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American Family Physician May 2016Cervical radiculopathy describes pain in one or both of the upper extremities, often in the setting of neck pain, secondary to compression or irritation of nerve roots... (Review)
Review
Cervical radiculopathy describes pain in one or both of the upper extremities, often in the setting of neck pain, secondary to compression or irritation of nerve roots in the cervical spine. It can be accompanied by motor, sensory, or reflex deficits and is most prevalent in persons 50 to 54 years of age. Cervical radiculopathy most often stems from degenerative disease in the cervical spine. The most common examination findings are painful neck movements and muscle spasm. Diminished deep tendon reflexes, particularly of the triceps, are the most common neurologic finding. The Spurling test, shoulder abduction test, and upper limb tension test can be used to confirm the diagnosis. Imaging is not required unless there is a history of trauma, persistent symptoms, or red flags for malignancy, myelopathy, or abscess. Electrodiagnostic testing is not needed if the diagnosis is clear, but has clinical utility when peripheral neuropathy of the upper extremity is a likely alternate diagnosis. Patients should be reassured that most cases will resolve regardless of the type of treatment. Nonoperative treatment includes physical therapy involving strengthening, stretching, and potentially traction, as well as nonsteroidal anti-inflammatory drugs, muscle relaxants, and massage. Epidural steroid injections may be helpful but have higher risks of serious complications. In patients with red flag symptoms or persistent symptoms after four to six weeks of treatment, magnetic resonance imaging can identify pathology amenable to epidural steroid injections or surgery.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Cervical Vertebrae; Humans; Magnetic Resonance Imaging; Massage; Myelography; Neural Conduction; Neuromuscular Agents; Physical Examination; Physical Therapy Modalities; Radiculopathy; Radiography; Tomography, X-Ray Computed
PubMed: 27175952
DOI: No ID Found -
Frontiers in Veterinary Science 2020Imaging is integral in the diagnosis of canine intervertebral disc disease (IVDD) and in differentiating subtypes of intervertebral disc herniation (IVDH). These include... (Review)
Review
Imaging is integral in the diagnosis of canine intervertebral disc disease (IVDD) and in differentiating subtypes of intervertebral disc herniation (IVDH). These include intervertebral disc extrusion (IVDE), intervertebral disc protrusion (IVDP) and more recently recognized forms such as acute non-compressive nucleus pulposus extrusion (ANNPE), hydrated nucleus pulposus extrusion (HNPE), and intradural/intramedullary intervertebral disc extrusion (IIVDE). Many imaging techniques have been described in dogs with roles for survey radiographs, myelography, computed tomography (CT), and magnetic resonance imaging (MRI). Given how common IVDH is in dogs, a thorough understanding of the indications and limitations for each imaging modality to aid in diagnosis, treatment planning and prognosis is essential to successful case management. While radiographs can provide useful information, especially for identifying intervertebral disc degeneration or calcification, there are notable limitations. Myelography addresses some of the constraints of survey radiographs but has largely been supplanted by cross-sectional imaging. Computed tomography with or without myelography and MRI is currently utilized most widely and have become the focus of most contemporary studies on this subject. Novel advanced imaging applications are being explored in dogs but are not yet routinely performed in clinical patients. The following review will provide a comprehensive overview on common imaging modalities reported to aid in the diagnosis of IVDH including IVDE, IVDP, ANNPE, HNPE, and IIVDE. The review focuses primarily on canine IVDH due to its frequency and vast literature as opposed to feline IVDH.
PubMed: 33195623
DOI: 10.3389/fvets.2020.588338 -
The New England Journal of Medicine Dec 2021
Review
Topics: Brain; Cerebrospinal Fluid Leak; Headache; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Myelography; Optic Nerve; Subarachnoid Space
PubMed: 34874632
DOI: 10.1056/NEJMra2101561 -
The American Journal of Medicine Dec 2021Cauda equina syndrome is a potentially devastating spinal condition. The diagnosis of cauda equina syndrome lacks sensitivity and specificity, sometimes occurring after... (Review)
Review
Cauda equina syndrome is a potentially devastating spinal condition. The diagnosis of cauda equina syndrome lacks sensitivity and specificity, sometimes occurring after irreparable neurological damage has happened. Timely diagnosis and treatment is imperative for optimal outcomes and for avoiding medicolegal ramifications. Cauda equina syndrome results from conditions that compress the nerves in the lumbosacral spinal canal. Although no consensus definition exists, it generally presents with varying degrees of sensory loss, motor weakness, and bowel and bladder dysfunction (the latter of which is required to definitively establish the diagnosis). A thorough history and physical exam is imperative, followed by magnetic resonance or computed tomography imaging myelogram to aid in diagnosis and treatment. Once suspected, emergent spinal surgery referral is indicated, along with urgent decompression. Even with expeditious surgery, improvements remain inconsistent. However, early intervention has been shown to portend greater chance of neurologic recovery. All providers in clinical practice must understand the severity of this condition. Providers can optimize long-term patient outcomes and minimize the risk of litigation by open communication, good clinical practice, thorough documentation, and expeditious care.
Topics: Cauda Equina Syndrome; Decompression, Surgical; Disease Management; Epidural Abscess; Hematoma, Epidural, Spinal; Humans; Intervertebral Disc Displacement; Lumbar Vertebrae; Magnetic Resonance Imaging; Myelography; Neurologic Examination; Spinal Injuries; Spinal Neoplasms; Spinal Stenosis; Spondylolisthesis; Tomography, X-Ray Computed
PubMed: 34473966
DOI: 10.1016/j.amjmed.2021.07.021 -
Neuroimaging Clinics of North America Nov 2019Spontaneous intracranial hypotension (SIH) is a clinical syndrome that is increasingly recognized as an important and treatable secondary cause of headaches. Insight... (Review)
Review
Spontaneous intracranial hypotension (SIH) is a clinical syndrome that is increasingly recognized as an important and treatable secondary cause of headaches. Insight into the condition has evolved significantly over the past decade, resulting in a greater understanding of the underlying pathophysiology, development of new diagnostic imaging tools, and a broadening array of targeted treatment options. This article reviews the clinical presentation and pathogenesis of SIH, discusses the important role of imaging in diagnosis, and describes how imaging guides treatment.
Topics: Bed Rest; Blood Patch, Epidural; Caffeine; Fluid Therapy; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Myelography; Tomography, X-Ray Computed
PubMed: 31677732
DOI: 10.1016/j.nic.2019.07.006 -
Neuroradiology Nov 2021Spontaneous intracranial hypotension (SIH) is an orthostatic headache syndrome with typical MRI findings among which engorgement of the venous sinuses, pachymeningeal... (Review)
Review
Spontaneous intracranial hypotension (SIH) is an orthostatic headache syndrome with typical MRI findings among which engorgement of the venous sinuses, pachymeningeal enhancement, and effacement of the suprasellar cistern have the highest diagnostic sensitivity. SIH is in almost all cases caused by spinal CSF leaks. Spinal MRI scans showing so-called spinal longitudinal extradural fluid (SLEC) are suggestive of ventral dural tears (type 1 leak) which are located with prone dynamic (digital subtraction) myelography. As around half of the ventral dural tears are located in the upper thoracic spine, additional prone dynamic CT myelography is often needed. Leaking nerve root sleeves typically associated with meningeal diverticulae (type 2 leaks) and CSF-venous fistulas (type 3 leaks) are proven via lateral decubitus dynamic digital subtraction or CT myelography: type 2 leaks are SLEC-positive if the tear is proximal and SLEC-negative if it is distal, and type 3 leaks are always SLEC-negative. Although 30-70% of SIH patients show marked improvement following epidural blood patches applied via various techniques definite cure mostly requires surgical closure of ventral dural tears and surgical ligations of leaking nerve root sleeves associated with meningeal diverticulae or CSF-venous fistulas. For the latter, transvenous embolization with liquid embolic agents via the azygos vein system is a novel and valuable therapeutic alternative.
Topics: Cerebrospinal Fluid Leak; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Myelography; Spine
PubMed: 34297176
DOI: 10.1007/s00234-021-02766-z -
JAMA Neurology May 2019Various signs may be observed on brain magnetic resonance imaging (MRI) in patients with spontaneous intracranial hypotension (SIH). However, the lack of a...
IMPORTANCE
Various signs may be observed on brain magnetic resonance imaging (MRI) in patients with spontaneous intracranial hypotension (SIH). However, the lack of a classification system integrating these findings limits decision making in clinical practice.
OBJECTIVE
To develop a probability score based on the most relevant brain MRI findings to assess the likelihood of an underlying spinal cerebrospinal fluid (CSF) leak in patients with SIH.
DESIGN, SETTING, AND PARTICIPANTS
This case-control study in consecutive patients investigated for SIH was conducted at a single hospital department from February 2013 to October 2017. Patients with missing brain MRI data were excluded. Three blinded readers retrospectively reviewed the brain MRI scans of patients with SIH and a spinal CSF leak, patients with orthostatic headache without a CSF leak, and healthy control participants, evaluating 9 quantitative and 7 qualitative signs. A predictive diagnostic score based on multivariable backward logistic regression analysis was then derived. Its performance was validated internally in a prospective cohort of patients who had clinical suspicion for SIH.
MAIN OUTCOMES AND MEASURES
Likelihood of a spinal CSF leak based on the proposed diagnostic score.
RESULTS
A total of 152 participants (101 female [66.4%]; mean [SD] age, 46.1 [14.3] years) were studied. These included 56 with SIH and a spinal CSF leak, 16 with orthostatic headache without a CSF leak, 60 control participants, and 20 patients in the validation cohort. Six imaging findings were included in the final scoring system. Three were weighted as major (2 points each): pachymeningeal enhancement, engorgement of venous sinus, and effacement of the suprasellar cistern of 4.0 mm or less. Three were considered minor (1 point each): subdural fluid collection, effacement of the prepontine cistern of 5.0 mm or less, and mamillopontine distance of 6.5 mm or less. Patients were classified into groups at low, intermediate, or high probability of having a spinal CSF leak, with total scores of 2 points or fewer, 3 to 4 points, and 5 points or more, respectively, on a scale of 9 points. The discriminatory ability of the proposed score could be demonstrated in the validation cohort.
CONCLUSIONS AND RELEVANCE
This 3-tier predictive scoring system is based on the 6 most relevant brain MRI findings and allows assessment of the likelihood (low, intermediate, or high) of a positive spinal imaging result in patients with SIH. It may be useful in identifying patients with SIH who are leak positive and in whom further invasive myelographic examinations are warranted before considering targeted therapy.
Topics: Adolescent; Adult; Aged; Brain; Case-Control Studies; Cerebrospinal Fluid Leak; Cranial Sinuses; Dura Mater; Female; Humans; Intracranial Hypotension; Logistic Models; Magnetic Resonance Imaging; Male; Middle Aged; Multivariate Analysis; Myelography; Subdural Space; Tomography, X-Ray Computed; Young Adult
PubMed: 30776059
DOI: 10.1001/jamaneurol.2018.4921 -
AJNR. American Journal of Neuroradiology Apr 2019Localization of the culprit CSF leak in patients with spontaneous intracranial hypotension can be difficult and is inconsistently achieved. We present a high yield...
BACKGROUND AND PURPOSE
Localization of the culprit CSF leak in patients with spontaneous intracranial hypotension can be difficult and is inconsistently achieved. We present a high yield systematic imaging strategy using brain and spine MRI combined with digital subtraction myelography for CSF leak localization.
MATERIALS AND METHODS
During a 2-year period, patients with spontaneous intracranial hypotension at our institution underwent MR imaging to determine the presence or absence of a spinal longitudinal extradural collection. Digital subtraction myelography was then performed in patients positive for spinal longitudinal extradural CSF collection primarily in the prone position and in patients negative for spinal longitudinal extradural CSF collection in the lateral decubitus positions.
RESULTS
Thirty-one consecutive patients with spontaneous intracranial hypotension were included. The site of CSF leakage was definitively located in 27 (87%). Of these, 21 were positive for spinal longitudinal extradural CSF collection and categorized as having a ventral (type 1, fifteen [48%]) or lateral dural tear (type 2; four [13%]). Ten patients were negative for spinal longitudinal extradural CSF collection and were categorized as having a CSF-venous fistula (type 3, seven [23%]) or distal nerve root sleeve leak (type 4, one [3%]). The locations of leakage of 2 patients positive for spinal longitudinal extradural CSF collection remain undefined due to resolution of spontaneous intracranial hypotension before repeat digital subtraction myelography. In 2 (7%) patients negative for spinal longitudinal extradural CSF collection, the site of leakage could not be localized. Nine of 21 (43%) patients positive for spinal longitudinal extradural CSF collection were treated successfully with an epidural blood patch, and 12 required an operation. Of the 10 patients negative for spinal longitudinal extradural CSF collection (8 localized), none were effectively treated with an epidural blood patch, and all have undergone ( = 7) or are awaiting ( = 1) an operation.
CONCLUSIONS
Patients positive for spinal longitudinal extradural CSF collection are best positioned prone for digital subtraction myelography and may warrant additional attempts at a directed epidural blood patch. Patients negative for spinal longitudinal extradural CSF collection are best evaluated in the decubitus positions to reveal a CSF-venous fistula, common in this population. Patients with CSF-venous fistula may forgo further epidural blood patch treatment and go on to surgical repair.
Topics: Adult; Blood Patch, Epidural; Cerebrospinal Fluid Leak; Female; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Male; Middle Aged; Myelography; Neuroimaging; Patient Positioning
PubMed: 30923083
DOI: 10.3174/ajnr.A6016 -
Chiropractic & Manual Therapies 2018We aim to summarize the available evidence on the diagnostic accuracy of imaging (index test) compared to surgery (reference test) for identifying lumbar disc herniation...
MAIN TEXT
We aim to summarize the available evidence on the diagnostic accuracy of imaging (index test) compared to surgery (reference test) for identifying lumbar disc herniation (LDH) in adult patients.For this systematic review we searched MEDLINE, EMBASE and CINAHL (June 2017) for studies that assessed the diagnostic accuracy of imaging for LDH in adult patients with low back pain and surgery as the reference standard. Two review authors independently selected studies, extracted data and assessed risk of bias. We calculated summary estimates of sensitivity and specificity using bivariate analysis, generated linked ROC plots in case of direct comparison of diagnostic imaging tests and assessed the quality of evidence using the GRADE-approach.We found 14 studies, all but one done before 1995, including 940 patients. Nine studies investigated Computed Tomography (CT), eight myelography and six Magnetic Resonance Imaging (MRI). The prior probability of LDH varied from 48.6 to 98.7%. The summary estimates for MRI and myelography were comparable with CT (sensitivity: 81.3% (95%CI 72.3-87.7%) and specificity: 77.1% (95%CI 61.9-87.5%)). The quality of evidence was moderate to very low.
CONCLUSIONS
The diagnostic accuracy of CT, myelography and MRI of today is unknown, as we found no studies evaluating today's more advanced imaging techniques. Concerning the older techniques we found moderate diagnostic accuracy for all CT, myelography and MRI, indicating a large proportion of false positives and negatives.
Topics: Humans; Intervertebral Disc Displacement; Low Back Pain; Lumbosacral Region; Magnetic Resonance Imaging; Myelography; Randomized Controlled Trials as Topic; Sciatica; Tomography Scanners, X-Ray Computed
PubMed: 30151119
DOI: 10.1186/s12998-018-0207-x