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Objective Using a US Food and Drug Administration (FDA) emergency use authorization (EUA) reverse transcription polymerase chain reaction (RT-PCR) method, we examined the analytic performance accuracy of saliva specimens as compared to nasopharyngeal (NP) specimens in symptomatic patients. Correlation between test results and symptoms was also evaluated. Methods Over a 5-week period in 2020, 89 matched saliva and nasopharyngeal swabs were collected from individuals exhibiting symptoms consistent with SARS-CoV-2. Specimens were tested with an FDA EUA-approved RT-PCR method, and performance characteristics were compared. Results The concordance rate between saliva and nasopharyngeal testing was 93.26%. The mean cycle threshold value of saliva when compared to the NP specimen was 3.56 cycles higher. As compared to NP swab, saliva testing demonstrates acceptable agreement but lower sensitivity. Conclusion When compared to a reference method using NP swabs, the use of saliva testing proved to be a reliable method. Self-collected saliva testing for SARS-CoV-2 allows for a viable option when trained staff or collection materials are in short supply.

The ongoing COVID-19 pandemic caused by SARS-CoV-2 has challenged diagnostic laboratories to re-examine traditional methods for collecting specimens and sample types used in molecular testing. Our goal was to demonstrate that saliva can be used for detecting SARS-CoV-2 and correlates well with established molecular methods using nasopharyngeal (NP) swabs.We examined use of a saliva collection device in conjunction with a laboratory-developed real-time reverse transcription-polymerase chain reaction (LDPCR) method for detecting SARS-CoV-2 in a symptomatic population and compared results with 2 US Food and Drug Administration (FDA)-approved methods (emergency use authorization [EUA]) that use specimens from NP swabs.The sensitivity of LDPCR compared with the reference methods was 75.0% (21/28); specificity, 98.1% (104/106). When cycle threshold values were compared between paired specimens using the LDPCR and a EUA reverse transcription PCR method, both targeting the open-reading frame gene, the mean value for saliva was 4.66 cycles higher than for NP specimens.Use of self-collected saliva in conjunction with an LDPCR for SARS-CoV-2 compared favorably with 2 FDA EUA methods using NP swabs. The use of an alternative sample type and assay method will aid in expanding the availability of testing during the ongoing COVID-19 pandemic.

Objective To estimate the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies in health care personnel. Methods The Mayo Clinic Serology Screening Program was created to provide a voluntary, two-stage testing program for SARS-CoV-2 antibodies to health care personnel. The first stage used a dried blood spot screening test initiated on June 15, 2020. Those participants identified as reactive were advised to have confirmatory testing via a venipuncture. Venipuncture results through August 8, 2020, were considered. Consent and authorization for testing was required to participate in the screening program. This report, which was conducted under an institutional review board–approved protocol, only includes employees who have further authorized their records for use in research. Results A total of 81,113 health care personnel were eligible for the program, and of these 29,606 participated in the screening program. A total of 4284 (14.5%) of the dried blood spot test results were "reactive" and warranted confirmatory testing. Confirmatory testing was completed on 4094 (95.6%) of the screen reactive with an overall seroprevalence rate of 0.60% (95% CI, 0.52% to 0.69%). Significant variation in seroprevalence was observed by region of the country and age group. Conclusion The seroprevalence for SARS-CoV-2 antibodies through August 8, 2020, was found to be lower than previously reported in other health care organizations. There was an observation that seroprevalence may be associated with community disease burden.

The coronavirus disease 2019 (COVID-19) pandemic created an extremely disruptive challenge for health care leaders that required a rapid, dynamic, and innovative response. The purpose of this manuscript is to share the leadership actions and decisions at Mayo Clinic in Florida during the first 6 months of the pandemic (February to July 2020). We note 4 strategies that contributed to an effective response: (1) leverage experience with disaster preparedness and mobilize regional and national networks; (2) use surge models to anticipate and to address supply chain issues as well as practical and financial effects of the pandemic; (3) adapt creatively to establish new safety and procedural protocols in various areas for various populations; and (4) communicate timely information effectively and be the common source of truth. Mayo Clinic in Florida was able to address the surges of patients with COVID-19, to provide ongoing tertiary care, and to restore function within the first 6 months with new, strengthened practices and protocols.

Bandscheibenerkrankungen konnen sich, uber das vertraute Bild des Bandscheibenvorfalls (Diskushernie) mit seinen typischen klinischen Merkmalen hinaus, durch ein breites Spektrum von Bildgebungsbefunden und klinischen Charakteristika manifestieren. Ziel dieses Reviews ist die bildliche Darstellung und Erorterung ungewohnlicher Manifestationen von Bandscheibenerkrankungen, denen der Radiologe begegnen kann: Bandscheibenvorfalle mit ungewohnlicher Lokalisation, Erkrankungen mit atypischen Bildgebungsbefunden und solche mit ungewohnlicher Pathophysiologie. Bei den vorgestellten Beispielen atypischer Bandscheibenvorfalle handelt es sich um Vorfalle in den dorsalen Epiduralraum sowie intradurale, symptomatische thorakale (einschlieslich solcher mit sehr grosen Kalzifikationen), extrem laterale (retroperitoneale), Fluor-18-Fluordesoxyglukose-avide, akute intravertebrale (Schmorl-Knoten) und massive lumbale Bandscheibenvorfalle. Als Beispiele mit atypischer Pathophysiologie werden Diskuszysten, fibrokartilaginose Ruckenmarksembolien, kalzifizierte Miniaturbandscheiben oder in Hohe eines Bandscheibenfachs auftretende Osteophytensporne als Ursache von Liquorlecks und intrakraniellem Unterdruck sowie die akute kalzifizierende Diszitis des Kindesalters vorgestellt. Die Grose der Bandscheiben ist bei diesem breiten Krankheitsspektrum sehr unterschiedlich und reicht von winzig (z. B. bei den verkalkten Miniaturbandscheiben als Ursache von Liquorlecks mit Austreten groser Liquormengen) bis zu extrem gros (z. B. bei den riesigen kalzifizierten, thorakalen intraduralen Bandscheibenvorfallen als Ursache von Myelopathien). Auch mit Blick auf den akuten Charakter der klinischen Symptomatik ist das vorgestellte Krankheitsspektrum breit: Es reicht von hyperakuten fibrokartilaginosen Embolien als Ursache von Ruckenmarksinfarkten uber akute Schmorl-Knoten bis hin zu chronischen intraduralen Herniationen. Zudem sind die typischen klinischen Verlaufe sehr verschieden, angefangen von den meist verheerenden Folgen eines Ruckenmarksinfarkts aufgrund einer fibrokartilaginosen Embolie bis zum gewohnlich spontanen Abklingen der akuten kalzifizierenden Diszitis des Kindesalters. Bei manchen Krankheiten sind grundliche differenzialdiagnostische Uberlegungen erforderlich, wahrend andere anhand der Bildgebungsbefunde relativ leicht zu diagnostizieren sind. Die pathophysiologischen Zusammenhange sind in manchen Fallen wohlbekannt, in anderen dagegen weitgehend ungeklart. Der Radiologe muss dieses breite Spektrum ungewohnlicher Bandscheibenerkrankungen kennen, um richtige radiologische Diagnosen stellen zu konnen.

Beyond the familiar disk herniations with typical clinical features, intervertebral disk pathologic conditions can have a wide spectrum of imaging and clinical manifestations. The goal of this review is to illustrate and discuss unusual manifestations of intervertebral disk pathologic conditions that radiologists may encounter, including disk herniations in unusual locations, those with atypical imaging features, and those with uncommon pathophysiologic findings. Examples of atypical disk herniations presented include dorsal epidural, intradural, symptomatic thoracic (including giant calcified), extreme lateral (retroperitoneal), fluorine 18 fluorodeoxyglucose-avid, acute intravertebral (Schmorl node), and massive lumbar disk herniations. Examples of atypical pathophysiologic conditions covered are discal cysts, fibrocartilaginous emboli to the spinal cord, tiny calcified disks or disk-level spiculated osteophytes causing spinal cerebrospinal fluid (CSF) leak and intracranial hypotension, and pediatric acute calcific discitis. This broad gamut of disease includes a variety of sizes of disk pathologic conditions, from the tiny (eg, the minuscule calcified disks causing high-flow CSF leaks) to the extremely large (eg, giant calcified thoracic intradural disk herniations causing myelopathy). A spectrum of clinical acuity is represented, from hyperacute fibrocartilaginous emboli causing spinal cord infarct, to acute Schmorl nodes, to chronic intradural herniations. The entities included are characterized by a range of clinical courses, from the typically devastating cord infarct caused by fibrocartilaginous emboli, to the usually spontaneously resolving pediatric acute calcific discitis. Several conditions have important differential diagnostic considerations, and others have relatively diagnostic imaging findings. The pathophysiologic findings are well understood for some of these entities and poorly defined for others. Radiologists' knowledge of this broad scope of unusual disk disease is critical for accurate radiologic diagnoses. Online supplemental material is available for this article. (©)RSNA, 2016.

BACKGROUND AND PURPOSE: Hereditary hemorrhagic telangiectasia is associated with a wide range of neurovascular abnormalities. The aim of this study was to characterize the spectrum of cerebrovascular lesions, including brain arteriovenous malformations, in patients with hereditary hemorrhagic telangiectasia and to study associations between brain arteriovenous malformations and demographic variables, genetic mutations, and the presence of AVMs in other organs. MATERIALS AND METHODS: Consecutive patients with definite hereditary hemorrhagic telangiectasia who underwent brain MR imaging/MRA, CTA, or DSA at our institution from 2001 to 2015 were included. All studies were re-evaluated by 2 senior neuroradiologists for the presence, characteristics, location, and number of brain arteriovenous malformations, intracranial aneurysms, and nonshunting lesions. Brain arteriovenous malformations were categorized as high-flow pial fistulas, nidus-type brain AVMs, and capillary vascular malformations and were assigned a Spetzler-Martin score. We examined the association between baseline clinical and genetic mutational status and the presence/multiplicity of brain arteriovenous malformations. RESULTS: Three hundred seventy-six patients with definite hereditary hemorrhagic telangiectasia were included. One hundred ten brain arteriovenous malformations were noted in 48 patients (12.8%), with multiple brain arteriovenous malformations in 26 patients. These included 51 nidal brain arteriovenous malformations (46.4%), 58 capillary vascular malformations (52.7%), and 1 pial arteriovenous fistula (0.9%). Five patients (10.4%) with single nidal brain arteriovenous malformation presented with hemorrhage. Of brain arteriovenous malformations, 88.9% (88/99) had a Spetzler-Martin score of ≤2. Patients with brain arteriovenous malformations were more likely to be female (75.0% versus 57.6%, P = .01) and have a family history of hereditary hemorrhagic telangiectasia (95.8% versus 84.8%, P = .04). The prevalence of brain arteriovenous malformation was 19.7% in endoglin (ENG) mutations and 12.5% in activin receptor-like kinase (1ACVRL1) mutations. CONCLUSIONS: Our study of 376 patients with hereditary hemorrhagic telangiectasia demonstrated a high prevalence of brain arteriovenous malformations. Nidal brain arteriovenous malformations and capillary vascular malformations occurred in roughly equal numbers.

PURPOSE A recently identified and treatable cause of spontaneous intracranial hypotension (SIH) is cerebrospinal fluid (CSF)-venous fistula, and a recently described computed tomography myelogram (CTM) finding highly compatible with but not diagnostic of this entity is the hyperdense paraspinal vein sign. We aimed to retrospectively measure the prevalence of the hyperdense paraspinal vein sign on CTMs in SIH patients without dural CSF leak, in comparison with control groups. METHODS Three CTM groups were identified: 1) SIH study group, which included dural CSF leak-negative standard CTMs performed for SIH, with early and delayed imaging; 2) Early control CTMs, which were performed for indications other than SIH, with imaging shortly after intrathecal contrast administration; 3) Delayed control CTMs, which included delayed imaging. CTMs were retrospectively reviewed for the hyperdense paraspinal vein sign by experienced neuroradiologists, blinded to the group assignment. All CTMs deemed by a single reader to be positive for the hyperdense paraspinal vein sign were independently reviewed by two additional neuroradiologists; findings were considered positive only if consensus was present among all three readers. For positive cases, noncontrast CTs and prior CTMs, if available, were reviewed for the presence of the sign. RESULTS Seven of 101 (7%) SIH patients had contrast in a spinal/paraspinal vein consistent with the hyperdense paraspinal vein sign; no patient in either control group (total n=54) demonstrated the hyperdense paraspinal vein sign (P = 0.0463). The finding occurred only at thoracic levels. Each patient had a single level of involvement. Six (86%) occurred on the right. Four occurred in female patients (57%). The sign was seen on early images in 3 of 7 cases (43%) and on both early and delayed images in 4 of 7 cases (57%). In 2 of 7 patients (29%), a noncontrast CT covering the relevant location was available and negative for the sign. A prior CTM was available in 2 of 7 patients (29%), and in both cases the hyperdense paraspinal vein sign was also evident. CONCLUSION The prevalence of the hyperdense paraspinal vein sign in SIH patients with dural CSF leak-negative standard CTM was 7%. As the sign was not seen in control groups, this sign is highly compatible with the presence of CSF-venous fistula. Since the CTMs were not specifically dedicated to identifying hyperdense paraspinal veins (i.e., they were not dynamic and were not preceded by digital subtraction myelography), the true prevalence of the sign may be higher. Radiologists should scrutinize conventional CTMs for this sign, especially in patients in whom a traditional dural CSF leak is not identified.

BACKGROUND AND PURPOSE: We adopted an imaging algorithm in 2011 in which extradural fluid on spinal MR imaging directs dynamic CT myelography. We assessed algorithm compliance and its effectiveness in reducing repeat or unnecessary dynamic CT myelograms. MATERIALS AND METHODS: CT myelograms for CSF leaks from January 2011 to September 2014 were reviewed. Patients with iatrogenic leaks, traumatic brachial plexus injuries, or prior CT myelography within 2 years were excluded. Completion and results of spinal MR imaging, CT myelographic technique, and the need for repeat CT myelography or unnecessary dynamic CT myelograms were recorded. RESULTS: The algorithm was followed in 102 (79%) of 129 patients. No extradural fluid was detected in 75 (74%), of whom 70 (93%) had no leak, 4 (5%) had a slow leak, and 1 (1%) had a fast leak. Extradural fluid was detected in 27 (26%): 24 (89%) fast leaks, 1 (4%) slow leak, and 2 (7%) with no leaks. When the algorithm was followed, 1 (1%) required repeat CT myelography and 3 (3%) had unnecessary dynamic CT myelograms. The algorithm was breached in 27 (21%) cases, including no pre-CT myelogram MR imaging in 11 (41%), performing conventional CT myelography when extradural fluid was present in 13 (48%), and performing dynamic CT myelography when extradural fluid was absent in 3 (11%). Algorithm breaches resulted in 4 (15%) repeat CT myelograms and 3 (12%) unnecessary dynamic CT myelograms, both higher than with algorithm compliance. CONCLUSIONS: Using spinal MR imaging to direct CT myelography resulted in significant reduction in repeat CT myelograms to localize fast leaks with minimal unnecessary dynamic CT myelograms.

Intravenous administration of gadolinium-based contrast material is associated with dose-dependent deposition in neuronal tissues that is unrelated to renal function, age, or time between exposure and death.

Background The occupational hazards of working in the interventional laboratory have been inadequately studied for physicians and remain unaddressed for nonphysician personnel. Objectives This study sought to determine whether the prevalence of work-related musculoskeletal pain, cancer, and other medical conditions is higher among physicians and allied staff who work in interventional laboratories compared with employees who do not. Methods Mayo Clinic employees who work in affiliated hospitals with interventional cardiology or interventional radiology laboratories took an electronic survey. Results were stratified on the basis of self-reported occupational exposure to procedures that involve radiation. Results There were 1,543 employees (mean age 43 ± 11.3 years, 33% male) who responded to the survey (response rate of 57%), and 1,042 (67.5%) reported being involved with procedures utilizing radiation. These employees reported experiencing work-related pain more often than the control group before (54.7% vs. 44.7%; p Conclusions Musculoskeletal pain is more common among healthcare workers who participate in interventional procedures and is highest in nonphysician employees. The diagnosis of cancer in employees who participate in procedures that utilize radiation was not elevated when compared to controls within the same departments, although any conclusion regarding causality is limited by the cross-sectional nature of the study, as well as the low overall prevalence of malignancy in our study group.

We have anecdotally observed patients with high-flow ventral cerebrospinal fluid (CSF) leaks resulting from penetrating osseous spicules or calcified discs to be relatively thin. The purpose of this study was to explore the validity of this observation and determine if a potential association exists between low body mass index (BMI) and high-flow spinal ventral CSF leaks resulting from such dura-penetrating lesions.Sixteen consecutive patients with precisely localized high-flow ventral spinal CSF leaks on dynamic myelography were identified. The cause of the CSF leak was determined. The BMI on the date nearest to and within 2 weeks of myelography was recorded. Utilizing exact sign test, the body mass index was compared to the average BMI from the National Health and Nutrition Examination Survey (Centers for Disease Control), matched to sex and age-range.The cohort consisted of 10 males (63%) and 6 females with a mean age of 54 years (range 37-72 years). In all patients, a spiculated osteophyte/calcified disc was identified at the site of the leak. Fourteen patients (88%) had a BMI below the matched national average, while only two patients (13%) had values above the national average (p = 0.004).Patients with high-flow ventral CSF leaks resulting from spiculated osteophyte or calcified disc as identified by dynamic myelography are more likely to have a BMI below the U.S. national average, matched for gender and age-range. This exploratory analysis requires confirmation as well as further characterization of potential pathophysiologic mechanisms and impact on radiographic and clinical assessments.

Objective The aim of this study was to determine 1) if repeat lumbar transforaminal epidural steroid injections (TFESIs) resulted in recovery of pain relief, which has waned since an index injection, and 2) if cumulative benefit could be achieved by repeat injections within 3 months of the index injection. Design Retrospective observational study with statistical modeling of the response to repeat TFESI. Setting Academic radiology practice. Patients Two thousand eighty-seven single-level TFESIs were performed for radicular pain on 933 subjects. Subjects received repeat TFESIs >2 weeks and

BACKGROUND AND PURPOSE: The role of vertebroplasty in patients with myeloma remains relatively undefined. Accordingly, we sought to better define the efficacy of vertebroplasty for myeloma-associated fractures and determine the effect of procedure timing relative to the initiation of systemic therapy on outcomes and complication rates. MATERIALS AND METHODS: Clinical, laboratory, and medication data were retrieved for 172 patients with multiple myeloma treated with vertebroplasty since October 2000. Quantitative outcome data (Roland-Morris Disability Questionnaire [scale, 0–24] and the Numeric Rating Scale [0–10] for pain at rest and with activity) were collected immediately pre- and postoperatively and at 1 week, 1 month, 6 months, and 1 year following vertebroplasty. Patients with ≥50% improvement on the Numeric Rating Scale and ≥40% improvement on the Roland-Morris Disability Questionnaire were classified as “responders.” Peri- and postoperative complications were also collected. RESULTS: Significant median improvement in the Roland-Morris Disability and rest and activity Numeric Rating Scale scores (15, 2, and 6 points, respectively; P .36). Patients on systemic therapy at the time of vertebroplasty were more likely to achieve “responder status,” compared with patients not on systemic therapy, for the Numeric Rating Scale pain at rest score ( P < .01) and the Roland-Morris Disability Questionnaire score ( P < .003), with no difference in complication rates (χ2 = 0.17, P = .68). CONCLUSIONS: Vertebroplasty is an effective therapy for patients with myeloma with symptomatic compression fractures. Favorable outcomes are more likely to be achieved when spinal augmentation is performed after systemic therapy is initiated. Complication rates were not affected by the timing of systemic therapy. IQR : interquartile range NRS : Numeric Rating Scale RDQ : Roland-Morris Disability Questionnaire

Objective To assess whether a nonparticulate steroid (dexamethasone, 10 mg) is less clinically effective than the particulate steroids (triamcinolone, 80 mg; betamethasone, 12 mg) in lumbar transforaminal epidural steroid injections (TFESIs) in subjects with radicular pain with or without radiculopathy. Design Retrospective observational study with noninferiority analysis of dexamethasone relative to particulate steroids. Setting Single academic radiology pain management practice. Subjects Three thousand six hundred forty-five lumbar TFESIs at the L4-5, L5-S1, or S1 neural foramina, performed on 2,634 subjects. Methods/Outcome Measures Subjects were assessed with a pain numerical rating scale (NRS, 0–10) and Roland–Morris disability questionnaire (R-M) prior to TFESI, and at 2 weeks and 2 months follow-up. For categorical outcomes, successful pain relief was defined as either ≥50% reduction in NRS or pain 0/10; functional success was defined as ≥40% reduction in R-M score. Noninferiority analysis was performed with δ = −10% as the limit of noninferiority. Continuous outcomes (mean NRS, R-M scores) were analyzed for noninferiority with difference bounds of 0.3 for NRS scores and 1.0 for R-M scores. Results With categorical outcomes, dexamethasone was demonstrated to be noninferior to the particulate steroids in pain relief and functional improvement at 2 months. Using continuous outcomes, dexamethasone was demonstrated to be superior to the particulate steroids in both pain relief and functional improvement at 2 months. Conclusion This retrospective observational study reveals no evidence that dexamethasone is less effective than particulate steroids in lumbar TFESIs performed for radicular pain with or without radiculopathy.

BACKGROUND AND PURPOSE: The clinical impact of facet joint bone scan activity is not fully understood. The hypothesis of this study is that facet joints targeted for percutaneous treatment in clinical practice differ from those with reported activity on technetium Tc99m methylene diphosphonate SPECT/CT. MATERIALS AND METHODS: All patients with a technetium Tc99m methylene diphosphonate SPECT/CT scan of the lumbar or cervical spine who underwent subsequent percutaneous facet joint steroid injection or comparative medial branch blocks at our institution between January 1, 2008, and February 19, 2013, were identified. Facet joints with increased activity were compared with those treated. A chart review characterized the clinical reasons for treatment discrepancies. RESULTS: Of 74 patients meeting inclusion criteria, 52 (70%) had discrepant imaging findings and treatment selection of at least 1 facet joint, whereas 34 patients (46%) had a side (right vs left) discrepancy. Only 92 (70%) of 132 facet joints with increased activity were treated, whereas 103 (53%) of 195 of treated facet joints did not have increased activity. The most commonly documented clinical rationale for discrepancy was facet joint activity that was not thought to correlate with clinical findings, cited in 18 (35%) of 52 patients. CONCLUSIONS: Facet joints undergoing targeted percutaneous treatment were frequently discordant with those demonstrating increased technetium Tc99m methylene diphosphonate activity identified by SPECT/CT at our institution, in many cases because the active facet joint(s) did not correlate with clinical findings. Further prospective double-blinded investigations of the clinical significance of facet joint activity by use of technetium Tc99m methylene diphosphonate SPECT/CT and comparative medial branch blocks are needed.

Objective To assess frequency of sedation in transforaminal epidural steroid injections (TFESI) and to analyze patient dissatisfaction and vasovagal rates. Design Retrospective audit over a 6-year period, January 1, 2006–December 31, 2011. Setting Single academic center radiology pain management practice. Subjects Four thousand four hundred thirty-two patients undergoing 6,878 consecutive TFESI. Outcome Measures Frequency of sedation for TFESI was assessed. Vasovagal and patient dissatisfaction rates were assessed, the latter by patients' responses to two follow-up survey questions at 2 weeks postprocedure. Results Six thousand eight hundred seventy-eight TFESI were performed, of which only 0.1% (N = 7) were performed with sedation. Only 0.4% (N = 28) of TFESI were complicated by vasovagal reaction. Seventy-two percent (N = 4,980) of nonsedated patients responded to the survey. Overall medical care in the nonsedated was rated as: excellent 51%, very good 30%, good 15%, fair 3%, and poor 1%. Ninety-five percent confidence interval (CI) for the 3.9% of the nonsedated patients who rated their care at best “fair” was (3.3, 4.4%). Likelihood of referring friends/family members in nonsedated patients was: definitely 53%, probably 28%, uncertain 16%, probably not 3%, definitely not 0.2%. Ninety-five percent CI for the 3.2% of the nonsedated patients who would at best “probably not refer” their friends/family was (2.7, 3.7%). Conclusions In our radiology pain management practice, sedation was rarely utilized for TFESI. A small minority of nonsedated patients rated their care at best fair and would at best probably not refer friends/family members. TFESI can be performed without sedation with low patient dissatisfaction and low vasovagal rates.

BACKGROUND AND PURPOSE: Imaging-guided cervical transforaminal epidural steroid injections have been shown to decrease verbal numerical pain scores and improve functionality (Roland Morris Disability Index). These injections are often administered in combination with local anesthetic. The purpose of this study was to determine if the immediate postprocedure VNPS predicts the long-term effectiveness of the injection. MATERIALS AND METHODS: A quality assurance data base review of 247 patient records was used to document the VNPS and RMDI of patients undergoing a single CT-guided CTESI. Pain scores were recorded before the procedure, immediately after the procedure, at 2 weeks, and at 2 months. The RMDI was recorded before the procedure, at 2 weeks, and at 2 months. Spearman rank correlation analysis and logistic regression models were used to determine if the immediate postprocedure or 2-week VNPS correlated with or predicted the longer-term VNPS and RMDI as measured at 2 weeks and 2 months. RESULTS: There was not a strong correlation between the pain score obtained immediately after the procedure and the 2-month outcome of the VNPS or RMDI. The pain scores at 2 weeks did correlate with the 2-month outcomes. The 2-week VNPS also was a significant predictor of patients who would achieve a >50% improvement in VNPS or RMDI at 2 months. CONCLUSIONS: Pain scores obtained immediately after completion of a single CT-guided CTESI do not predict the long-term effectiveness of this procedure. However, patient response at 2 weeks does correlate with the long-term effectiveness of these injections as measured by the VNPS and the RMDI.

Sacroplasty has emerged as a treatment option for patients with painful osteoporotic sacral insufficiency fractures. We report short-term outcomes in a consecutive cohort of patients treated with sacroplasty.We retrospectively reviewed 57 patients treated with sacroplasty for painful osteoporotic sacral fractures at our institution between 2004 and 2011. An 11-point numerical rating scale pain score was recorded at rest and at activity pre- and post-procedure. Opioids prescribed to the patient both pre- and post-procedure were recorded.Mean duration of pain prior to sacroplasty was 3 weeks (IQR 2-5). Procedural complications were minimal. Median post-procedure follow-up time was 2.5 weeks (IQR 1-5) among 45 patients with available data. Thirty-seven (82%) of the 45 patients experienced a numerical or descriptive decrease from initial pain at follow-up. Median activity pain scores collected from 13 patients decreased from 10 (IQR 8.5-10) pre-procedure to 6 (IQR 4-6.8) post-procedure (p0.0001), and median rest pain scores collected from 29 patients decreased from 7 (IQR 4-8.5) to 2 (IQR 1-3.5)(p0.0001). Twenty-two (76%) of 29 patients had at least a 30% decrease in rest pain scores. The median number of opioids prescribed per patient decreased from 1 (IQR 1-2) pre-procedure to 0 (IQR 0-1) post-procedure (p0.0001). Thirty-four of 57 patients (60%) had decreased opioid usage, 15 (26%) patients had unchanged usage and 8 (14%) had increased usage.Our series demonstrates that sacroplasty is a safe and effective treatment in patients with painful osteoporotic insufficiency fractures.

The objective of our study was to review the clinical utility of digital subtraction myelography for the diagnosis of spinal CSF leaks in patients with spontaneous intracranial hypotension (SIH) and those with superficial siderosis.Procedure logs from 2007 to 2011 were reviewed to identify cases in which digital subtraction myelography was performed to diagnose spinal CSF leaks. Electronic medical records were reviewed to obtain information regarding diagnosis and outcome. For patients to be included in the study, preprocedural spinal MRI had to show an extradural fluid collection spanning more than one vertebral level and postmyelographic CT had to confirm the presence of an active CSF leak. If digital subtraction myelography successfully showed the site of the CSF leak, the location was documented.Eleven patients (seven men and four women; mean age, 49.0 years) underwent digital subtraction myelography during the study period. Six patients had SIH and five patients had superficial siderosis. The extradural fluid collection on spinal MRI averaged a length of 15.5 vertebral levels. Digital subtraction myelography successfully showed the site of the CSF leak in nine of the 11 patients, and all of the dural tears were located in the thoracic spine between T3 and T11.Digital subtraction myelography is a valuable diagnostic tool for the localization of rapid spinal CSF leaks and should be considered in patients who are clinically suspected to have a dural tear that is accompanied by a longitudinally extensive extradural fluid collection on spinal MRI.

Background and purposeBrain capillary vascular malformations (CVMs) are known to occur with relatively high frequency in hereditary hemorrhagic telangiectasia (HHT) patients. These lesions are thought to have a benign natural history but this has not been systematically studied. The purpose of our study was to examine the natural history of CVMs in a consecutive series of HHT patients.Materials and methodsConsecutive patients with untreated CVMs receiving serial imaging were included. Baseline data including demographics, HHT gene mutations, and Curacao diagnostic criteria were collected. The primary outcome was rupture on follow-up. A secondary outcome was new focal neurological deficit or seizure related to the lesion.Results22 patients with 42 CVMs were included. Mean age was 45.9±16.9 years. 18 patients (81.8%) were women and 4 (18.2%) were men. 19 patients (86.4%) had definite HHT and 3 patients (13.6%) had probable HHT. Mean follow-up was 4.6±3.7 years. There were a total of 100.2 patient years of follow-up and 222.5 lesion years. No lesions ruptured on follow-up and no patient had focal neurological deficits or seizures related to the lesions.ConclusionsOur study found that CVMs in HHT patients have a benign natural history as no patients had hemorrhage or other symptoms related to these lesions. These findings should be confirmed in additional multicenter longitudinal studies.

BACKGROUND AND PURPOSE: Image-guided cervical transforaminal epidural injections play an important role in the management of cervical radicular pain syndromes. The safety and efficacy of these injections via an anterolateral approach has been well-studied. The goal of this retrospective review was to determine the safety and efficacy of CT-guided transforaminal epidural injections by using a posterior approach. MATERIALS AND METHODS: Retrospective review of patient records was used to define VNPS and RMDI of patients undergoing CT-guided transforaminal cervical epidural injections between 2006 and 2010. Pain scores were recorded preprocedure, immediately postprocedure, at 2 weeks, and at 2 months. The RMDI was recorded preprocedure, at 2 weeks, and at 2 months. Data analysis of 247 patients was completed. Differences in VNPS scores and the RMDI were then compared on the basis of a CT-guided approach (anterolateral versus posterior). RESULTS: There was no statistical difference in the degree of pain relief and improvement in the RMDI between the CT-guided transforaminal anterolateral approach and the posterior approach at 2 weeks and at 2 months. Both groups demonstrated a statistically significant improvement in pain scores and the RMDI. Approximately 35% of patients in both groups demonstrated >50% pain relief at 2 months. There were no serious complications in either group. CONCLUSIONS: CT-guided transforaminal cervical epidural injections by using a posterior approach are safe and effective.

To determine if operator variability, prior vertebroplasty experience, or acquired vertebroplasty experience affects clinical outcomes.Informed consent was obtained from all patients and all data were handled in a manner consistent with institutional review board guidelines and the Health Insurance Portability and Accountability Act. Outcomes from 841 vertebroplasties, sorted by operator, were studied; two operators had previous vertebroplasty experience and five were neurointerventionalists who were initially new to the procedure. Objective (Roland-Morris Disability Questionnaire [RDQ] and analog pain scales) and subjective (mobility, narcotic use) scores were monitored before and after vertebroplasty at specified intervals following treatment. Perioperative cement volume utilization, complications, and number of treated levels were recorded. Random-effects and repeated-measures analyses of variance were used to assess operator differences and variability in clinical outcomes while generalized linear mixed-model regression analyses were used to track changes in clinical outcomes over time.All operators provided similar average durable clinical improvements in postoperative pain and disability with nonsignificant interoperator variability. However, generalized linear model regression suggests that four of five initially novice operators showed significant changes in several procedural measures and clinical outcomes over the study timeframe, including cement volume utilization (reduction of 3.64 to 4.63 cm(3)), 1 week RDQ score (reduction of 4.79 to 8.62 points) and postoperative rest pain (reduction of 1.18 to 2.03 points).Changes over time in measured outcomes suggest the presence of a training effect among novice operators. Cement volume utilization and immediate postprocedural pain decrease with experience but long-term clinical outcomes are insensitive to operator experience.

BACKGROUND AND PURPOSE: Vertebroplasty is commonly used for osteoporotic and neoplastic compression fractures, yet little evidence exists for its use in traumatic nonosteoporotic compression fractures. The purpose of this study was to evaluate the safety and efficacy of percutaneous vertebroplasty for patients with traumatic nonosteoporotic compression fractures. MATERIALS AND METHODS: We performed a retrospective review of 819 patients (982 procedures) who underwent percutaneous vertebroplasty, to identify patients who had normal bone mineral densitometry scores or had no previous diagnosis of osteoporosis, multiple myeloma, or history of long-term steroid use. Follow-up evaluations included pain at rest and with activity (assessed with the visual analog scale [VAS]), medication use, and mobility. Roland-Morris Disability Questionnaire (RDQ) scores were also collected. Statistical analysis included a 2-tailed t test comparing postprocedure outcomes with baseline values. RESULTS: Fifteen patients (53% women) were included. Mean age and t -score were 60 years and −0.35, respectively. We found significant improvements in the VAS scores, both at rest and with activity, and in the RDQ scores, starting at the 2-hour follow-up. Additionally, we found marked decreases in medication use and improvements in mobility. The complication rate was low and characterized by asymptomatic extravasation of cement. CONCLUSIONS: From our study, we have shown that vertebroplasty can be successfully and safely used in patients with traumatic nonosteoporotic compression fractures. Vertebroplasty in these patients should be used after failure of conservative treatments and may be used in place of more invasive spinal reconstruction techniques.

Purpose: To retrospectively evaluate the complications of diagnostic cerebral catheter angiography in 19 826 consecutive patients. Materials and Methods: This HIPAA-compliant study had institutional review board approval, with waiver of informed consent. Demographic, procedural, and complication data in 19 826 consecutive patients undergoing diagnostic cerebral angiography at one institution from 1981 through 2003 were retrospectively reviewed. Neurologic, systemic, and local complications were recorded on the basis of clinical follow-up results after each angiographic examination. Events that occurred within 24 hours of angiography were considered to be complications of the procedure. Multivariable analysis was employed to identify patient and procedural factors significantly associated with neurologic complications. Results: Neurologic complications occurred in 522 examinations (2.63%), and 27 of these (0.14%) were strokes with permanent disability. Twelve deaths occurred (0.06%). Access-site hematoma w...

To investigate whether there are differences in fluoroscopy time and patient dose for fluoroscopically guided lumbar transforaminal epidural steroid injections (TFESIs) performed by staff radiologists versus with trainees and to evaluate the effect of patient body mass index (BMI) on fluoroscopy time and patient dose, including their interactions with other variables.Single-level lumbar TFESIs (n=1844) between 1 January 2011 and 31 December 2013 were reviewed. Fluoroscopy time, reference point air kerma (Ka,r), and kerma area product (KAP) were recorded. BMI and trainee involvement were examined as predictors of fluoroscopy time, Ka,r, and KAP in models adjusted for age and gender in multivariable linear models. Stratified models of BMI groups by trainee presence were performed.Increased age was the only significant predictor of increased fluoroscopy time (p0.0001). Ka,r and KAP were significantly higher in patients with a higher BMI (p0.0001 and p=0.0009). When stratified by BMI, longer fluoroscopy time predicted increased Ka,r and KAP in all groups (p0.0001). Trainee involvement was not a statistically significant predictor of fluoroscopy time or Ka,r in any BMI category. KAP was lower with trainees in the overweight group (p=0.0009) and higher in male patients for all BMI categories (p0.02).Trainee involvement did not result in increased fluoroscopy time or patient dose. BMI did not affect fluoroscopy time; however, overweight and obese patients received significantly higher Ka,r and KAP. Male patients received a higher KAP in all BMI categories. Limiting fluoroscopy time and good collimation practices should be reinforced in these patients.

BACKGROUND AND PURPOSE: The Patient Reported Outcomes Measurement Information System is a newly developed outcomes measure promulgated by the National Institutes of Health. This study compares changes in pain and physical function–related measures of this system with changes on the Numeric Rating Pain Scale, Roland Morris Disability Index, and the European Quality of Life scale 5D questionnaire in patients undergoing transformational epidural steroid injections for radicular pain. MATERIALS AND METHODS: One hundred ninety-nine patients undergoing transforaminal epidural steroid injections for radicular pain were enrolled in the study. Before the procedure, they rated the intensity of their pain by using the 0–10 Numeric Rating Pain Scale, Roland Morris Disability Index, and European Quality of Life scale 5D questionnaire. Patients completed the Patient Reported Outcomes Measurement Information System Physical Function, Pain Behavior, and Pain Interference short forms before transforaminal epidural steroid injections and at 3 and 6 months. Seventy and 43 subjects replied at 3- and 6-month follow-up. Spearman rank correlations were used to assess the correlation between the instruments. The minimally important differences were calculated for each measurement tool as an indicator of meaningful change. RESULTS: All instruments were responsive in detecting changes at 3- and 6-month follow-up (P < .0001). There was significant correlation between changes in Patient Reported Outcomes Measurement Information System scores and legacy questionnaires from baseline to 3 months (P < .05). There were, however, no significant correlations in changes from 3 to 6 months with any of the instruments. CONCLUSIONS: The studied Patient Reported Outcomes Measurement Information System domains offered responsive and correlative psychometric properties compared with legacy instruments in a population of patients undergoing transforaminal epidural steroid injections for radicular pain.

OBJECT Precise localization and understanding of the origin of spontaneous high-flow spinal CSF leaks is required prior to targeted treatment. This study demonstrates the utility of ultrafast dynamic CT myelography for the precise localization of high-flow CSF leaks caused by spiculated spinal osteophytes. METHODS This study reports a series of 14 patients with high-flow CSF leaks caused by spiculated spinal osteophytes who underwent ultrafast dynamic CT myelography between March 2009 and December 2010. There were 10 male and 4 female patients, with an average age of 49 years (range 37–74 years). The value of ultrafast dynamic CT myelography in depicting the CSF leak site was qualitatively assessed. RESULTS In all 14 patients, ultrafast dynamic CT myelography was technically successful at precisely demonstrating the site of the CSF leak, the causative spiculated osteophyte piercing the dura, and the relationship of the implicated osteophyte to adjacent structures. Leak sites included 3 cervical, 11 thoracic, and 0 lumbar levels, with 86% of the leaks occurring from C-5 to T-7. Information obtained from the ultrafast dynamic CT myelogram was considered useful in all treated CSF leaks. CONCLUSIONS Spinal osteophytes piercing the dura are a more frequent cause of high-flow CSF leaks than previously recognized. Ultrafast dynamic CT myelography adds value beyond standard dynamic myelography or digital subtraction myelography in the diagnosis and anatomical characterization of high-flow spinal CSF leaks caused by these osteophytes. This information allows for appropriate planning for percutaneous or surgical treatment.

Background and Purpose: Cardiac myxomas can present with a myriad of neurological complications including stroke, cerebral aneurysm formation and metastatic disease. Our study had two objectives: (1) to describe the neuroimaging findings of patients with cardiac myxomas and (2) to examine the relationship between a history of embolic complications secondary to myxoma and intracranial aneurysm formation, hemorrhage and metastatic disease. We hypothesized that patients who present with embolic complications related to myxoma would be more likely to have such complications. Materials and Methods: We searched our institutional database for all patients with pathologically proven cardiac myxomas from 1995 to 2014 who received neuroimaging. Neuroimaging findings were categorized as acute ischemic stroke, intracerebral hemorrhage, oncotic aneurysm, and cerebral metastasis. Cardiac myxoma patients were divided into those presenting with embolic complications (i.e. lower extremity emboli or cerebral emboli) and those presenting with non-embolic complications prior to surgical resection of the myxoma. The prevalence of intracranial hemorrhage, myxomatous aneurysm formation, and cerebral metastases was compared in myxoma patients presenting with and without embolic complications using a Chi-squared test. Results: Forty-seven consecutive patients were included in this study. Sixteen patients (34.0%) had imaging evidence of acute ischemic stroke. Of these, 13 had acute ischemic strokes directly attributed to the cardiac myxoma (27.7%) and 3 had acute ischemic strokes secondary to causes other than myxoma (6.4%). Seven patients (14.9%) had aneurysms. Two patients (4.3%) had parenchymal metastatic disease on long-term imaging. Fourteen patients (29.8%) presented with ischemic symptoms that were attributed to cardiac myxoma (1 with lower extremity ischemia, 1 with lower extremity ischemia and ischemic stroke, and 12 with ischemic stroke). Patients presenting with embolic complications related to the myxoma (ischemic stroke or lower extremity ischemia) were more likely to have imaging evidence of intracranial hemorrhage (21.4 vs. 3.0%, p = 0.09), oncotic aneurysm (35.7 vs. 6.1%, p = 0.03), and cerebral metastasis (14.3 vs. 0.0%, p = 0.07) on follow-up imaging. Conclusions: Ischemic stroke and intracranial oncotic aneurysm were found in a substantial proportion of cardiac myxoma patients undergoing neuroimaging. Patients presenting with embolic complications of cardiac myxoma are more likely to have intracranial hemorrhage, intracranial oncotic aneurysms, and cerebral metastatic disease.

OBJECTIVE AND IMPORTANCE We present two cases of a far lateral extraforaminal synovial cyst at the L5–S1 level of the spine. Neither case was diagnosed as a synovial cyst before surgery because of their atypical location. Only one other case of an extraforaminal synovial cyst, located at L4–L5, has

Objective To assess whether computed tomography(CT)-guided injections of local anesthetic and corticosteroid into chronic lumbar pars interarticularis defects may identify and provide benefit to a cohort of patients where the pars defects act as a primary axial pain generator. Design Retrospective practice audit. Setting Single academic radiology pain management practice. Patients 59 consecutive patients undergoing CT-guided injections of lumbar pars defects. Methods Patients were assessed with a pain numerical rating scale (NRS, 0–10) and Roland–Morris disability questionnaire (R–M) prior to injection and at 2 weeks and 2 months follow-up. For categorical outcomes, successful pain relief response was defined as either ≥50% reduction in NRS or pain 0/10; functional response was defined as ≥40% reduction in R–M score. Continuous outcomes (mean NRS, R–M scores) were assessed for significant change following injection. Results For categorical outcomes, 37.9% of patients were responders at 2 months' follow-up; 20.7 % had complete relief of index pain. For functional recovery, 34.5% were responders at 2 months. Using continuous outcomes, mean NRS was 5.4 ± 2.1 prior to injection and 3.6 ± 2.6 at 2 months (P

Objective To assess whether the immediate anesthetic response of pain relief (sensory blockade) or weakness (motor blockade) after lumbar transforaminal epidural steroid injection (TFESI) is associated with longer term effectiveness in pain relief and functional recovery. Design Retrospective observational study. Setting Single academic radiology practice. Subjects Three thousand six hundred forty-five lumbar TFESIs performed on 2,634 subjects. Methods Subjects completed a pain numerical rating scale (NRS, 0–10) and Roland–Morris disability questionnaire (R-M) prior to and immediately after TFESI (NRS) and at 2 weeks and 2 months follow-up. Successful pain relief was ≥50% NRS reduction; functional success was ≥40% R-M reduction. Post-procedure motor weakness was recorded. Logistic regression models assessed association of immediate post-procedure NRS response, and NRS or R-M response at 2 weeks, with successful outcomes at 2 months. C-index assessed model discrimination; values closer to 1.0 indicated better discrimination. Results Immediate NRS response was weakly associated with 2-month outcomes (C-index = 0.58). NRS and R-M responses at 2 weeks were more strongly associated with the 2-month response (C-indices 0.77, 0.80, respectively). Post-procedure motor blockade had little association with successful 2-month NRS or R-M outcomes (C-indices 0.51, 0.50, respectively). Patients that responded at 2 weeks were more likely to be responders at 2 months than those who were non-responders at 2 weeks (odds ratio = 6.49, confidence interval 5.38, 7.84). Conclusion Immediate post-TFESI pain relief does not strongly predict longer term effectiveness in pain relief or functional recovery. Response in pain relief or functional recovery at 2 weeks is more strongly associated with 2-month outcomes.

Study Design. Technical report. Objective. To convey the mechanism of venous air embolism (VAE) during percutaneous spinal procedures and its proper identification and management. Summary of Background Data. Percutaneous spinal procedures such as vertebroplasty and kyphoplasty are commonplace techniques employed to alleviate back pain for compression fractures. VAE is a real and likely underappreciated phenomenon that is important to recognize. Methods. A case report is used to illustrate the clinical scenario of VAE during vertebroplasty performed for a T9 compression fracture. Results. The rapid sumping of fluid and air was identified during the procedure and believed to be due to a large air/venous interface within the trabecular bone. The needle was capped and no undue harm occurred to the patient. Conclusion. VAE is a complication with associated morbidity and mortality from percutaneous procedures for the treatment of compression fractures. An understanding of the causes, prevention, identification, and management when it occurs will serve to improve patient care and reduce morbidity.

✓ The authors report their experience using electrolytically detachable coils for the treatment of ruptured posterior circulation aneurysms. Twenty-six patients with 28 posterior circulation aneurysms were treated. All patients were referred for endovascular treatment by experienced vascular neurosurgeons. Patients underwent follow-up angiography immediately after treatment, 1 to 6 weeks posttreatment, and 6 months posttreatment. Six-month follow-up angiograms obtained in 19 patients with 20 aneurysms demonstrated that 18 (90%) of the 20 aneurysms were 99 to 100% occluded, one aneurysm (5%) was approximately 90% occluded, and one aneurysm (5%) was approximately 75% occluded. The patient with the aneurysm that was approximately 75% occluded needed additional treatment, consisting of parent artery balloon occlusion, and was considered a treatment failure (3.8% of patients). There was one treatment-associated mortality (3.8%) but no treatment-associated serious neurological or nonneurological morbidity in the patient group. There was no recurrent aneurysm rupture during treatment or during the mean 27-month follow-up period. Endovascular treatment of ruptured posterior circulation aneurysms with electrolytically detachable coils can be accomplished with low morbidity and mortality rates. The primary goal of treatment—preventing recurrent aneurysm—can be achieved over the short term. Endovascular coil occlusion will play an important role in the treatment of ruptured posterior circulation aneurysms, particularly if long-term efficacy in preventing recurrent aneurysm hemorrhage can be documented.

Objectives. To assess the clinical effectiveness of single lumbar transforaminal epidural steroid injections (TFESIs) in subjects with radicular pain with or without radiculopathy. Design. Retrospective observational series. Setting. Single academic radiology pain management practice. Subjects. Two thousand twenty-four subjects undergoing single lumbar TFESIs at the L4-5, L5-S1, or S1 neural foramina. Methods / Outcome Measures. Subjects were assessed with a pain numerical rating scale (NRS, 0–10) and Roland–Morris disability questionnaire (R–M, 23-point Deyo modification) prior to TFESI and at 2 weeks and 2 months follow-up. Successful pain relief (responders) was defined as either ≥50% reduction in NRS or pain 0/10; functional success was defined as ≥40% reduction in R–M score. Results. There were statistically significant (P

Recent studies have described the safety and efficacy of computed tomography (CT)-guided cervical transforaminal epidural steroid injections with both the anterolateral and posterior approach. Although fluoroscopy is the most common form of image guidance for these procedures, CT guidance offers many advantages. However, some key features of CT guidance in these procedures need to be considered to ensure safe and technically successful outcomes.

BACKGROUND AND PURPOSE: The prevalence of facet joint signal change in acute/subacute lumbar vertebral body compression fractures is unknown. We hypothesized that facet joint signal change on MR imaging is more common in facet joints associated with an acute/subacute lumbar compression fracture than those associated with normal vertebral bodies or ones that have a chronic compression fracture. MATERIALS AND METHODS: Three neuroradiologists and a neuroradiology fellow retrospectively graded facet joint inflammatory change on MR imaging in 900 facet joints in 75 patients with at least 1 painful osteoporotic lumbar compression fracture. Facet joint signal change was assessed on T2-weighted images with chemical fat-saturation, STIR images, and/or gadolinium-enhanced T1-weighted images with chemical fat-saturation. Each facet joint from the T12/L1 to L5/S1 level was assessed individually. An overall facet joint signal-change score, which is a composite measure of the grade of signal change for all 4 facet joints associated with a given lumbar vertebral level, was devised, and statistical significance was assessed via Wilcoxon rank sum tests. RESULTS: The overall facet joint signal-change scores were significantly higher at vertebral body levels affected by an acute/subacute compression fracture compared with control levels, which were associated with either normal bodies or chronic compression fractures. CONCLUSIONS: Our findings suggest an association between facet joint signal change on MR imaging and acute/subacute lumbar vertebral body compression fractures.

To determine the MR appearance of spinal cord multiple sclerosis (MS) plaques in patients presenting with myelopathy by using a high-field (1.5 T) imager.We studied 119 patients who underwent high-field (1.5 T) MR studies of the spinal cord for evaluation of myelopathy. All 119 patients were thought to have possible findings of spinal cord MS at the time of the MRI interpretation.Sixty-four plaques were studied in 47 patients with clinically definite MS and adequate quality MRI. Of these patients 68% had a single spinal cord plaque, 19% had two plaques, and 13% had three or more plaques. Sixty-two percent of the plaques occurred in the cervical spinal cord and most frequently involved the posterior (41%) and lateral (25%) aspects of the spinal cord. None of the 64 lesions involved the entire thickness of the spinal cord. The lesion length varied from 2 to 60 mm, with 84% of the lesions15 mm in length. The spinal cord diameter was unchanged in 84% of plaques, enlarged at the level of the lesion in 14%, and atrophic in 2%. Just over half (55%) of the plaques enhanced with intravenously administered gadolinium. Of the patients who received synchronous head and spinal cord examinations on the same day, 24% had normal findings on the MR study of the head. Follow-up spinal cord studies were available in nine patients. New lesions developed in two patients, while previously described lesions resolved. In three patients only new lesions developed. In four patients no change occurred in the existing number of cord plaques.Spinal cord demyelinating plaques present as well-circumscribed foci of increased T2 signal that asymmetrically involve the spinal cord parenchyma. Knowledge of their usual appearance may prevent unnecessary biopsy. An MR examination of the head may confirm the imaging suggestion of spinal cord demyelinating disease, because up to 76% of patients have abnormal intracranial findings. In the remaining 24% of cases in which the clinical diagnosis is not certain and MR findings in the head are negative, a follow-up spinal cord study is recommended, because these lesions evolve and change over time.

BACKGROUND AND PURPOSE: Precise anatomic understanding of the vascular anatomy of SDAVFs is required before treatment. This study demonstrates the utility of C-arm conebeam CT to locate precisely the fistulous point in SDAVFs and the courses of their feeding arteries and draining veins. MATERIALS AND METHODS: This retrospective study reports 14 consecutive patients with SDAVFs who underwent DSA and C-arm conebeam CT angiography. SDAVF sites included 5 thoracic, 7 lumbar, and 2 sacral fistulas. Selective DSA initially identified the location and arterial supply of the SDAVF. C-arm conebeam CT angiography was then performed with selective injection into the feeding artery. Reconstructed images were reviewed at a workstation with the referring surgeon, in conjunction with the standard 2D DSA images. The value of C-arm conebeam CT in depicting the fistula and the relationship to adjacent structures was qualitatively assessed. RESULTS: In all 14 patients, C-arm conebeam CT angiography was technically successful and precisely demonstrated the site of the fistula, feeding arteries, draining veins, and the relationship of the fistula to adjacent osseous structures. Information obtained from the C-arm conebeam CT angiogram was considered useful in all surgically (12 patients) and endovascularly (2 patients) treated SDAVFs. CONCLUSIONS: 3D C-arm conebeam CT angiography is a useful adjunct to 2D DSA in the anatomic characterization of SDAVFs. The technique allowed improved visualization of the vascular anatomy of the SDAVFs and clearer definition of their spatial relationships to adjacent structures.

BACKGROUND AND PURPOSE: Vertebroplasty has been commonly used for the treatment of vertebral compression fractures. Practitioners usually attempt to maximize filling of the vertebral body with polymethylmethacrylate (PMMA), either by using a bipediculate approach with separate infusions in both hemivertebrae or by using a unipediculate approach with central needle placement that allows bilateral hemivertebral filling. This study serves to investigate the clinical efficacy of a unipediculate approach in which the cement injected does not cross the midline, with resultant “hemivertebroplasty.” MATERIALS AND METHODS: A retrospective review of 917 vertebroplasty procedures was performed. A radiologic review of each vertebroplasty in the data base was performed to extract the vertebroplasties in which there was filling of only 1 side of the hemivertebra, which we term “hemivertebroplasty.” Pre- and postoperative evaluations (1-week to 2-year postprocedure) included a Visual Analog Scale (VAS) for pain, the Roland-Morris Disability Questionnaire (RDQ) scores, and information regarding new fractures and retreatment of augmented fractures. RESULTS: No significant difference was found between the hemivertebroplasty cases and the bilaterally filled vertebroplasty group in reducing VAS or RDQ scores. Moreover, survival analysis showed no significant difference in the risk of incident fracture between groups (hazard ratio = 0.81; 95% confidence interval, 0.33–2.65). CONCLUSIONS: On the basis of our results, unilateral “hemivertebroplasty” is as effective in reducing pain with activity and at rest and decreasing the RDQ scores as bilateral vertebral filling. Additionally, vertebrae undergoing unilateral filling were at no greater risk of refracture or fracture of adjacent vertebrae than bilaterally filled vertebrae.

BACKGROUND AND PURPOSE: Despite the literature supporting the efficacy of vertebroplasty for treatment of osteoporotic vertebral compression fractures, few reports exist documenting its use in the treatment of compression fractures in multiple myeloma patients. Accordingly, we sought to characterize the imaging characteristics, clinical course, and outcomes in myeloma patients treated with vertebroplasty. MATERIALS AND METHODS: We performed a retrospective review of clinical outcome data from 67 multiple myeloma patients treated with vertebroplasty since October 2000. Quantitative outcome data including the Roland Morris Disability Questionnaire (RDQ) and Visual Analog Scales for pain and qualitative outcome data (self-reported pain, mobility, and narcotic use) were collected preoperatively, immediately after vertebroplasty, and at 1 week, 1 month, 6 months, and 1 year after treatment. RESULTS: Significant improvements in all of the outcome measures were observed postoperatively and throughout the duration of follow-up. Quantitative outcome measures (RDQ, analog pain scale 0–10, with rest and activity) improved by 11.0 (48%; P < .0001), 2.7 (25%; P < .001), and 5.3 (48%; P < .0001) points, respectively, with persistent improvement at 1 year (P < .01; P < .03; P < .001). Eighty-two percent and 89% of patients experienced a significant improvement in subjective rest pain and activity pain, respectively. Subjective scores achieved durable improvements, with 65% of patients requiring fewer narcotics after vertebroplasty and 70% having improved mobility. CONCLUSION: Vertebroplasty provides significant and durable pain relief for patients with intractable spinal pain secondary to compression fractures resulting from multiple myeloma.

To retrospectively evaluate the complications of diagnostic cerebral catheter angiography in 19,826 consecutive patients.This HIPAA-compliant study had institutional review board approval, with waiver of informed consent. Demographic, procedural, and complication data in 19 826 consecutive patients undergoing diagnostic cerebral angiography at one institution from 1981 through 2003 were retrospectively reviewed. Neurologic, systemic, and local complications were recorded on the basis of clinical follow-up results after each angiographic examination. Events that occurred within 24 hours of angiography were considered to be complications of the procedure. Multivariable analysis was employed to identify patient and procedural factors significantly associated with neurologic complications.Neurologic complications occurred in 522 examinations (2.63%), and 27 of these (0.14%) were strokes with permanent disability. Twelve deaths occurred (0.06%). Access-site hematoma was the most common complication overall (4.2%). Factors independently associated with an increased risk of neurologic complication included the indication of atherosclerotic cerebrovascular disease (odds ratio [OR], 2.494), the indication of subarachnoid hemorrhage (OR, 2.523), and the comorbidity of frequent transient ischemic attack (OR, 1.674). Factors independently associated with a decreased risk of neurologic complication were increasing chronologic year in which the procedure was performed (OR, 0.659 per 5-year interval) and involvement of a trainee in the procedure (OR, 0.710).In this review, diagnostic catheter cerebral angiography was found to have relatively low complication rates.

We report the radiographic findings in a case of histologically proven giant cell (temporal) arteritis coupled with high-grade stenoses affecting the internal carotid and vertebral arteries. The 69-year-old patient sought medical assessment because of transient ischemic attacks. The stenoses, which were extradural just proximal to the dural entry point, were thought to be a manifestation of the giant cell arteritis.

Vertebroplasty alters spinal biomechanics and may lead to incident vertebral fractures. The endplate localization of prevalent and incident fractures was evaluated in 86 patients. In the absence of vertebroplasty, superior endplate fractures predominate. After the procedure, inferior endplate fractures are disproportionately common in adjacent vertebrae immediately above the treated level, potentially supporting a causative relationship between vertebroplasty and incident fractures. Introduction: To determine retrospectively whether new-onset fractures after vertebroplasty tend to cluster in the endplate immediately adjacent to the cemented vertebra. Materials and Methods: Institutional Review Board approval and patient consent for use the use of medical records were obtained for this study. We performed a retrospective review of patients with new (incident) vertebral fractures after vertebroplasty. The median age for these patients was 72.5 years, and 58 (67.4%) were women. Fractures were diagnosed on the basis of MRI or bone scan and were catalogued based on their location within the vertebral body (superior endplate, inferior endplate, or holo-vertebral). 2 and generalized estimating equation (GEE) analyses were used to compare the distribution of fracture subtypes among pre-existing (prevalent) and incident fractures. Results: The patients had 313 prevalent osteoporotic vertebral fractures and were treated at 137 vertebral levels. Among prevalent fractures, superior endplate fractures predominated (57% superior, 11% inferior; p < 0.0001). After vertebroplasty, 186 incident fractures developed in these 86 patients. Seventy-seven (41%) of these incident fractures occurred adjacent to treated vertebrae. Nonadjacent, incident fractures, like prevalent fractures, occurred predominantly along superior endplate. Incident fractures immediately above treated levels, however, localized disproportionately to the inferior endplate (30% superior, 57% inferior; p < 0.0001). Conclusions: There are an increased number of inferior endplate fractures of the vertebral body immediately cephalad to the treated level.

We present two cases of a far lateral extraforaminal synovial cyst at the L5-S1 level of the spine. Neither case was diagnosed as a synovial cyst before surgery because of their atypical location. Only one other case of an extraforaminal synovial cyst, located at L4-L5, has been reported in the literature.Both women presented with radicular leg pain and examination findings consistent with L5 root compression.During surgery, the cyst was not associated with the facet joint. One cyst was adherent to the nerve root. Both cysts were completely resected, with excellent pain relief.These cases serve as a stimulus to look outside the spinal canal and foramen in patients with symptoms suggesting nerve root compression. Far lateral extraforaminal synovial cyst should be included in the differential diagnosis.