Purpose: To evaluate MRI findings of lateral lumbar disc herniations (LLDHs) and to determine whether those correlate with clinical symptoms. Materials and Methods: The study included 105 patients with LLDHs that were diagnosed by MRI. The distribution and location of the LLDHs (foraminal, extraforaminal, and foraminal and extraforaminal), the displacement of adjacent nerves, and the detection rate of LLDHs from axial and sagittal images were reviewed retrospectively by two radiologists. 36 patients were included in evaluating whether location of LLDHs and displacement of adjacent nerve correlate with radiculopathy. Results: The distributions of the LLDHs were 3.4% at L1-2, 14.4% at L2-3, 33% at L3-4, 33% at L4-5, and 16.9% at L5-S1. The locations were foraminal in 38.6% of cases, extraforaminal in 45.4% of cases, and foraminal and extraforaminal in 16% of cases. In addition, 77.3% of the diagnosed LLDH cases displaced the adjacent nerve. The detection rates of LLDHs in the axial and sagittal images were 100% and 77.3%, respectively. In 36 patients, 47.4% had radiculopathy related to LLDHs. Location of LLDHs and displacement of adjacent nerve had no statistically significant difference between patients with or without radiculopathy. Conclusion: MRI is an effective method for evaluating the location of LLDHs and their influence on adjacent nerves. The axial image is more important than the sagittal image in diagnosing LLDHs. The location of LLDHs and the displacement of adjacent nerve were not found to be related to radiculopathy.
Nonseptic inflammation of the olecranon bursa is frequent because of its superficial location.1 This olecranon bursitis can be due to variable causes such as trauma, overuse, inflammatory arthropathy, chronic degenerative osteoarthritis, rheumatoid arthritis (RA), and gout.2–4 A cyst (or geode) is a subarticular cystic lesion, and this is often seen in osteoarthritis and RA.5 Other forms of arthritis, such as hemophilia, calcium pyrophosphate deposition disease, and gout, can show cysts.5–7 These cysts are usually small but can enlarge and reach 5 or 6 cm in diameter.8 Although cysts are common in RA, cysts occurring in the olecranon have been rarely reported,9–12 and most of them were related to spontaneous fractures through olecranon cysts.9–11 To our knowledge, a report of communication between olecranon bursitis and an olecranon cyst has not been reported in the English literature. We present a case of olecranon bursitis in a 23-year-old rheumatoid patient in which communication with an olecranon cyst was confirmed on sonography and at surgery. On color scale sonography, compression with the ultrasound transducer on the bursa was useful for confirming the communication between the olecranon bursa and the cyst by observation of the color flow signal. A 23-year-old woman had pain, swelling, and a soft, palpable, masslike lesion in the left elbow. She had known RA with polyarthralgia, especially in both wrists and the left elbow, for 3 years. Radiographs of the left elbow joint (Figure 1) showed a large cystic lesion in the olecranon of the ulna and elbow changes consistent with RA. In the olecranon, a relatively well-defined osteolytic lesion with a narrow transitional zone, a thin sclerotic rim, and inner bony ridges or septations was shown. There was no matrix calcification or periosteal reaction. In addition, anterior joint capsular distension and posterior soft tissue bulging were noted. The changes suggested an olecranon cyst as the underlying abnormality, but a differential diagnosis such as a giant cell tumor or other bone tumor had to be included. Radiograph (lateral view) of the left elbow shows a relatively well-defined osteolytic lesion in the olecranon. Soft tissue swelling (white arrows) is shown in the posterior aspect of elbow, and anterior joint capsular bulging (black arrows) is suggested. On sonography (Figure 2), olecranon bursitis was noted, with inner marked synovial hypertrophies, an echogenic fluid collection, and septations. In addition, a communication between the olecranon bursitis and the intramedullary portion of the olecranon was shown through a posterior cortical defect of the olecranon. To-and-fro flow movements were noted through this cortical defect on compression with the ultrasound transducer, and this finding was noted as movement of echogenic material on gray scale sonography and a color flow signal on color scale sonography. In addition, irregular cortical margins, subchondral erosions, a hypertrophied, echogenic synovium with hypervascularity, and joint effusion were shown in the elbow joint. These findings suggested prominent and chronic synovitis such as RA. Magnetic resonance imaging (MRI) was then performed. A, Transverse sonogram shows the olecranon bursa (B) with inner echogenic material. A posterior cortical defect (arrow) of the olecranon (O) is also shown. B, Longitudinal sonogram shows echogenic material and posterior enhancement (arrows) from the bursa (B) in the intraosseous portion of the olecranon (O). C, Transverse color scale sonogram shows a color flow signal (F) from to-and-fro movements of inner fluid and debris through the cortical defect (communication between the bursa and geode) on compression with the transducer. On MRI (Figure 3), it was possible to easily see that the osteolytic lesion in the olecranon was a cyst. Magnetic resonance imaging also showed the presence of communications between the bursitis and the cyst and between the cyst and the articular joint space of the elbow. The patient underwent open synovectomy, removal of the bursa, and careful curettage of the cyst with autogenous iliac bone grafts to relieve the elbow arthritis with bursitis and to prevent a pathologic fracture. During surgery, marked synovial hypertrophy and rice bodies were visible all over the elbow joint. The bursa was distended with inner fluid and inflammatory granulelike tissue, and the cyst was filled with an extensive granulationlike appearance of the tissue. In addition, there were communications between the olecranon bursitis and the olecranon cyst and between the olecranon cyst and the articular elbow joint space. Histologic examination of the tissue in the bursa and cyst revealed nonspecific chronic inflammation similar to a pannus, with lymphoplasmacytic infiltration and eosinophilic nodular proliferation. There was no bacterial growth on a culture of aspirated fluid. The postoperative course of the patient was uneventful, and she was asymptomatic with no radiologic findings of recurrence at the 5-month follow-up. The olecranon bursa is a subcutaneous space lined with a synovial membrane that secretes fluid to provide smooth and almost frictionless motion between the skin, the subcutaneous tissues, and the olecranon. Nonseptic olecranon bursitis can be due to overuse, repetitive trauma, inflammatory arthropathy, or obesity.1 In addition, diseases that lead to a complicated aspect of affected and noninfected bursae include chronic degenerative arthritis, repetitive trauma, acute trauma, RA, and gout.1 Bursitis can be diagnosed by sonography, computed tomography, and MRI. On these imaging modalities, a fluid collection with lobulation, septation, complexity, wall thickening, adjacent joint effusion, soft tissue edema, and wall enhancement posterior to the olecranon can indicate a diagnosis of olecranon bursitis.1 A. Sagittal proton-weighted fat-suppressed MRI (repetition time, 2200 milliseconds; echo time, 20 milliseconds) shows a large cyst (C) in the olecranon. A communication (arrow) between the cyst and the articular joint space is clearly shown. There are synovial changes and subchondral changes in the elbow joint with joint capsular bulging. B, Enhanced axial T1-weighted fat-suppressed MRI (repetition time, 600 milliseconds; echo time, 20 milliseconds) shows a communication between the olecranon bursa (B) and the olecranon cyst (C) through a posterior cortical defect. Thick peripheral enhancements are shown in the walls of the cyst and bursa. Thick and irregular synovial enhancements (arrows) are visible in the elbow joint space. The term “geode” was originally a geologic term meaning a rounded pocket of gas in a mineral specimen.5,13 Geode (or cyst) is used interchangeably with subchondral cyst and can be subarticular, subchondral, or synovial.7 Cyst formation is most commonly associated with osteoarthritis but is also associated with other forms of arthritis such as RA, hemophilia, calcium pyrophosphate deposition disease, and gout.7 In RA, the commonly affected sites by cysts are the tibial plateau and the femoral neck.13,14 Large cysts may be confused with other destructive lesions that develop close to joints. These include osteomyelitis, septic arthritis, pigmented villonodular hyperplasia, hemophilia, and tumors such as giant cell tumors and metastases.7 Although the mechanism of cyst formation has not been made clear, 2 theories have been suggested.7,13 One is that the pannus, arising from the synovial membrane under inflammatory conditions, causes destruction of articular cartilage and extends to the subchondral bone. At this time, the pannus becomes a cyst, with increased pressure from the joint cavity being transmitted to subchondral space.15 In this theory, communication between the articular cavity and the cyst may be essential. Actually, there were communications between cysts and joint cavities in surgically proven and image-based reports by Maher et al,5 Torikai et al,12 and Lohse et al.16 Another theory involves the development of true intraosseous rheumatoid nodules in the subchondral regions.13,17 In our case, a cortical defect between the nonarticular cortex of the olecranon and the olecranon bursa was present. In addition, there were several cortical defects in the articular side of the olecranon, showing communications with the articular cavity and the cyst. Therefore, we think that first the cyst formation was made from invagination of the intra-articular synovium into the olecranon; the second inflammatory synovium in the cyst eroded the posterior olecranon cortex; and then a communication between the olecranon cyst and the olecranon bursa was formed, rather than secondary cyst formation after direct erosion of the posterior olecranon cortex by the inflammatory olecranon bursa. We think that detection of communications between an olecranon cyst and a bursa/articular joint is important because communications through the cortex are weak areas, and these can be beginnings of cortical fractures. In addition, more careful procedures are needed to prevent intraoperative fractures and recurrence of intraosseous cysts and superficial bursitis in these areas during the curettage and bone grafting. In conclusion, we report unusual findings of communication between the olecranon bursa and an olecranon cyst confirmed by sonography before MRI and surgery. On color scale sonography, compression with the ultrasound transducer on the bursa was useful for confirming the communication between the olecranon bursa and the cyst by observation of the color flow signal.
Purpose: To compare the MR findings of a sequestered disc with an extruded disc. Materials and Methods: MR images of 28 patients with a sequestered disc and 18 patients with an extruded disc were retrospectively reviewed. Patients with sequestered discs were divided into two groups whether definite separation from the parent disc was or was not seen. In the latter group (definite separation not seen) and the extruded disc group of patients, the signal intensities of the herniated discs were compared with the signal intensities of the parent discs and were evaluated on T1- and T2-weighted images. We also assessed the presence of a notch within the herniated disc. Results: In the sequestered disc group of patients (28 discs), only 5 discs (18%) showed obvious separation from the parent disc. Among the remaining 23 discs with indefinite separation, the notch was visible in 14 discs (61%) and 9 discs (39%) had no notch. In the extruded disc group (18 discs), the notch was visible in 2 (11%) discs and the difference between the two groups was statistically significant (p = 0.0002). The signal intensities of the herniated discs on T1-weighted images were isointense in both the sequestered and extruded discs. The difference of incidence of high signal intensities on T2-weighted images was not statistically significant (p = 0.125). Conclusion: It is necessary to consider the possibility of the presence of a sequestered disc when a herniated disc material shows a notch.
Purpose : To compare lumbar disc changes between initial lumbar spine (L-spine) MRI and follow-up (f/u) MRI that were performed due to recurred backaches. Materials and Methods : A total 50 patients who had undergone f/u L-spine MRI were retrospectively reviewed. Five discs (L1-S1) were surveyed in each f/u MRI. Lumbar disc changes were defined as no change, aggravations, or improvements compared to initial disc states. These states were defined on the basis of morphologic status and disc levels. Results : In a total of 250 discs in 50 patients, 31 discs (12.4%) showed morphologic changes of disc lesions, whereas 219 discs (87.6 %) showed no changes. Among the 31 disc lesions, 24 were aggravated and 7 were partially improved. And on the basis of disc status, initially abnormal discs revealed any morphologic changes of the degree of disc herniation. A total of 33.3% of the morphologic changes are noted in initially extruded discs. Fifteen morphologic changes of disc lesions were located at the L4-5 level. Conclusion : Our results suggest that correlations between lumbar disc herniations and back pain symptoms are limited, and that evaluations of extra disc lesions are required.
OBJECTIVE. The purpose of this study was to evaluate the capability of clinical, gray-scale sonographic, and color Doppler sonographic features for differentiating tuberculous and pyogenic epididymal abscesses.
Purpose: To evaluate the feasibility of peripheral bone densitometry for the assessment of bone density, and to compare it with dual energy X-ray absorptiometry (DXA). Materials and Methods: Radiographic absorptiometry (RA) of the middle phalange, peripheral DXA (pDXA) of the calcaneus, and the DXA were performed for two groups: Group 1 was a normal group of 54 healthy young women and group 2 was a group of 54 postmenopausal women considered to be at a high risk for osteoporosis. For the normal group, RA and pDXA were scanned twice to assess the repeatability of the methods. The Tscores were compared to determine whether there was a correlation between the peripheral and axial bone densitometries. The cutoff values of RA and pDXA for the diagnosis of osteopenia were determined. Results: Each examination showed different T-scores for a given person. The T-scores of RA were higher than those of pDXA for the normal group, whereas the T-scores of pDXA were higher for high-risk group. The coefficients of repeatability were 0.88 in RA and 1.53 in pDXA. The correlation coefficient for DXA was higher in RA than in pDXA. The cutoff values for osteopenia were -1.773 for RA and -1.75 for pDXA, as compared to -1.0 for DXA. Conclusion: The data suggests that RA is a viable screening method for osteoporosis. However, there should be consideration for the fact that bone density depends on examination methods or sites.
Poster: ECR 2008 / C-863 / Color Doppler twinkling artifact in various conditions during abdominal ultrasonography: Pearls and pitfalls by: H. C. Kim, D. M. Yang, W. Jin; Seoul/KP
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