery for cervical compressive myelopathy. However, the prognostic value of such signal remains controversial. One reason for the controversy is the lack of proper quantitative methods to assess MRI signal intensity. PurposeTo quantify signal intensity and to correlate intramedullary signal changes on MRI T1- and T2-weighted images (WIs) with clinical outcome and prognosis. Study designRetrospective case study. Patient samplePatients (n=148; cervical spondylotic myelopathy, n=102 and ossified posterior longitudinal ligament, n=46) who underwent surgery for cervical compressive myelopathy and had high signal intensity change on sagittal T2-WI MRI before surgery between 2006 and 2010. Outcome measureNeurologic assessment was conducted with the Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy. The rate of neurologic improvement was calculated with the use of preoperative and postoperative JOA scores. MethodsQuantitative analysis of MRI signal on both T1- and T2-WIs via use of the signal intensity ratio (SIR; signal intensity of lesion relative to that at C7-T1 disc level) was performed. Correlations between SIR on T1- and T2-WIs and preoperative JOA score, JOA improvement rate, disease duration, and MRI morphologic classification (cystic or diffuse type) were analyzed. Multivariate regression analysis for JOA improvement rate was also analyzed. In a substudy, 25 patients underwent follow-up MRI starting from 6 months after surgery to analyze the relationship between changes in SIR on follow-up MRI and clinical outcome. ResultsSIR on T1-WIs, but not SIR on T2-WIs, correlated with postoperative neurologic improvement. The disease duration correlated negatively with SIR on T1-WIs and JOA improvement rate but not with SIR on T2-WIs. SIR on T2-WIs of “cystic type” was significantly greater than of “diffuse type,” but SIR on T1-WI and JOA improvement rate were not different in the two types. Stepwise multivariate regression analysis indicated that SIR on T1-WIs and long disease duration were significant predictors of postoperative neurologic outcome. SIR on follow-up T1-WI and changes in SIR on T1-WI after surgery correlated positively with postoperative improvement rate. SIR on follow-up T2-WI and changes on T2-WI correlated negatively with postoperative neurologic improvement. ConclusionsOur results suggest that low intensity signal on preoperative T1-WIs but not T2-WIs correlated with poor postoperative neurologic outcome. Furthermore, decreased signal intensity on postoperative T1-WIs and increased signal intensity on postoperative T2-WIs are predictors of poor neurologic outcome.

Systematic Review of Magnetic Resonance Imaging Characteristics That Affect Treatment Decision Making and Predict Clinical Outcome in Patients With Cervical Spondylotic Myelopathy

Systematic review. To determine whether there are magnetic resonance imaging (MRI) characteristics in patients with cervical spondylotic myelopathy that affect treatment decisions or predict postsurgical outcomes or adverse events. Although the role of MRI in confirming the clinical diagnosis of cervical spondylotic myelopathy and directing surgical management is well established, its potential value as a prognostic tool is largely unknown. A systematic search was conducted using PubMed and the Cochrane Collaboration Library for articles published between January 1, 1956, and November 20, 2012. The overall body of evidence with respect to each clinical question was determined on the basis of precepts outlined by the Grading of Recommendation Assessment, Development and Evaluation Working Group and recommendations made by the Agency for Healthcare Research and Quality. The initial search yielded 268 citations. Twenty publications met all inclusion criteria and were included in the review. Three of these assessed MRI predictors of clinical deterioration in the case of conservative treatment and 17 evaluated MRI anatomic or cord characteristics that could predict surgical outcome or adverse events. There is low evidence suggesting that a high signal intensity (SI) grade on T2WI is not associated with patient deterioration during conservative treatment. High SI grade on T2WI, along with compression ratio and canal diameter, was not an important predictor of outcome. There is low evidence identifying number of high SI segments on T2WI, low SI segments on T1WI, combined T1/T2 SI, and SI ratio as important negative predictors of surgical outcome. On the basis of this review and on low-quality evidence, we have identified 3 important negative predictors of surgical outcome: number of high SI segments on T2WI, combined T1/T2 signal change, and SI ratio.EVIDENCE-BASED CLINICAL RECOMMENDATIONS: We suggest that when clinically feasible, surgeons rely on MRI to confirm the diagnosis of CSM and rely on clinical history and examination to determine progression and severity of disease. Low. Weak. T2 signal may be a useful prognostic indicator when used in combination with low SI change on T1WI, or as a ratio comparing compressed with noncompressed segments, or as a ratio of T2 compared with T1WI. We suggest that if surgeons use MRI signal intensity to estimate the risk of a poor outcome after surgery, they use high SI change on T2WI in combination with other signal intensity parameters, and not in isolation. Low. StrENGTH OF RECOMMENDATION: Weak.

Characteristics of Clinical and Imaging Findings in Adolescent Lumbar Spondylolysis Associated with Sports Activities

Abstract Background: Adolescent lumbar spondylolysis is considered to be a fatigue fracture caused by repeated mechanical stress and sports activities are often thought to be the cause. The incidence of lumbar spondylolysis has been reported to be generally 3%-6%, and 4%-10% among patients complaining LBP. In athletes, the incidence of lumbar spondylolysis during adolescence has ranged from approximately 15% to 50%. The purpose of this study was to prospectively investigate to determine the imaging and pain characteristics of spondylolysis on lumbar extension among adolescent patients with Low Back Pain (LBP) who played sports. Methods: 100 patients (a mean age of 14.8 years) were selected as the subjects and were investigated sports activities, duration of LBP, and pain with lumbar repetitive extension. Plain X-ray, CT, and high-intensity signal changes in the pedicle on T2 MRI were examined for diagnostic indications of lumbar spondylolysis. Results: Spondylolysis was confirmed by plain X-ray in 34 patients, 8 were confirmed on CT. Spondylolysis was eventually identified in 42 of the 100 patients (42.0%). High-intensity signal changes in the pedicle on T2 MRI were recognized in 29 cases. Pain with lumbar extension occurred in 69 of the 100 patients (69.0%) including 34 of the 42 patients with spondylolysis (81.0%) and 35 of the 58 patients without spondylolysis (60.3%). Therefore, the sensitivity of the lumbar extension was 81.0% (34/42), and its specificity was 39.7% (23/58). Conclusion: Among adolescent athletes, the incidence of lumbar spondylolysis was 42.0%, and of the 69 patients with pain with lumbar extension, 34 (81.0%) were confirmed to have spondylolysis. Pain with lumbar extension appears to be a good screening indicator for adolescent lumbar spondylolysis.

A case of reversible posterior leukoencephalopathy syndrome in a patient on peritoneal dialysis

Reversible posterior leukoencephalopathy syndrome (RPLS) is a recently identified clinical and radiologic entity. The characteristic radiologic findings are bilateral gray and white matter edema in the posterior regions of the cerebral hemispheres. The typical clinical syndrome includes headache, confusion, visual symptoms, and seizures. RPLS most often occurs in the setting of hypertensive crisis, preeclampsia, or with cytotoxic immunosuppressive therapy, but many other clinical settings are described, such as cryoglobulinemia, hemolytic uremic syndrome, systemic lupus erythematosus, and use of erythropoietin. A 24-year-old man, diagnosed as having anaphylactoid purpura nephritis at 12 years of age and who started peritoneal dialysis (PD) at 23 years of age, was admitted to our hospital with a seizure and consciousness disturbance. His blood pressure (BP) and body fluid volume had not been controlled well because of poor compliance with medication and PD. T2-weighted magnetic resonance imaging (MRI) revealed high signal intensity changes restricted to the cortex and subcortical white matter of the cerebellum. On the other hand, diffusion-weighted imaging showed an isointense signal. From these findings, he was diagnosed as having RPLS. With appropriate control of BP and volume control by PD and hemodialysis, his symptoms improved, and a follow-up cranial MRI 1 month later was almost normal. To the best of our knowledge, this is the first report of RPLS in an adult PD patient.

Chronic Spinal Cord Injury in the Cervical Spine of a Young Soccer Player

A 17-year-old male soccer player presented with numbness in the upper- and lower-left extremities of 6 months' duration. He had no apparent history of trauma but experienced neck pain during heading of the ball 5 years prior. A high-signal intensity area was seen on T2-weighted magnetic resonance imaging (MRI) of the cervical spine. No muscle weakness was observed. Hypoesthesia was observed in bilateral forearms, hands, and extremities below the inguinal region. Plain radiographs in the neutral position showed local kyphosis at C3/4. A small protrusion of the C3/4 disk was observed on T1-weighted MRI. A high-signal area in the spinal cord at the C3/4 level was observed on T2-weighted MRI, but this was not enhanced by gadolinium. Multiple sclerosis, intramedullary spinal cord tumor, sarcoidosis and malignant lymphoma, and spinal cord injury were all considered in the differential diagnosis. However, in view of the clinical, laboratory, and radiological investigations, we concluded that repeated impacts to the neck caused by heading of the ball during soccer induced a chronic, minor spinal cord injury. This contributed to the high-signal intensity change of the spinal cord in T2-weighted MRI. The present case demonstrates that repeated impact may cause chronic spinal cord injury. Soccer, American football, or rugby players presenting with neck or extremity symptoms should not be overlooked for the possibility of latent spinal cord injury, as this could present later development of more severe or unrecoverable spinal cord injuries.