Roger Bodley

Imaging in chronic spinal cord injury—indications and benefits

As most patients who have suffered spinal cord injury can now expect a normal life span, the late complications of these injuries are seen increasingly frequently. Regular surveillance of both the renal tract and the central nervous system (CNS) is important as the treatment of impending, potentially fatal complications can be implemented before damage has progressed too far. Renal tract complications are particularly dangerous as they are often clinically silent but regular surveillance to detect early deterioration in renal function, particularly from reversible causes such as reflux or obstruction can pre-empt problems. Follow-up protocols depend on the bladder management regime but most centres advocate regular ultrasound with less frequent isotope function studies. With the increasing ability to diagnose and treat the neurological complications, surveillance of the state of the spinal cord with MRI is also important and many centres now advocate checks every few years with sagittal midline T2W sections are sufficient unless changes are noted, when axial T1W sections can be added without significant examination time penalty. Imaging is critical in acute problems. In addition to suffering from the usual normal conditions, patients with spinal cord injury suffer others peculiar to, or particularly related to, the injury, which may be missed as their symptomatology is greatly altered by their paraplegic or quadriplegic status and they may often present as generally unwell but with no obvious cause. This review discusses the role of radiology in routine surveillance of the CNS and the renal tract as well as in assessing specific conditions such as deteriorating neurology or renal function, pain, spinal instability, pressure sores, ectopic ossification, muscular spasm, spinal instability, airway problems and elective operations on the renal tract.

Ultrasound in the early diagnosis of heterotopic ossification in patients with spinal injuries

Heterotopic ossification (HO) is a potentially disabling complication of spinal injuries and other chronic disorders. It is of unknown aetiology and currently there is no easy or convenient diagnostic method that will allow very early confirmation of the inflammatory changes that precede osteoid and, later, true bone formation. Clinical experience, however, indicates that early treatment with radiotherapy, antiinflammatory agents or diphosphonates is needed to control the progression.This study was undertaken to assess the role of ultrasound (US) in the very early diagnosis of HO in patients with spinal injuries.US was found to be very sensitive in detecting focal soft tissue abnormalities around joints and in the muscles of these patients. If combined with a Doppler study to exclude deep venous thrombosis (DVT), and infection or tumour could be excluded clinically, US was extremely accurate in predicting the presence or absence of early HO changes within hours of the clinical manifestation. In 2 patients it successfully predicted HO in the opposite leg before clinical signs were evident.This study also provided supportive evidence of the theory of microtrauma in the aetiology of HO.As ultrasound is portable, safe, cheap, reproducible and accurate, it is the method of choice in the early diagnosis of HO. It allows early treatment to prevent the formation of osteoid and subsequent bone formation.

Brain Activation Sequences Following Electrical Limb Stimulation of Normal and Paraplegic Subjects

In current clinical practice the degree of paraplegia or quadriplegia is objectively determined with transcranial magnetic stimulation (TMS) and somatosensory-evoked potentials (SSEP). We measured the MEG signal following electrical stimulation of upper and lower limbs in two normal and three clinically complete paraplegic subjects. From the MEG signal we computed distributed estimates of brain activity and identified foci just behind the central sulcus consistent in location with primary somatosensory (SI) for arm and foot and secondary somatosensory (SII) areas. Activation curves were computed from regions of interest defined around these areas. Activation of the SI foot area was observed in normal and paraplegic subjects when the upper limb was stimulated. Surprisingly, for each paraplegic subject, stimulation below the lesion was followed by cortical activations. These activations were weak, only loosely time-locked to the stimulus and were seen intermittently behind the central sulcus and nearby cortical areas. Statistical analysis of tomographic solutions and activation curves showed consistent responses following foot stimulation in one paraplegic (PS1) and intermittently in another paraplegic subject. We repeated the same experiment for PS1 in a different laboratory and the results from the analysis of foot stimulation from both laboratories revealed statistically significant focal cortical response only in the contralateral SI foot area.

Conservative management of gigantic splenic cyst during pregnancy; a differential diagnosis for chest pain caused by the forgotten organ

Splenic cyst is extremely rare in pregnancy. All the six cases that had been described in literatures were treated surgically. However, we report the first case of a huge splenic cyst during pregnancy managed by conservative approach in the form of analgesia, antibiotics and percutaneous aspiration.

Radiological percutaneous gastrostomy placement for enteral feeding.

Many patients who are unable to swallow have normal intestinal absorption and therefore do not need expensive and potentially problematic parenteral nutrition. Long term nasogastric tubes are unpleasant and interfere with communications, thus a gastrostomy is often felt to be appropriate. Traditionally this has been inserted at laparotomy but recently, other less invasive techniques of insertion such as endoscopy have been used for placement. We describe three patients where a percutaneous gastrostomy was placed by a radiological technique that we feel deserves wider recognition. It is quicker, cheaper and more versatile than the endoscopic method and avoids the unpleasant necessity for intubation by other than a fine-bore nasogastric tube.

Percutaneous endoscopic gastrostomy

I agree that this is a very useful technique. However, I do not believe that a good case has been made for preferring PEG to the radiological technique as the reasons given in the final paragraph of the discussion are not necessarily always true. (a). I am not aware that the endoscopic approach would reliably avoid damage to structures lying between the skin and the stomach. I think this can be demonstrated radiologically just as well, if not better. (b). The gastrostomy tube being pulled rather than pushed through the gastric wall means that it has to be inserted via the mouth and along a wire into the oesophagus. This is not a pleasant procedure and I do believe that with appropriate radiological technique there is no risk of damage to the posterior structures. particularly if the stay suture is used. One disadvantage not mentioned is the need for two operators and the relatively unpleasant procedure of endoscopy. An occasional disadvantage of the radiological method is a difficult nasogastric intubation.