Marc Wybier

Lumbar disc herniation. Computed tomography scan changes after conservative treatment of nerve root compression.

In 21 patients with computed tomography-diagnosed lumbar herniated nucleus pulposus, nerve root pain resolved after conservative treatment. A subsequent computed tomography scan was performed 6 months or more after presentation. This follow-up computed tomography scan was compared with the initial one. A definite decrease in size of the herniated nucleus pulposus was observed in 14 patients: disappearance in 5, obvious decrease in 5, and moderate decrease in 4. No definite change was observed in seven patients. Major computed tomography scan changes occurred significantly more frequently in large herniated nucleus pulposus than in small ones (p. < 0.05). This study suggests that large lumbar herniated nucleus pulposus can decrease and even disappear in some patients treated successfully with conservative care.

Paraplegia complicating selective steroid injections of the lumbar spine. Report of five cases and review of the literature.

BackgroundSelective steroid injections of the lumbar spine carry a risk of paraplegia of sudden onset. Seven cases have been reported in the English literature since 2002.Materials and methodsFive new cases have been analyzed, all coming from Paris area centers. Injections were performed between 2003 and 2008. The following items were searched for: location of a previous lumbar spine surgery if any, symptoms indicating the procedure, route of injection, imaging technique used for needle guidance, injection of a contrast medium, type of steroid, other drugs injected if any, paraplegia level, post-procedure MR findings. The current and reported cases were compared.ResultsMR findings were consistent with spinal cord ischemia of arterial origin. The high rate of patients who had been operated on in these cases does not correspond to that of patients undergoing injections. The presence of epidural scar might increase the risk. The foraminal route was the only one involved in nonoperated patients. Foraminal, interlaminar, or juxta-zygoapophyseal routes were used in operated-on patients.ConclusionThe high rate of French cases when compared to the literature might arise from the almost exclusive use of prednisolone acetate, a molecule with a high tendency to coalesce in macro-aggregates, putting the spinal cord at risk of arterial supply embolization.

Radiologic assessment of lumbar intervertebral instability and degenerative spondylolisthesis

Despite many efforts, there is no clear and widely accepted definition of lumbar instability because there are no unquestionable and currently applicable clinical or radiologic criteria available for this entity. This article reviews the current concepts of lumbar instability and the different imaging modalities used to make the diagnosis as evident as possible.

Solitary plasmacytoma of the spine. Long-term clinical course

The data for 19 patients with solitary plasmacytoma of the spine were reviewed with regard to clinical course and prognosis (median follow‐up, 96 months). Eight patients presented with spinal cord compression. A monoclonal immunoglobulin was initially detected in seven of 15 evaluable patients. Treatment included radiotherapy (18 of 19) and/or surgery (11 of 19) and chemotherapy (eight of 19). Spinal cord compression was reversed in every patient. The expected survival rate was 85% at 10 years after diagnosis. Local recurrence or dissemination was observed in 13 patients. It occurred within 5 years of diagnosis in 11 patients and was localized (that is, local recurrence or single bone metastasis) in eight patients. It was always associated with the appearance or an increase of the M component. Dissemination frequently had a “metastatic” pattern with no diffuse bone marrow plasmacytosis. The incidence of local recurrence (five patients) and leukemia (four patients) was high. Local recurrence and/or dissemination were significantly more frequent in patients with the M component at diagnosis than in those without it (P < 0.05; relative risk, R = 4). The effectiveness of surgery and chemotherapy combined with radiotherapy is also discussed.

Musculoskeletal imaging in progress: the EOS imaging system.

The EOS 2D/3D radio-imaging device (Biospace med, France) can disclose a digital radiographic image of bones with a very low radiation dose. This in turn allows in obtaining a single image of a large field of view, as wide as the full skeleton. The simultaneous capturing of spatially paired AP and lateral X-ray images is also a specificity of EOS imaging, which further provides secondary 3D (volumic) reformation of skeletal images. The main indications of this new imaging technology are assessment and follow-up of balance disorders of the spine and of the lower limbs.

Transforaminal epidural corticosteroid injections and spinal cord infarction.

Transforaminal epidural injection under radiological control allows selective deposition of an appropriate corticosteroid next to the nerve root responsible for radicular pain. In clinical everyday practice, this procedure is proposed to patients suffering from lumbar or cervical nerve root pain who are unresponsive to oral antiinflammatory drugs. Pain usually originates in intervertebral degenerative changes or disc herniations. This type of treatment is available since many decades due to medical consensus and good clinical results from open studies. However, statistical evidence of its clinical efficacy is lacking, except for certain criteria, such as short term improvement of lumbar radicular pain of recent onset. The poor number of controlled studies is not only due to financial considerations. It is also difficult to reach a consensus on the clinical aims of such studies: has radicular pain to be treated after a rather long period of oral treatment, or after a short evolution to avoid resistance due to chronicity? Is the procedure expected to bring only short term or also long term improvement? Should pain be the only criterion to be evaluated, or should the whole functional handicap be taken in account? Now, recent scientific papers, as well as our own and, we could fear to say, increasing domestic experience (unpublished data from the French Pharmacovigilance Working Group) revealed that transforaminal epidural image-guided corticosteroid injections performed at the cervical [1e6] or lumbar [7e10] spine may be followed by severe spinal cord ischemic infarction. In other words, an outpatient presenting with a stressful but benign and anyway reversible pain is going to be definitely tetraplegic or paraplegic few minutes after a welltrained operator just took off the needle from the site of a routinely performed injection. Some cervical transforaminal epidural injections into the cervical spine were also lethal, either immediately or after initial tetraplegia [5]. To date, few is known about these events. Their number is unknown. In 2007, an attempt of recording cases of spinal cord infarction following cervical transforaminal epidural injections [11] resulted in 287 (21.4%) answers from 1340 anonymous

Imaging of lumbar degenerative changes involving structures other than disk space.

Degenerative changes in the lumbar spine involve intervertebral disks and intervertebral posterior elements at different extents. Much less attention has been directed toward degenerative changes of the posterior vertebral elements, however, when compared with intervertebral disk degeneration. These changes may involve the apophyseal joints, the bony elements of the neural arch, the intervening soft tissues, and the spinal longitudinal ligament. Roentgenographic, CT, and MR findings in these changes are depicted.

PERCUTANEOUS TREATMENTS OF PAINFUL SHOULDER

Percutaneous treatments are useful in two, frequent, painful conditions involving the shoulder. In frozen shoulder syndrome, distention arthrography with intra-articular injection of steroid is used to provide pain relief and to improve joint motion. In rotator cuff tendon calcifications, needle aspiration of calcific deposits is used to treat pain. Surgery should be restricted to failures of needle aspiration. The techniques of these procedures are described and their results are reported.

Prognostic value of early computed tomography in radiculopathy due to lumbar intervertebral disk herniation. A prospective study

OBJECTIVE To prospectively evaluate the relationship between the early computerized tomography (CT) features of disk herniation and the clinical outcome in patients with recent-onset sciatic or femoral neuralgia treated conservatively. Early CT is often used, despite the absence of data on usefulness for predicting outcomes. METHODS Of 78 patients with sciatica or femoral neuralgia of less than 1 months duration, presumably due to a disk herniation, 75 were found by CT to have a disk herniation at the expected level. All patients were treated conservatively. The 60 patients who were reassessed clinically after 3 months were included in the study. Based on the results of the clinical assessment, the patients were classified as having a good outcome (complete or partial recovery) or a poor outcome. CT findings were compared in these two groups. RESULTS None of the features of disk herniation studied on the CT scans were significantly correlated with the clinical outcome. A larger herniation or presence of a free fragment was more common in the good outcome group, but the differences were not statistically significant (P= 0.07). CONCLUSION In this study, early CT scan did not predict the clinical outcome of patients with nerve root pain from lumbar disk herniation. None of the CT criteria was associated with a poor clinical outcome. Early CT scan has no prognostic value in this setting.

Tumeurs et pseudo-tumeurs des tissus mous de la régionpied-cheville

Soft tissue tumors and pseudotumors of the foot and ankle Soft tissue masses around thefoot and ankle are frequent. While benign lesions are two times more frequentthan malignant lesions, the latter still represent one third of all lesions. The main purpose of this article is to propose a systematicapproach to the differential diagnosis of soft tissue tumors of the foot andankle based on a combination of 5 elements: clinical history and physicalexamination, top 10 most frequent diagnoses, patient age, lesion location, andMRI features of the mass. Selected soft tissue tumors will be described andillustrated with emphasis on these 5 elements.