E. Puglielli

Degenerative disorders of the spine

Patients with back pain and degenerative disorders of the spine have a significant impact on health care costs. Some authors estimate that up to 80% of all adults experience back pain at some point in their lives. Disk herniation represents one of the most frequent causes. Nevertheless, other degenerative diseases have to be considered. In this paper, pathology and imaging of degenerative spine diseases will be discussed, starting from pathophysiology of normal age-related changes of the intervertebral disk and vertebral body.

Rectal endometriosis: MRI study with rectal coil

Accepted: 3 May 2004 Published online: 29 July 2004

Usefulness of Imaging Fusion for Therapeutic Planning in Skull Base Lesions

We propose critical considerations on the usefulness of CT, MRI, and fMRI imaging fusion for the treatment of skull base lesions evaluating 41 cases (24 meningiomas: six petroclival, seven clinoidal, four olfactory, two in the foramen magnum, two spheno-petro-clival, one in the planum sphenoidale, one in the posterior pyramid and one in the PCA; five acoustic schwannomas, three epidermoids, two pituitary adenomas, two craniopharingiomas, two posterior fossa aneurysms, one trigeminal schwannoma, one dermoid and one juvenile angiofibroma). Data were collected, fused, integrated and reconstructed by a dedicated Stealth-Station system for Neuronavigation. CT images were acquired on axial non-overlapping slices, 1–3 mm thick; MRI images were obtained with a 1.5 T system, same FOV and thickness. During surgery the Mean Fiducially Error measured at 6 cm depth and anatomical distortion due to CSF loss was evaluated. Neuronavigation was possible in all cases and successfully applied in preoperative planning and during surgical procedures. The Mean Fiducially Error at 6 cm was 1.7 mm. CSF loss during surgery produced modifications on planned anatomy in a mean value of 0.6 mm. In all cases, imaging fusion for pre and intra-operative neuronavigation provided great advantages in the choice of the best approach, placing of bone flap, correct definition of tumour boundaries and meningeal implant, relationship with functional areas, early identification and real-time correction of the surgical route with respect of deep normal or distorted anatomic or pathologic structures and their eventual encasement or involvement by the pathologic primary process. Neuronavigation appeared ideal for skull base meningiomas making surgical manoeuvres safer, more effective and less invasive. In skull base lesions, CSF loss appeared not significant due to the fact that posterior fossa structures are strictly connected to each other and to the bone, thus are poorly affected by surgical deliquoration. We propose the possible extension of imaging fusion technique with the aim of optimizing the target in radiotherapy for intracranial tumours.

Un raro caso di vitreo iperplastico primitivo persistente bilaterale (VPIP) Studio RM e follow-up

We describe the magnetic resonance features of a rare case of bilateral persistent primitive vitreous. After an initial MR scan, a follow-up investigation disclosed a stationary picture. Thanks to its multiplanar features, MR allowed the correct identification and characterization of the malformation together with its associated endobulbar changes. The exceptional presence of a bilateral lesion, described in very few literature reports, makes the diagnosis difficult on a clinical basis. Current neuroradiological techniques offer crucial diagnostic support and allow differential diagnosis. Technical know-how and a knowledge of the symptoms of this disease are essential.

RM in pediatria Revisione delle tecniche anestesiologiche in 1800 casi

We describe the anaesthesiological protocol and monitoring system for children receiving sedation or general anaesthesia during MR investigation at our hospital. Constant recourse to sedation and analgesia during diagnostic procedures in children makes non-invasive monitoring of vital parameters essential in these patients. The use of short-acting drugs has the advantage of offering effective sedation with an increasingly low incidence of side effects. We report the ten year experience of a single anaesthetist monitoring children undergoing MR scans. Diagnostic quality MR investigation was possible in all cases. The personal experience of a single anaesthetist optimized an effective and safe anaesthesiological protocol.

Pneumorachide cervicale Descrizione di un caso post traumatico in una bambina di otto anni

We describe an eight-year-old girl who developed cervical pneumorachis after traumatic injury. The child presented subcutaneous and mediastinal emphysema and subluxation of the large horns of the hyoid bone disclosed by CT scan a few hours after an accidental fall with mandibular impact. The CT scan also showed a left paramedian collection of air in the spinal canal probably caused by a minor tracheal lesion with passage of air in the posterior mediastinum, paravertebral soft tissues and through the nerve sheaths in the extradural spine. The CT picture normalized after ten days. The presence of air in the epidural space of the spinal canal is more commonly associated with epidural abscess, disc degeneration and sometimes lumbar puncture. Some literature reports describe cases of pneumorachis secondary to pelvic trauma.

Considerazioni sulla patologia traumatica dorsale in età pediatrica Esperienza di 4 anni presso una struttura Ospedaliera non specialistica

Trauma remains one of the major causes of death in children and adolescents. The mechanisms underlying response to traumatic injury differ radically in adults and children for anatomical and biomechanical reasons. This study is a retrospective review of all patients admitted to our hospital with suspect spinal trauma from 1999 to date, analysing in children the incidence, type of bone injury, possible spinal cord involvement and clinical condition on discharge. Of 143 cases of spinal trauma examined at our hospital over a four-year period by x-ray, computed tomography and magnetic resonance imaging, 21 were aged between six and 16 years. In agreement with literature reports, the incidence was lower than that in adults, but carried a worse prognosis. Although not common, spinal trauma in childhood entails a high incidence of severe permanent neurological disability due to direct involvement of the spinal cord. It is necessary for neuoradiologists to be familiar with problems relating to the biomechanics of the spine in childhood since prompt diagnosis may reduce the neurological deficits and allow appropriate management of these young patients.

Ruolo delle sequenze FLAIR post contrasto nella diagnosi precoce delle meningiti

Sono sempre più numerose le indicazioni all’utilizzo del mezzo di contrasto in Risonanza Magnetica (RM) nello studio delle patologie del sistema nervoso centrale. Il mezzo di contrasto maggiormente utilizzato è rappresentato dai composti del gadolinio, che determinano un accorciamento dei tempi di rilassamento T1 e T2. Alle dosi cliniche è però predominante l’effetto sul tempo di rilassamento T1 ed infatti l’esame post-contrastografico viene effettuato generalmente utilizzando sequenze T1-pesate . L’effetto paramagnetico del gadolinio può però manifestarsi anche in altri tipi di sequenze come in quelle pesate in densità protonica (DP) e T2-pesate . Particolare interesse è stato posto da numerosi autori nell’utilizzo post-contrastografico di sequenze fast inversion recovery con attenuazuione del segnale liquorale (FLAIR) . Iniziali valutazioni cliniche hanno dimostrato che tale tecnica offre informazioni non ottenibili con il solo studio T1 post-gadolinio. Scopo di questo lavoro è stato quello di valutare l’utilità clinica delle sequenze fast-FLAIR post-contrasto in comparazione con le sequenze fast-SE T1-pesate in pazienti con sospetto coinvolgimento meningeo di natura infettiva.

Patologia degenerativa disco-somatica: Valore predittivo della Neuroradiologia

L’evoluzione spontanea dell’ernia discale lombo-sacrale in pazienti trattati con terapia conservativa in alcune casistiche presenta un incidenza di più del 70% dei casi . Le ipotesi variamente formulate comprendono la migrazione caudale del frammento erniato, il riassorbimento all’interno dell’anulus, o, più verosimili e accreditate, la disidratazione per distacco dal disco genitore e la fagocitosi. La disidratazione è evento finale della deafferentazione di materia nutritizia per disconnessione dal disco. A questa consegue il raggrinzimento e la frammentazione del disco. La fagocitosi deriva dal considerare il materiale erniato come altamente flogogeno . Il nucleo, in particolare, presenta antigeni segregati che, una volta esposti, attivano processi flogistici. La flogosi realizzata è in sé in grado di amplificare il meccanismo algogeno per rilascio di chemio mediatori. D’altro canto lo stesso tessuto flogistico e l’ipervascolarizzazione ad esso legata, comportano incremento del fattore compressivo meccanico esercitato dall’ernia stessa.Al primo evento di incremento dell’irritazione radicolare consegue, tuttavia, l’attivazione di fagocitosi e di eliminazione del materiale erniato. La RM è in grado di seguire in modo ravvicinato e congruo ogni passo degli eventi sommariamente riportati, testimoniando la successione degli eventi infiammatori e la regressione anatomica dell’ernia . Elementi predittivi dell’evoluzione dell’ernia del disco

Utilità della tecnica di fusione delle immagini nella pianificazione chirurgica delle lesioni del basicranio

La recente possibilità di effettuare una navigazione virtuale all’interno del cranio e della colonna vertebrale ha offerto alla moderna neurochirurgia l’opportunità di utilizzare i dati degli esami di Tomografia Computerizzata (TC) e di Risonanza Magnetica (RM), acquisiti pre-operatoriamente, come riferimenti anatomici trasferibili all’interno del campo chirurgico. Tale procedimento consente di tracciare i punti di interesse chirurgico in un modello tridimensionale virtuale costruito utilizzando i parametri relativi all’anatomia particolare di ciascun paziente, acquisiti mediante le moderne tecniche di diagnostica per immagini. Lo scopo del nostro lavoro è dunque verificare la possibilità di impiego della fusione di immagini RM e TC nella quotidiana pratica di chirurgia delle lesioni del basicranio .