Charles H. Cho

Magnetic resonance imaging validation of pituitary gland compression and distortion by typical sellar pathology

OBJECT Identification of the normal pituitary gland is an important component of presurgical planning, defining many aspects of the surgical approach and facilitating normal gland preservation. Magnetic resonance imaging is a proven imaging modality for optimal soft-tissue contrast discrimination in the brain. This study is designed to validate the accuracy of localization of the normal pituitary gland with MRI in a cohort of surgical patients with pituitary mass lesions, and to evaluate for correlation between presurgical pituitary hormone values and pituitary gland characteristics on neuroimaging. METHODS Fifty-eight consecutive patients with pituitary mass lesions were included in the study. Anterior pituitary hormone levels were measured preoperatively in all patients. Video recordings from the endoscopic or microscopic surgical procedures were available for evaluation in 47 cases. Intraoperative identification of the normal gland was possible in 43 of 58 cases. Retrospective MR images were reviewed in a blinded fashion for the 43 cases, emphasizing the position of the normal gland and the extent of compression and displacement by the lesion. RESULTS There was excellent agreement between imaging and surgery in 84% of the cases for normal gland localization, and in 70% for compression or noncompression of the normal gland. There was no consistent correlation between preoperative pituitary dysfunction and pituitary gland localization on imaging, gland identification during surgery, or pituitary gland compression. CONCLUSIONS Magnetic resonance imaging proved to be accurate in identifying the normal gland in patients with pituitary mass lesions, and was useful for preoperative surgical planning.

Sacral Fractures and Sacroplasty

Pain from sacral insufficiency fractures or metastatic tumor to the sacrum, refractory to radiation and/or chemotherapy, can be extremely debilitating to affected patients. Conservative medical therapy with rest, limited ambulation, and pain medication has been the mainstay of treatment. Open surgical fixation is reserved for severe fracture that does not heal with rest. A minimally invasive treatment, sacroplasty, is gaining popularity and uses image-guided, percutaneous injection of surgical cement into the fracture. This article reviews the incidence, causes, diagnosis, presentation, and treatment options for sacral fractures, and describes detailed technical steps of the sacroplasty procedure.

Cervical nerve injection: computed tomography guidance with intravenous contrast and extraforaminal needle placement. Series of seven consecutive case reports

BACKGROUND CONTEXT Image-guided cervical nerve injections are being performed with increasing frequency. Severe complications are being reported. PURPOSE The purpose of this study is to introduce a technique for cervical nerve injection that may decrease the possibility for severe complications. STUDY DESIGN/SETTING This is a series of case reports describing the technique and clinical follow-up. PATIENT SAMPLE The sample comprises seven consecutive cases of unilateral neck and arm pain referred for cervical nerve injection. OUTCOME MEASURES Retrospective evaluation of pain relief before and after the injection and at follow-up is reported as case studies. METHODS The technique for computed tomography guided cervical nerve injection is described with case reports of seven consecutive patients. RESULTS The results are case reports of each of the seven patients after unilateral cervical nerve injection. CONCLUSION A technique for cervical nerve injection is described with the results of the injection. This technique may allow some standardization in the procedure, decrease the learning curve for training physicians, and minimize the potential complications.

Redesign and Implementation of the Radiology Clerkship: From Traditional to Longitudinal and Integrative

PURPOSE The authors discuss the evolution and application of 3 radiology teaching methods-a fundamentals-of-imaging course, a combined clinical-radiology case conference, and a radiology objective structured clinical examination-to medical education at the Brigham and Womens Hospital site of Harvard Medical School. METHODS The evolution of the medical student radiology teaching program from content needs assessment to blueprint creation, through implementation, is outlined. RESULTS The 3 components of the teaching program are described. The changes in format in response to feedback and challenges faced in deploying this new curriculum are detailed. Results from student surveys and the radiology objective structured clinical examination scores from recent years are also presented. CONCLUSIONS As radiology assumes an increasingly central role in patient care and diagnosis, the need for effective integration of radiology teaching into medical education becomes more critical. The concepts presented here have been deemed to be successful by students and faculty members and may be applicable to other institutions.

Kyphoplasty: Balloon Assisted Vertebroplasty

Pain relief after Percutaneous Vertebroplasty (PV) has been reported in 85-90% of patients with Vertebral Compression Fractures (VCFs),1-4 but the deformity of the vertebral body or the subsequent kyphosis (usually related to multiple compressions) was not a primary focus of this procedure when it was first introduced5 (For a more exhaustive treatment of vertebroplasty, see Chap. 12).

The Lumbar Neural Foramen and Transforaminal Epidural Steroid Injections: An Anatomic Review With Key Safety Considerations in Planning the Percutaneous Approach

OBJECTIVE The purpose of this article is to review the anatomy of the lumbar neural foramen and to describe techniques of transforaminal epidural steroid injections with emphasis on safety. Rare cases of paraplegia have been reported. CONCLUSION Although no consensus currently exists about which approach is the safest, knowledge of the foraminal anatomy is a key consideration when choosing a needle approach for transforaminal epidural steroid injections.

Cervical spine mass imaging: MRI or CT

A 23-year-old man presents with a 4-year history of chronic neck pain, which the patient initially attributed to playing football throughout high school and college. Over the past 6 months, the patient started experiencing left leg sciatica and left hamstring tightness and developed bandlike abdominal paresthesia over the past 4 months. More recently, he noticed erectile dysfunction and mild urinary retention. Physical examination showed hypesthesia in both flanks and anterior thighs. The examination was

Pharmaceuticals used in image-guided spine interventions.

As image-guided (nonvascular) spine interventions have become progressively more common in the interventional radiologic community, there is a growing need for physician expertise regarding the materials and pharmaceuticals that are used for these procedures. This article is intended to provide information to address these needs.

Is focused magnetic resonance imaging adequate for treatment decision making in acute traumatic thoracic and lumbar spine fractures seen on whole spine computed tomography

PURPOSE To assess whether a focused magnetic resonance imaging (MRI) limited to the region of known acute traumatic thoracic or lumbar fracture(s) would miss any clinically significant injuries that would change patient management. STUDY DESIGN/SETTING A multicenter retrospective clinical study. PATIENT SAMPLE Adult patients with acute traumatic thoracic and/or lumbar spine fracture(s). OUTCOME MEASURES Pathology identified on MRI (ligamentous disruption, epidural hematoma, and cord contusion), outside of the focused zone, an alteration in patient management, including surgical and nonsurgical, as a result of the identified pathology outside the focused zone. METHODS Records were reviewed for all adult trauma patients who presented to the emergency department between 2008 and 2016 with one or more fracture(s) of the thoracic and/or lumbar spine identified on computed tomography (CT) and who underwent MRI of the entire thoracic and lumbar spine within 10 days. Exclusion criteria were patients with >4 fractured levels, pathologic fractures, isolated transverse, and/or spinous process fractures, prior vertebral augmentation, and prior thoracic or lumbar spine instrumentation. Patients with neurologic deficits or cervical spine fractures were also included. MRIs were reviewed independently by one spine surgeon and one musculoskeletal fellowship-trained emergency radiologist for posterior ligamentous complex (PLC) integrity, vertebral injury, epidural hematoma, and cord contusion. The surgeon also commented on the clinical significance of the pathology identified outside the focused zone. All cases in which pathology was identified outside of the focused zone (three levels above and below the fractures) were independently reviewed by a second spine surgeon to determine whether the pathology was clinically significant and would alter the treatment plan. RESULTS In total, 126 patients with 216 fractures identified on CT were included, with a median age of 49 years. There were 81 males (64%). Sixty-two (49%) patients had isolated thoracolumbar junction injuries and 36 (29%) had injuries limited to a single fractured level. Forty-seven (37%) patients were managed operatively. PLC injury was identified by both readers in 36 (29%) patients with a percent agreement of 96% and κ coefficient of 0.91 (95% CI 0.87-0.95). Both readers independently agreed that there was no pathology identified on the complete thoracic and lumbar spine MRIs outside the focused zone in 107 (85%) patients. Injury outside the focused zone was identified by at least one reader in 19 (15%) patients. None of the readers identified PLC injury, cord edema, or noncontiguous epidural hematoma outside the focused zone. Percent agreement for outside pathology between the two readers was 92% with a κ coefficient of 0.60 (95% CI 0.48-0.72). The two spine surgeons independently agreed that none of the identified pathology outside of the focused zone altered management. CONCLUSIONS A focused MRI protocol of three levels above and below known thoracolumbar spine fractures would have missed radiological abnormality in 15% of patients. However, the pathology, such as vertebral body edema not appreciated on CT, was not clinically significant and did not alter patient care. Based on these findings, the investigators conclude that a focused protocol would decrease the imaging time while providing the information of the injured segment with minimal risk of missing any clinically significant injuries.

CT-Guided Percutaneous Spine Biopsy Specimen Adequacy, Pathology Concordance, and Negative Predictive Value with Battery-Powered Drill and Manual Approaches

OBJECTIVE Determine computed tomography-guided percutaneous spine biopsy specimen adequacy, pathology-imaging concordance, and negative predictive value with battery-powered drill vs manual approach. MATERIALS AND METHODS One-hundred-fourteen consecutive computed tomography-guided percutaneous spine biopsies in 109 patients (age: 61.1 ± 15.4 years; range: 17-90 years; males: 55, 50.5%; females: 54, 49.5%) performed at a single institution from September 2013 through January 2017 were retrospectively reviewed. Specimen adequacy was recorded. Imaging-pathology concordance was assessed. Chi-square tests compared specimen adequacy and imaging-pathology concordance obtained with a battery-powered drill vs manual approach. Negative predictive values were calculated. RESULTS Battery-powered drill yielded slightly better, but not statistically significant, specimen adequacy (96% vs 90% overall, P = 0.270; 96% vs 89% for suspected neoplasm, P = 0.278; 95% vs 90% for suspected infection, P = 0.514), pathology-imaging concordance (82% vs 74% overall, P = 0.301; 92% vs 77% for suspected neoplasm, P = 0.107; 71% vs 65% for suspected infection, P = 0.602), and negative predictive value (65% vs 41% overall; 75% vs 33% for suspected neoplasm; 58% vs 33% for suspected infection). Four battery-powered drill procedures were technically unsuccessful. CONCLUSIONS Use of a battery-powered drill appears to yield similar to slightly better spine biopsy specimens than a manual approach, but also appears to carry a greater risk of technical failure. The battery-powered drill may be particularly helpful for procedures with complex approaches, but trajectory planning remains of paramount importance.