Ayhan Mutlu

The role of DTI in early detection of cervical spondylotic myelopathy: a preliminary study with 3-T MRI.

IntroductionThe radiological diagnosis of cervical spondylotic myelopathy (CSM) has to be made as soon as possible, since surgery performed in earlier stages during the course of CSM was reported to be more successful when compared with later stages. We hypothesized that diffusion tensor imaging (DTI) may detect CSM in earlier stages, before the appearance of signal increase in T2-weighted sequences.MethodsA total of 16 patients with neurological signs and symptoms of CSM but without hyperintensity in spinal cord on T2-weighted sequences enrolled in the study. The magnetic resonance (MR) examinations were performed on a 3-T MR imaging system. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) maps were generated on axial plane. The ADC and FA measurements in each individual were made at the level of most severe cervical canal stenosis and at a nonstenotic level. Student’s t test was used to compare FA and ADC values of the spinal cord in stenotic and nonstenotic segments. We also investigated if there was a correlation between DTI parametrics and duration of clinical symptoms by using Pearson correlation analysis.ResultsAll patients showed changes in DTI parametrics at stenotic segments. While FA values of the spinal cord at the stenotic level showed a statistically significant reduction, there was a statistically significant increase in the measured ADC values (p < 0.001). There was no statistical correlation between the duration of symptoms and DTI parametrics.ConclusionOur preliminary findings indicate that DTI may show abnormalities in the spinal cord before the development of T2 hyperintensity on conventional sequences in patients with CSM.

Ischiofemoral impingement syndrome: another cause of extraspinal sciatica.

A 76-year-old woman was admitted to our hospital with complaints of right buttock pain and sciatica. Magnetic resonance imaging was performed. The magnetic resonance imaging showed right ischiofemoral narrowing, edema, and increased signal intensity within the quadratus femoris muscle (Fig. 1). The initial visual analogue scale was 8–9. Computerized tomography-guided percutaneous steroid and local anesthetic injection was performed. Then non-steroidal antiinflammatory drug treatment and exercise program was initiated. After 12 weeks of treatment, pain of the right hip was decreased gradually to visual analogue scale 2–3. Ischiofemoral space is the smallest distance between the ischial tuberosity and lesser trochanter of the femuron axial T1weighted images. Ischiofemoral impingement is characterized by abnormalities of quadratus femoris muscle and narrowing of the space between the lesser trochanter of the femur and the ischial bone (1). It is usually seen in women and is a rare cause of sciatica. The common causes are history of surgery, fracture or arthrosis, hamstrings tendinopathy, or congenital.

A Case of Anomalous Origin and Course of Vertebral Artery in a Patient with Klippel Feil Syndrome

Patients with Klippel-Feil syndrome (KFS) have an increased incidence of vascular anomalies as well as vertebral artery (VA) anomalies. In this article, we presented imaging findings of a 15-year-old female patient with KFS with a rare association of extraforaminal cranially ascending right VA that originated from the ipsilateral carotid bulb. Trifurcation of the carotid bulb with VA is a very unusual variation and to the best of our knowledge, right-sided one has not been reported in the literature.

Selective Thoracic Fusion Provides Similar Health-Related Quality of Life but Can Cause More Lumbar Disc and Facet Joint Degeneration: A Comparison of Adolescent Idiopathic Scoliosis Patients With Normal Population 10 Years After Surgery

OBJECTIVES To evaluate the long-term behavior of the lumbar curve in patients with adolescent idiopathic scoliosis treated with selective thoracic fusion and to assess the clinical and radiologic outcomes in this fusion group compared with an age- and gender-matched group. SUMMARY OF BACKGROUND DATA Selective thoracic fusion for the treatment of adolescent idiopathic scoliosis (AIS) preserves lumbar motion segments but leaves a residual deformity. By avoiding fusion of the lumbar spine, a greater mobility may be preserved, which may be an advantage in long-term follow-up in terms of degenerative changes in unfused segments. METHODS Group A included 25 AIS patients with mean a age of 23.8 years and a mean 11.4 years of follow-up. Group B included 30 age- and gender-matched subjects without any deformity. Preoperative, postoperative, and follow-up radiographs were reviewed. All patients had MRIs taken at the final follow-up in order to evaluate disc degeneration (DD) and facet joint degeneration (FJD) at the unfused lumbar spine. Clinical evaluation was done by using Scoliosis Research Society-22R, Oswestry Disability Index, and numerical rating scale. RESULTS Sagittal and coronal balance and lowest instrumented vertebra disc angulation were stable over time. Mean grading of lumbar DD was 2.16 (2-4) in Group A and 1.86 (1-3) in Group B. Lumbar FJDs were 2.05 (1-4) in Group A and 1.60 (1-3) in Group B. There was significant difference between the two groups for DD except for the L4-L5 level (p = .26). FJD was significantly higher in the L1-L2 and L2-L3 levels (L1-L2, p = .002, L2-L3, p = .002) but not for the other levels. Outcome scores were similar without significant differences between the two groups (p > .05). CONCLUSION Selective thoracic fusion provides satisfactory outcomes at more than 10 years of follow-up. Our study demonstrated a moderate increase in the rate of disc degeneration in the unfused segments. Facet joint degeneration was significant at the upper two levels adjacent to the lowest instrumented vertebra.

A case of combined congenital anterior and posterior arch anomaly of C1 vertebra

A very rare case of the craniovertebral junction (CVJ) anomaly is reported owing to its rarity and clinical significance. Computed tomography (CT) and magnetic resonance imaging (MRI) studies of the cervical spine of a 56 -year-old female patient presented with head trauma, revealed an anterior midline arch cleft of atlas with totally aplastic posterior neural arch, as well as anteriorly subluxed right atlantoaxial joint. The coexistence of a total aplasia of the posterior neural arch and anterior arch cleft of atlas is very rare. Congenital anomalies affecting the craniovertebral junction (CVJ) may mimic traumatic injury in the setting of a previous trauma. In this presented case, the absence of an associated bone and soft-tissue edema on the MR imagings helped us to make a differention between the acute traumatic injury and congenital anomaly

Solitary plasmacytoma of the thoracic spine

A31-year-old man was admitted to our hospital with back pain for 3 months. His medical and family history was unremarkable. Physical examination revealed tenderness to palpation of the thoracic spine. Radiographs of the thoracic spine showed height loss of the T5 vertebral body. Computerized tomography and magnetic resonance imaging were performed. Computed tomography showed expansile lytic lesion with thinned cortex (Fig. 1). The lesion has low signal intensity on T1-weighted magnetic resonance images and high signal intensity on T2-weighted magnetic resonance images (Fig. 2). Corpectomy, reconstruction with titanium mesh cage, and anterior and posterior stabilization were performed. Pathology was consistent with plasmacytoma. Solitary plasmacytoma of bone is a seldom malignancy. It most commonly affects the axial skeleton. Thoracic vertebrae are most commonly involved.

Congenital cervicothoracic spondyloptosis in a 7-month-old patient.

A 7-month-old patient presented with cervicothoracic bulge recognized by the parents. Cervicothoracic computed tomography and magnetic resonance imaging were performed to demonstrate the pathology. Distinct anterior displacement and inferior slippage of cervical vertebral block over subjacent thoracic vertebrae, impaction of the thoracic vertebral block into the enlarged cervical spinal canal, and multilevel posterior fusion defects throughout the cervical vertebrae were seen in his CT images (Fig. 1). Spinal cord was angulated and thickened at the level of impaction by the thoracic vertebral block, and there were irregularity and increased focal nodular signal intensity in the anterior part of the distal

Large thoracic extradural schwannoma atypically invading T2 vertebra

A 53-year-old woman presented with a complaint of back pain. Her medical history and physical examination were unremarkable. Magnetic resonance imaging of the thoracic spine showed a large extradural mass on the right side at the T2– T3 levels (Fig. 1). The lesion widened the right neural foramen and had a large extraspinal component with extension into the posterior mediastinum. The lesion invaded the posterior and right posterolateral parts of the T2 vertebral body (Fig. 2). It was heterogeneously hypointense to muscles on T1weighted, and hyperintense on T2-weighted images. Postcontrast images showed intense enhancement of the lesion. The tumor was resected, and T2 corpectomy was also performed. Histopathologic examination revealed the diagnosis of schwannoma without malignant transformation. Schwannoma is the most common spinal nerve sheath tumor, which is followed by neurofibroma and ganglioneuroma. Invasion and osteolytic expansion of the vertebral body by schwannoma is extremely rare. Schwannoma should be included in the differential diagnosis of large extradural lesion causing invasion and destruction of the spine, especially if it shows typical imaging findings such as neural foraminal widening and adjacent bony remodeling [1].

Benign notochordal cell tumor of C2 vertebra mimicking metastasis

A 28-year-old man was admitted to our hospital with cervical pain for 3 months. The patient had a history of testicular seminoma and was operated 6 years ago. His physical examination and lateral cervical spine x-ray were normal. Magnetic resonance imaging was performed, and the images showed hypointense signal on T1-weighted images and hyperintense signal on T2-weighted images at the C2 vertebral body (Figure). Transoral biopsy was performed due to suspicion of metastasis; pathology was consistent with benign notochordal cell tumor. Metastasis or chordoma was not detected. Benign notochordal cell tumor is a rare intraosseous benign lesion of notochordal cell origin. Differential diagnosis includes chordoma, metastatic disease, hemangioma, lymphoma, and Paget disease. Onur Levent Ulusoy, MD Suleyman Tutar, MD Ersin Ozturk, Assoc. Prof. Ayhan Mutlu, MD Istanbul Florence Nightingale Hospital Department of Radiology 34381, Sisli, Istanbul, Turkey GATA Haydarpasa Teaching Hospital Department of Radiology 34668, Uskudar, Istanbul, Turkey

Back pain due to spinal metastatic leiomyosarcoma

A 25-year-old female patient presented with severe back pain. Contrast-enhanced thoracic magnetic resonance imaging revealed a large mass lesion at the body of the T11 vertebra and adjacent paravertebral soft tissues including the retroaortic area. The lesion was hypointense on T1-weighted images and hyperintense on T2-weighted images (Fig. 1A–C, E, and F). After intravenous contrast medium administration, the lesion showed diffuse and significant contrast enhancement (Fig. 1D and G). Computed tomography-guided percutaneous core needle biopsy was performed for the definitive diagnosis (Fig. 2, Left). The histopathologic diagnosis of the lesion was reported as metastatic leiomyosarcoma. The patient was given a neoadjuvant chemotherapy as the first step of treatment. The soft tissue component of the lesion demonstrated a marked decrease in size on her control contrast-enhanced thoracic MRI performed at the end of this chemotherapy protocol (Fig. 2, Middle and Right). After this initial treatment, T11 corpectomy operation was performed so as to resect the bony part of the lesion.