John E. O’Toole

Position statement on percutaneous vertebral augmentation: a consensus statement developed by the Society of Interventional Radiology (SIR), American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), American College of Radiology (ACR), American Society of Neuroradiology (ASNR), American Society of Spine Radiology (ASSR), Canadian Interventional Radiology Association (CIRA), and the Society of NeuroInterventional Surgery (SNIS).

Radiological Associa Radiology (M.D.K.), U Angeles; Departmen Diego, Medical Cen (M.E.J.), University o sion of Neurointerv Hospital, Boston, M (J.K.M.), Riverside M and Neurological Ins lenburg Radiology A ment of Radiology (A Neurological Surgery and Surgeons; Depa York–Presbyterian H York; Department of Chicago, Illinois; Iow Radiology Associates ment of Radiology (S kee, Wisconsin; D Christiana Care Healt (J.F.C.), Geisinger H Radiology (P.L.M.), V STANDARDS OF PRACTICE

ACR Appropriateness Criteria Low Back Pain.

Most patients presenting with uncomplicated acute low back pain (LBP) and/or radiculopathy do not require imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags raising suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture, and infection. Many imaging modalities are available to clinicians and radiologists for evaluating LBP. Application of these modalities depends largely on the working diagnosis, the urgency of the clinical problem, and comorbidities of the patient. When there is concern for fracture of the lumbar spine, multidetector CT is recommended. Those deemed to be interventional candidates, with LBP lasting for > 6 weeks having completed conservative management with persistent radiculopathic symptoms, may seek MRI. Patients with severe or progressive neurologic deficit on presentation and red flags should be evaluated with MRI. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR appropriateness criteria management of vertebral compression fractures.

This is an updated review of management of vertebral compression fracture for both benign osteoporotic and malignant causes. Vertebral compression fracture radiologic imaging evaluation is discussed. A literature review is provided of current indications for vertebral augmentation with percutaneous vertebroplasty and kyphoplasty as well as medical management. Limitations and potential benefits of these procedures are discussed. Variant tables describing various clinical situations are also provided to assist in determining appropriate use of these treatments for patient care. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to formulate recommendations for imaging or treatment.

Clinical experience using polyetheretherketone (PEEK) intervertebral structural cage for anterior cervical corpectomy and fusion

Anterior cervical corpectomy and fusion (ACCF) is commonly performed for various pathologies involving the cervical spine. Although polyetheretherketone (PEEK) cages have been widely used following anterior cervical discectomy and fusion (ACDF), clinical literature demonstrating its efficacy following ACCF is sparse. A retrospective review of patients enrolled in a prospective database who underwent single/multi-level ACCF was performed. Fifty-nine patients were identified who underwent corpectomy reconstruction with PEEK cages for symptomatic degenerative, neoplastic, infectious, or traumatic pathologies of the cervical spine. Thirty-five patients having at least 6 months follow-up (FU) were included in the final analysis. The mean age of patients was 51 years (range, 18-81 years) with FU ranging from 6 to 33 months (mean, 6.6 months). None of the patients had dysphagia at last FU. There was no implant failure with fusion occurring in all patients. While 57% of patients (20/35) remained stable with no progression of myelopathy, 43% (15/35) improved one (11 patients) or two (four patients) Nurick grades after surgery. The use of PEEK cages packed with autograft or allograft is safe and effective following anterior cervical corpectomy, demonstrating high fusion rates and good clinical results. This synthetic material obviates the morbidity associated with autograft harvest and possible infectious risks of allograft. The wide array of cage dimensions facilitates ease of use in patients of all sizes and appears safe for use in the typical pathologic conditions encountered in the cervical spine.

Rapidly progressive quadriparesis heralding disseminated coccidioidomycosis in an immunocompetent patient.

Coccidioides species are dimorphic fungi endemic to southwestern USA and northern Mexico. Disseminated coccidioidomycosis is rare with an estimated incidence of 1% in affected individuals and usually presents as meningitis when the central nervous system is involved. Spinal involvement with coccidioidomycosis, though not uncommon, predominantly manifests as osseous involvement leading to osteomyelitis and epidural abscess formation. Progressive quadriparesis as a presenting symptom secondary to intramedullary spinal cord coccidioidomycosis is very unusual and to our knowledge has not been described. We report a patient with disseminated coccidioidomycosis who presented with rapidly progressive quadriparesis due to cervical intramedullary spinal cord involvement. The absence of known coccidioidomycosis with atypical clinical presentation made the diagnosis elusive, requiring emergent cervical laminectomies with dural biopsy for decompression of the spinal cord and confirmation of the diagnosis. The patient eventually succumbed to the progressive course of the disease. Although rare, disseminated coccidioidomycosis can present as new, rapidly progressing quadriparesis in patients who have traveled to endemic areas. A high index of suspicion in such patients with appropriately directed laboratory investigations and consideration of early biopsy might unravel the diagnosis facilitating early antifungal treatment with the potential to minimize morbidity and mortality associated with disseminated coccidioidomycosis.

A rare intramedullary spinal cord metastasis from uterine leiomyosarcoma.

Leiomyosarcoma is a rare smooth-muscle-derived malignancy with a significant malignant potential. Systemic metastases are a common late complication of leiomyosarcoma typically to lungs, liver, brain and bones. We report a 44-year-old woman with a prior history of uterine leiomyosarcoma who presented to us with a cervicothoracic intramedullary lesion and recent onset of neurological deficits. She underwent surgery with histological confirmation of a diagnosis of metastatic leiomyosarcoma, which was followed by adjuvant radiation and chemotherapy. To our knowledge there is no prior report of intramedullary spinal cord metastases (ISCM) from a leiomyosarcoma in the English literature. We report the present patient in view of the rarity of ISCM and its clinical significance. Even though ISCM are unusual, they should be suspected in any patient with primary malignancy irrespective of the histology. The overall prognosis remains grim irrespective of the treatment modality chosen and recognition of the same is important in preoperative counseling and overall treatment approach.

Current Techniques in the Management of Cervical Myelopathy and Radiculopathy

Posterior decompressive procedures are a fundamental component of the surgical treatment of symptomatic cervical degenerative disease. Posterior approaches have the appeal of avoiding complications associated with anterior approaches such as esophageal injury, recurrent laryngeal nerve paralysis, dysphagia, and adjacent-level disease after fusion. Although open procedures are effective, the extensive subperiosteal stripping of the paraspinal musculature leads to increased blood loss, longer hospital stays, and more postoperative pain, and potentially contributes to instability. Minimally invasive access has been developed to limit approach-related morbidity. This article reviews current techniques in minimally invasive surgical management of cervical myelopathy and radiculopathy.

Inverted Mercedes Benz sign in lumbar spinal subdural hematoma.

A previously healthy 27-year-old male boxer developed lower back pain 3 days after a fight, which progressed during the next several days to the point that the patient was unable to walk secondary to pain. This was followed by pain and paresthesias radiating down both the legs when he presented to the emergency department. A lumbar magnetic resonance imaging (MRI) was performed, suspecting acute disc herniation. MRI, however, demonstrated the presence of signal intensity consistent with blood and a diagnosis of spinal hematoma, possibly subdural, was considered (Figure 1). Careful evaluation of the axial MRI demonstrated the presence of an inverted Mercedes Benz sign, suggestive of a spinal subdural hematoma (Figure 2). He denied being on any anticoagulant medications. He did realize that he was being hit in the belly a number of times during the fight. On examination, the patient was in moderate discomfort, but with an essentially normal neurologic examination with no focal deficits and preserved rectal tone and sensation. He was admitted with close neurologic monitoring. Post void residual was obtained and found to be normal. His pain was adequately controlled with medications resulting in symptomatic relief. The patient maintained his neurologic examination with gradual resolution of his symptoms over a couple of days and was discharged home. He was completely intact with no pain or neurologic deficits at 2 months follow-up.

Disseminated spinal myxopapillary ependymoma in an adult at initial presentation: A case report and review of the literature

Abstract Disseminated spinal myxopapillary ependymoma (MPE) is extremely rare in adults. We report a 63-year-old man with chronic low-back pain found to have multiple MPEs in the thoracic, lumbar and sacral spine. Diagnostic and management strategies of disseminated MPE are discussed with a review of pertinent literature.

ACR Appropriateness Criteria® Myelopathy

Patients presenting with myelopathic symptoms may have a number of causative intradural and extradural etiologies, including disc degenerative diseases, spinal masses, infectious or inflammatory processes, vascular compromise, and vertebral fracture. Patients may present acutely or insidiously and may progress toward long-term paralysis if not treated promptly and effectively. Noncontrast CT is the most appropriate first examination in acute trauma cases to diagnose vertebral fracture as the cause of acute myelopathy. In most nontraumatic cases, MRI is the modality of choice to evaluate the location, severity, and causative etiology of spinal cord myelopathy, and predicts which patients may benefit from surgery. Myelopathy from spinal stenosis and spinal osteoarthritis is best confirmed without MRI intravenous contrast. Many other myelopathic conditions are more easily visualized after contrast administration. Imaging performed should be limited to the appropriate spinal levels, based on history, physical examination, and clinical judgment. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.