Kurt P. Schellhas

Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography.

Study Design. This study correlated a specific lumbar disc abnormality described as the high‐intensity zone observed on high‐field magnetic resonance imaging with discography. Objectives. To analyze the significance of high‐intensity zones in lumbar discs of symptomatic patients with low back/radicular pain. Summary of Background Data. Aprill and Bogduk described an 86% incidence of concordantly painful discography in lumbar discs exhibiting a posterior high‐intensity zone on T2‐weighted magnetic resonance imaging studies performed on back pain sufferers. They assert that the high‐intensity zone is a reliable marker of discogenic pain in symptomatic subjects. Methods. Consecutive cases of lumbar spine high‐field magnetic resonance imaging using T2‐weighted images on symptomatic patients followed by discography at all high‐intensity zone levels and at non‐high‐intensity zone control levels were reviewed until 100 high‐intensity zone discs in 63 patients were found. Seventeen lifelong asymptomatic (for low back/radicular pain) adults were also scanned as magnetic resonance imaging controls. All magnetic resonance scans and discograms were agreed on by at least two of the radiologist authors. Results. Eighty‐seven of 100 of the high‐intensity zone discs proved concordantly painful at discography. All 87 painful and concordant discs exhibited abnormal morphology with anular tears extending either well into or through the outer third of the anulus fibrosus. Sixtyfive of 67 non‐high‐intensity zone control discs were nonconcordant and of lower sensation intensity than the high‐intensity zone discs. Only one high‐intensity zone was found in the control subjects. Conclusions. In patients with symptomatic low back pain, the high‐intensity zone is a reliable marker of painful outer anular disruption.

cervical Discogenic Pain : Prospective Correlation of Magnetic Resonance Imaging and Discography in Asymptomatic Subjects and Pain Sufferers

Study Design Asymptomatic subjects and chronic head/neck pain sufferers were studied with high-field magnetic resonance imaging and cervical discography to compare and correlate both tests. Objectives To assess the accuracy of magnetic resonance imaging and discography in identifying the source(s) of cervical discogenic pain. Summary of Background Data Previous retrospective studies describe a generally poor correlation between magnetic resonance imaging and provocative discography in the cervical spine. Methods Ten lifelong asymptomatic subjects and 10 nonlitigious chronic neck/head pain patients underwent discography at C3-C4 through C6-C7 after magnetic resonance imaging. Disc morphology and provoked responses were recorded at each level studied. Results Of 20 normal discs by magnetic resonance from the asymptomatic volunteers, 17 proved to have painless anular tears discographically. The average response per disc (N = 40) for this group was 2.42, compared to 5.2 (N = 40) for the neck pain group. In the pain patients, 11 discs appeared normal at magnetic resonance imaging, whereas 10 of these proved to have anular tears discographically. Two of these 10 proved concordantly painful with intensity ratings of at least 7/10. Discographically normal discs (N = 8) were never painful (both groups), whereas intensely painful discs all exhibited tears of both the inner and outer aspects of the anulus. Conclusions Significant cervical disc anular tears often escape magnetic resonance imaging detection, and magnetic resonance imaging cannot reliably identify the source(s) of cervical discogenic pain.

Pediatric internal derangements of the temporomandibular joint: effect on facial development.

To evaluate the relationship between internal derangement(s) of the temporomandibular joint(s) (TMJ) and disturbed facial skeleton growth (dysmorphogenesis), 128 consecutive children (103 girls, 25 boys), who were 14 years of age or younger and had undergone combined radiographic and magnetic resonance (MR) imaging studies of both TMJs, were retrospectively analyzed. Imaging studies had been performed to investigate suspected TMJ derangement because of symptoms that included, either individually or in various combinations, pain, mechanical TMJ dysfunction, and facial skeleton abnormalities, such as mandibular deficiency (particularly retrognathia) and lower facial (mandibular) asymmetry, manifested by chin deviation from the midline. Of these patients, 112 were found to have at least one internally deranged TMJ on imaging studies; in 85 patients, both TMJs were abnormal. Of the 60 retrognathic patients 56 were found to have TMJ derangement, generally bilateral and often of advanced stage. In cases of lower facial asymmetry, the chin was uniformly deviated toward the smaller or more degenerated TMJ. Both TMJs were normal in 16 patients, most of whom had normal facial structure. We conclude that TMJ derangements are both common in children and may contribute to the development of retrognathia, with or without asymmetry, in many cases.

Thoracic discography in healthy individuals : A controlled prospective study of magnetic resonance imaging and discography in asymptomatic and symptomatic individuals

STUDY DESIGN A prospective case-control investigation. OBJECTIVES To determine the responses to thoracic discography of asymptomatic individuals. SUMMARY OF BACKGROUND DATA Literature regarding lumbar and cervical discography reveals that even morphologically abnormal discs often are not painful, whereas painful discs typically exhibit anular or endplate disruption. METHODS Ten adult lifelong asymptomatic volunteers, ages 23 to 45 years, underwent magnetic resonance imaging of the thoracic spine, followed by four-level discography. Provocative responses were graded on a scale of 0 (no sensation) to 10 (extreme pain or pressure), and filmed discs were graded using a modified Dallas scheme. Concomitantly, 10 nonlitigious adults (6 men and 4 women, ages 31 to 55 years) experiencing chronic thoracic pain were similarly studied as a control group. RESULTS The mean pain response in the asymptomatic volunteers was 2.4/10. Three discs were intensely painful (scores of 7/10, 8/10, 10/10), with all three exhibiting prominent endplate irregularities and anular tears typical of thoracolumbar Scheuermanns disease. On discography, 27 of 40 discs were abnormal, with endplate irregularities, anular tears, and/or herniations. Ten discs read as normal on magnetic resonance imaging showed anular pathology on discography. In the group with chronic thoracic pain, the average pain response was 6.3/10 (P < 0.05). Of the 48 discs studied, 24 were concordantly painful, with a pain response of 8.5/10 (P < 0.05); 17 had nonconcordant pain/pressure, with an average pain of 4.8/10 (P < 0.05); and 5 had no response. On magnetic resonance imaging 21 of the 48 discs appeared normal. However, on discography, only 10 were judged as normal. CONCLUSIONS On discography, thoracic discs with prominent Schmorls nodes may be intensely painful, even in lifelong asymptomatic individuals, but the pain is unfamiliar or nonconcordant. Thoracic discography may-demonstrate disc pathology not seen on magnetic resonance imaging.

Mandibular retrusion, temporomandibular joint derangement, and orthognathic surgery planning.

One-hundred consecutive orthognathic surgery candidates with mandibular retrusion were selected for retrospective analysis. Patients had undergone imaging studies that included magnetic resonance imaging (MRI) of both temporomandibular joints to assess the presence or absence, stage, and activity of suspected internal derangement(s). Patients were divided into stable and unstable deformity groups based on the presence or absence of change in their facial contour and/or occlusal disturbances in the 24 months prior to evaluation. Each of the 58 unstable and 30 of 42 stable patients were found to have internal derangements of at least one temporomandibular joint. The degree of joint degeneration directly paralleled the severity of retrognathia in most cases. We concluded that temporomandibular joint internal derangement is common in cases of mandibular retrusion and leads to the facial morphology in a high percentage of patients. Preoperative temporomandibular joint imaging with MRI is recommended prior to orthognathic surgical correction of retrognathic deformities.

Selective Cervical Nerve Root Blockade: Prospective Study of Immediate and Longer Term Complications

BACKGROUND AND PURPOSE: Selective cervical nerve root blockade (SCNRB) is a useful procedure for evaluating and treating patients with cervical radiculopathy. Reports of complications related to injections within the cervical nerve root foramen have raised serious doubts regarding the safety of this procedure. This study was performed to prospectively evaluate the safety of fluoroscopically guided outpatient diagnostic and therapeutic SCNRB. MATERIALS AND METHODS: Eight hundred two consecutive fluoroscopically guided diagnostic and/or therapeutic SCNRBs in 659 patients were performed during a 14-month period (November 2006–December 2007) at affiliated outpatient imaging centers. Each examination was performed by 1 of 8 experienced procedural radiologists by using an anterior oblique approach, with the needle position confirmed with radiographic contrast before injection of an admixture of local anesthetic and steroid. All patients were assessed immediately and at 30 minutes following the procedure. Additionally, 460 patients were called by telephone 30 days following the procedure. All complications were recorded. RESULTS: Of the 802 attempted procedures, 799 were successfully completed. Three procedures were aborted due to anxiety, challenging body habitus, or persistent venous opacification observed during contrast injection and despite needle repositioning. There were no serious complications, such as stroke, spinal cord insult, permanent nerve root deficit, infection, or significant hematoma. There were 33 minor complications occurring within 30 minutes of the procedure; the most common was vasovagal symptoms. Three hundred forty-five patients were successfully contacted by telephone at 30 days postinjection, 9 of whom reported increased or new pain symptoms. CONCLUSIONS: With our technique, fluoroscopically guided SCNRB is a safe outpatient procedure with a low immediate and delayed complication rate.

Facial Skeleton Remodeling Due to Temporomandibular Joint Degeneration: An Imaging Study of 100 Patients

One hundred patients with recently acquired, externally visible mandibular deformity and no history of previous extraarticular mandible fracture were selected for retrospective analysis. All had been investigated clinically and with radiography, tomography, and high-field surface-coil MR imaging to determine the presence or absence and extent of temporomandibular joint degeneration. Temporomandibular joint degeneration was found in either one or both joints of each patient studied. Chin deviation was always toward the smaller mandibular condyle or more diseased joint, and many patients either complained of or exhibited malocclusion, often manifested by unstable or fluctuating occlusion disturbances. Three radiologically distinct forms of degenerative vs adaptive osteocartilaginous processes--(1) osteoarthritis, (2) avascular necrosis, and (3) regressive remodeling--involving the mandibular condyle and temporal bone were identified in joints most often exhibiting meniscus derangement. Osteoarthritis and avascular necrosis of the mandibular condyle and temporal bone were generally associated with pain, mechanical joint symptoms, and occlusion disturbances. Regressive remodeling was less frequently associated with occlusion disturbances, despite remodeling of the facial skeleton, and appears to result from regional osteoporosis. Forty patients (52 joints) underwent open arthroplasty procedures, including either meniscectomy or microsurgical meniscus repair, at which time major radiologic diagnoses were confirmed. Surgical and pathologic findings included meniscus displacement, disk degeneration, synovitis, joint effusion, articular cartilage erosion, cartilage healing/fibrosis, cartilage hypertrophy, osseous sclerosis, osteophyte formation, osteochondritis dissecans, localized or extensive avascular necrosis, and decreased mandibular condyle mass and vertical dimension. We conclude that temporomandibular joint degeneration is the principal cause of both acquired facial skeleton remodeling and unstable occlusion in patients with intact dentition and without previous mandible fracture.

Selective Cervical Nerve Root Blockade: Experience with a Safe and Reliable Technique Using an Anterolateral Approach for Needle Placement

BACKROUND AND PURPOSE: Our aim was to evaluate the safety and clinical utility of a fluoroscopically guided anterolateral oblique approach technique for outpatient diagnostic and therapeutic selective cervical nerve root blockade (SCNRB). MATERIALS AND METHODS: During a 13-year period (1994 through February 2007), 4612 patients underwent fluoroscopically guided diagnostic and/or therapeutic extraforaminal SCNRB by using an anterior oblique approach at affiliated outpatient imaging centers. Each procedure was performed by 1 of 6 procedural radiologists, all highly experienced in and actively performing spinal injections on a full-time basis in clinical practice. All of the proceduralists were thoroughly experienced with lumbar injections before endeavoring to perform SCNRBs. Nonionic contrast was injected in nearly all patients (except isolated patients with contrast allergy), and a minimum of 2 projection filming procedures were performed to document the accuracy of needle placement and contrast dispersal before the injection of therapeutic substances. All clinically significant complications beyond skin discoloration and temporary exacerbation of symptoms were recorded. RESULTS: There were no serious neurologic complications, such as stroke, spinal cord insult, or permanent nerve root deficit. One life-threatening anaphylactic reaction occurred and was attributed to the injected materials and not the specific procedure itself. Another patient had a 3- to 4-minute grand mal seizure, from which he fully recovered within 30 minutes. There were no infections. CONCLUSION: The technique we describe for fluoroscopically guided SCNRB is a useful and safe outpatient procedure when performed by skilled and experienced proceduralists.

Temporomandibular Joint: MR Fast Scanning

Eleven hundred ninety temporomandibular joints (TMJ) in 662 patients were studied with high field strength surface coil magnetic resonance using high resolution T1-weighted closed-mouth and short p...

Magnetic resonance imaging of the temporomandibular joint: preliminary evaluation of partial flip angle three-dimensional volume acquisitions against conventional single and multiecho pulse sequences.

The authors imaged 20 temporomandibular joints (TMJs) in 20 patients with high field surface coil magnetic resonance imaging, to compare the accuracy and the clinical utility of thin section partial flip angle (PFA) three dimensional (3D) volume acquisitions with T1-weighted images (T1WI), spin echo, multiecho, long TR/short and long TE images, PFA gradient recalled acquisition in the steady state (GRASS) images in the diagnosis of internal derangement of the TMJ. Pathological conditions demonstrated on imaging studies included disk derangement, joint effusion, and osteocartilaginous lesions, such as degenerative arthritis, osteoporosis, osteochondritis dissecans and early avascular necrosis of the mandibular condyle.