One hundred ten cases of the transient neurological phenomenon, cervical cord neurapraxia (CCN), are presented. The authors established a classification system for CCN, developed a new computerized measurement technique for magnetic resonance (MR) imaging, investigated the relationship of the cervical cord to the canal, and analyzed clinical, x-ray, and MR data. One hundred nine males and one female were included in the study; the average age of the participants was 21 years (range 13-33 years). All episodes occurred during sports participation; 87% occurred while the patient was playing football. Follow-up review lasting an average of 3.3 years was available for 105 patients (95%). Narrowing of the sagittal diameter of the cervical canal in the adult spine was confirmed to be a causative factor. Cervical cord neurapraxia was not associated with permanent neurological injury and no permanent morbidity occurred in patients who returned to contact activities. Of the patients returning to contact activities, 35 (56%) experienced a recurrent episode. The risk of recurrence was increased with smaller spinal canal/vertebral body ratio (p < 0.05), smaller disc-level canal diameter (p < 0.05), and less space available for the cord (p < 0.05). There was no correlation between either the classification of the CCN episode or the disease noted on MR imaging and x-ray films and the risk of recurrence. The authors conclude that: 1) CCN is a transient neurological phenomenon and individuals with uncomplicated CCN may be permitted to return to their previous activity without an increased risk of permanent neurological injury; 2) congenital or degenerative narrowing of the sagittal diameter of the cervical canal is a causative factor; 3) the overall recurrence rate after return to play is 56%; and 4) the risk of recurrence is strongly and inversely correlated with sagittal canal diameter and it is useful in the prediction of future episodes of CCN (p < 0.001). These data will enable the physician to counsel individuals regarding a predicted risk of recurrence based on canal measurements.

Adolescent↗

PubMed1996

The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players.

An evaluation of forty-five athletes who had had an episode of transient neurapraxia of the cervical spinal cord revealed a consistent finding of developmental narrowing of the cervical spinal canal. The purpose of the present epidemiological study was to determine the relationship, if any, between a developmentally narrowed cervical canal and reversible and irreversible injury of the cervical cord with use of various cohorts of football players as well as a large control group. Cohort I comprised college football players who were asymptomatic and had no known history of transient neurapraxia of the cervical cord. Cohort II consisted of professional football players who also were asymptomatic and had no known history of transient neurapraxia of the cervical cord. Cohort III was a group of high-school, college, and professional football players who had had at least one episode of transient neurapraxia of the cervical cord. Cohort IV comprised individuals who were permanently quadriplegic as a result of an injury while playing high-school or college football. Cohort V consisted of a control group of male subjects who were non-athletes and had no history of a major injury of the cervical spine, an episode of transient neurapraxia, or neurological symptoms. The mean and standard deviation of the diameter of the spinal canal, the diameter of the vertebral body, and the ratio of the diameter of the spinal canal to that of the vertebral body were determined for the third through sixth cervical levels on the radiographs for each cohort. In addition, the sensitivity, specificity, and positive predictive value of a ratio of the diameter of the spinal canal to that of the vertebral body of 0.80 or less was evaluated. The findings of the present study demonstrated that a ratio of 0.80 or less had a high sensitivity (93 per cent) for transient neurapraxia. The findings also support the concept that symptoms may result from a transient reversible deformation of the spinal cord in a developmentally narrowed osseous canal. The low positive predictive value of the ratio (0.2 per cent) however, precludes its use as a screening mechanism for determining the suitability of an athlete for participation in contact sports. Developmental narrowing of the cervical canal in a stable spine does not appear to predispose an individual to permanent catastrophic neurological injury and therefore should not preclude an athlete from participation in contact sports.

Adolescent↗

PubMed1995

Insufficiency fracture of the talus: diagnosis with MR imaging.

PURPOSE: To describe the clinical setting and pattern of talar insufficiency stress fractures as diagnosed with magnetic resonance (MR) imaging. MATERIALS AND METHODS: The authors retrospectively reviewed the clinical history and MR images from four patients with five talar insufficiency fractures. All patients were women (age range, 30-70 years). Images were evaluated for the location and orientation of fractures and the presence of concomitant osseous and soft-tissue injury. RESULTS: Concomitant fractures were identified in two patients. Only two fractures were typical in location and orientation at the talar neck. Three fractures were atypical in location and orientation. One occurred horizontally in the talar body and two occurred in the posteromedial talus (one was oriented vertically and one horizontally). Two patients had associated concomitant stress fractures--one in the distal tibia and one in the calcaneus. CONCLUSION: The location and orientation of talar insufficiency fractures is more variable than previously recognized. Specific diagnoses and coexisting fractures can be determined with MR imaging.

Adult↗

PubMed1995

Spindle cell lipoma of the foot: a case report and literature review.

Lipomas are among the most commonly encountered soft tissue tumors in clinical practice, though they are rare in the foot. Although a presumptive diagnosis is typically made clinically, those tumors with atypical clinical features may require radiological consultation. Difficulty arises when radiographic features are not typical of lipoma. We present a fatty soft tissue tumor of the foot with nonadipose elements on magnetic resonance imaging evaluation. Differentiation of lipoma variants (e.g., spindle cell lipoma, atypical lipoma, pleomorphic lipoma, lipoblastoma, angiolipoma) from liposarcoma based on imaging features is not possible, necessitating surgical resection for definitive histological diagnosis.

Aged↗

PubMed1995

Practice parameters/clinical policies: the new approach to the practice of medicine.

Practice parameters or clinical policies and the future practice of medicine are covered in a series of three articles. In Part I, the term practice parameters is defined, and the background of practice parameters at the federal, AMA, and specialty society level is discussed. In Part II, the development, application, dissemination, and monitoring of practice parameters, including the clinical usage and impact, will be discussed. In Part III, the advantages, disadvantages, and legal implications of practice parameters will be reviewed.

American Medical Association↗

PubMed1995

The Nicolas Andry Award. The pathomechanics and pathophysiology of cervical spinal cord injury.

Cervical cord injuries caused during American football games have resulted in reversible, incompletely reversible, and irreversible neurologic deficits. An explanation for this variable response to injury has been obtained from the study of the histochemical responses of a squid axon injury model to mechanical deformation. Data obtained indicate that recovery or lack thereof is directly proportional to the intracellular calcium concentration which in turn is directly proportional to the amount and rate of tension applied to the axon. It is concluded that in most instances of acute spinal injury, disruption of cord function is a result of the effects of local cord anoxia and the increased concentration of intracellular calcium. It is proposed that implementation of therapeutic measures that restore blood flow and reduce cytosolic calcium will increase neurologic recovery.

Adult↗

PubMed1994

Stress fractures of the lower extremities.

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Foot↗

PubMed1994

Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain.

Plantar lateral foot pain may be caused by various entities and the painful os peroneum syndrome (a term coined by the authors) should be included in the differential diagnosis. Painful os peroneum syndrome results from a spectrum of conditions that includes one or more of the following: (1) an acute os peroneum fracture or a diastasis of a multipartite os peroneum, either of which may result in a discontinuity of the peroneus longus tendon; (2) chronic (healing or healed) os peroneum fracture or diastasis of a multipartite os peroneum with callus formation, either of which results in a stenosing peroneus longus tenosynovitis; (3) attrition or partial rupture of the peroneus longus tendon, proximal or distal to the os peroneum; (4) frank rupture of the peroneus longus tendon with discontinuity proximal or distal to the os peroneum; and/or (5) the presence of a gigantic peroneal tubercle on the lateral aspect of the calcaneus which entraps the peroneus longus tendon and/or the os peroneum during tendon excursion. Familiarity with the various clinical and radiographic findings and the spectrum of conditions represented by the painful os peroneum syndrome can prevent prolonged undiagnosed plantar lateral foot pain. Clinical diagnosis of the painful os peroneum syndrome can be facilitated by the single stance heel rise and varus inversion stress test as well as by resisted plantarflexion of the first ray, which can localize tenderness along the distal course of the peroneus longus tendon at the cuboid tunnel.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1993

Osteoid osteomas of the femoral neck: report of four cases evaluated with isotopic bone scanning, CT, and MR imaging.

Four patients, ranging in age from 6 to 32 years, with surgically proved parosteal lesions of the femoral neck are presented. In one case, magnetic resonance (MR) imaging was the initial study ordered prior to plain radiography, and in three cases MR imaging was performed after plain radiography. Findings in the MR images were abnormal in all four cases; however, the nidus was not identified prospectively. Incorrect diagnoses based on findings at MR imaging of secondary marrow edema and/or synovitis included Ewing tumor, osteonecrosis, stress fracture, Lyme arthritis, and juvenile inflammatory arthritis. In all four cases, the correct diagnosis of intracapsular osteoid osteoma was made following (a) review of plain radiographs leading to a high index of suspicion and (b) performance of thin-section computed tomographic (CT) studies (in one case a screening CT study with 1-cm-thick sections failed to depict the lesion). In three cases, isotopic bone scans provided useful guidance for planning the CT examination.

Adult↗

PubMed1993

Diastasis of bipartite sesamoids of the first metatarsophalangeal joint.

Injury to the metatarsophalangeal (MP) joint of the great toe, often termed "turf-toe", is a common occurrence in football. We have identified four cases of first MP plantar capsular injury with diastasis of a bipartite sesamoid. In three cases, observation and protection resulted in progressive widening of the fragments associated with pain and disability. These players required resection of the distal sesamoid fragment and repair of the volar capsule. The fourth player underwent acute repair of the medial retinaculum and capsule. All players have had a full return to sports activity. Diastasis of components of a partite sesamoid provides objective evidence of disruption of the plantar capsular mechanism. Early recognition of this condition confirmed by stress radiographs is recommended. Treatment may include early protection followed by resection, if painful, or acute repair of the retinaculum. Previous descriptions of turf-toe have not included injuries to the sesamoid complex of the first MP joint. In our opinion, the term turf-toe should represent the consequences of a hyperextension injury to the first MP joint in which the volar capsule has been disrupted proximal to the sesamoid. A classification for first MP joint injuries is presented.

Adult↗

PubMed1993

Delivery of health care: the problem, the proposed solutions, and managed care--part 1.

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Cost Control↗

PubMed1993

Redefining cervical spinal stenosis using MRI.

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Athletic Injuries↗

PubMed1992

The hallux sesamoids revisited.

The hallux sesamoids are vulnerable to significant injury and weight-bearing stress in both the athlete and the nonathlete. Unfortunately, they are often dismissed as inconsequential accessory bones. The historical significance, embryology, anatomy, and physiology of the sesamoids and the salient features of both traumatic and nontraumatic pathologic conditions affecting these structures are presented. Because the sesamoids can be responsible for prolonged disabling foot pain and discomfort, it is important for both clinician and radiologist to pay attention to these bones and recognize the early signs of abnormality.

Bone Diseases↗