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PubMed1993

Vertebral bone metastasis of small cell carcinoma of lung in a diabetic patient, initially diagnosed as pyogenic vertebral osteomyelitis.

A 40-year-old man with a 3-year history of uncontrolled NIDDM, 2-pack/month cigarette smoking habit and alcohol abuse, was admitted to our university hospital. He presented with severe back pain, persistent cough and fever. A left lung infiltrate was noted on chest X-ray film. Staphylococcus aureus was isolated from arterial blood. Thoracic bone destruction with pleural mass lesion confirmed by computed tomography (CT) and magnetic resonance image (MRI). These findings mislead our diagnosis to pyogenic osteomyelitis associated with NIDDM. An absence of marked clinical and roentgenological improvement after antibiotic therapy and strict glycemic control with insulin was noted. This suggested to us the need for needle biopsy of the osteolytic and mass lesions confirmed by imaging techniques. This resulted in making the diagnosis of metastasis of small cell carcinoma from the left lung. The correlation between NIDDM and pulmonary small cell carcinoma possibly induced by genetic abnormality remains to be resolved. By making the most of imaging techniques and needle biopsy, the possibility of pulmonary small cell carcinoma complicating NIDDM can be appropriately evaluated.

Adult↗
PubMed2005

What proportion of incident radiographic vertebral deformities is clinically diagnosed and vice versa?

UNLABELLED: We prospectively examined, in a large cohort of older women, the proportion of incident radiographic vertebral deformities diagnosed as incident clinical vertebral fractures in the same women at the same vertebral level. The proportion of deformities clinically diagnosed ranged from <15% for milder deformities to nearly 30% for more severe deformities. INTRODUCTION: The relationship between radiographic and clinical vertebral fractures is incompletely understood. No previous study has prospectively compared the agreement between incident radiographic vertebral deformities and incident community-recognized, radiographically confirmed vertebral fractures in the same women at the same vertebral level(s). MATERIALS AND METHODS: This analysis of data from the Fracture Intervention Trial included all participants who completed both baseline and at least one scheduled follow-up lateral spinal radiograph (n = 6084). Incident vertebral deformities were defined at a given vertebral level as a reduction between baseline and closeout radiographs of > or = 20% and 4 mm in any vertebral height and subdivided into two severity categories. Incident clinical vertebral fractures were those reported to clinical centers by participants and confirmed by the study radiologist, who compared the community spinal radiograph with the participant's baseline study radiograph using semiquantitative methods. RESULTS: A total of 446 incident radiographic vertebral deformities were identified in 330 women, whereas 121 women experienced one or more confirmed incident clinical vertebral fracture. Of incident radiograpic vertebral deformities, 22.6% were also clinically diagnosed as incident vertebral fractures, with clinical diagnoses made for 28.4% of the deformities that exceeded 30% and 4 mm height loss (severe deformity) compared with 14.3% for deformities that involved > or = 20% and 4 mm but < 30% height loss (milder deformity). Of incident clinical vertebral fractures, 72.7% were morphometrically identified as incident deformities, most of them as severe deformities. More than 20% of incident clinical fractures were not identified as incident deformities by even the most liberal morphometric criterion used in this study. CONCLUSIONS: Approximately one-fourth of incident radiographic vertebral deformities were clinically diagnosed as new vertebral fractures, although the proportion clinically diagnosed was increased for more severe deformities. Whereas most incident clinical vertebral fractures were identified as severe morphometric deformities, approximately one-fourth did not meet even the most liberal study criterion for morphometric deformity. Further study of factors that may explain the discordance between incident vertebral deformities and incident clinical vertebral fractures is important.

Aged↗
PubMed2005

Identification of vertebral fractures: an update.

Osteoporotic vertebral fracture is associated with increased morbidity and mortality. As a powerful predictor of future fracture risk, the identification of vertebral fracture helps target individuals who will benefit from anti-fracture therapy. The identification of vertebral fractures is problematic because (1) "normal" radiological appearances in the spine vary greatly both among and within individuals; (2) "normal" vertebrae may exhibit misleading radiological appearances due to radiographic projection error; and (3) "abnormal" appearances due to non-fracture deformities and normal variants are common, but can be difficult to differentiate from true vertebral fracture. Various methods of vertebral fracture definition have been proposed, but there is no agreed gold standard. Quantitative methods of vertebral fracture definition are objective and reproducible, but the major limitation of these methods is their inability to differentiate between vertebral deformity and vertebral fracture. The qualitative visual approach draws on the expertise of the reader, but it is a subjective method with poor interobserver agreement. Semiquantitative assessment of vertebral fracture is a standardized visual method, which is commonly applied in research studies as a surrogate gold standard. This method is more objective and reproducible than a purely qualitative approach, but can be difficult to apply. The established methods focus primarily on the identification of "reduced" or short vertebral height as an indication of vertebral fracture, but this is also a feature of some non-fracture deformities and normal variants. A modified visual approach known as algorithm-based qualitative assessment of vertebral fracture (ABQ) has recently been introduced, and this focuses on radiological evidence of change at the vertebral endplate as the primary indicator of fracture. Preliminary testing of the ABQ method has produced promising results, but the method requires further evaluation. Vertebral imaging by means of dual energy X-ray absorptiometry (DXA) scanner produces images of near-radiographic quality at a fraction of the radiation dose incurred by conventional radiography. There is growing interest in vertebral fracture assessment using this technique as a means of assessing a patient's fracture risk. Given the increasing availability of new technology and the importance of accurate diagnosis of vertebral fracture, there is an urgent need for better awareness of and training in the definition of vertebral fracture. Methods of vertebral fracture definition should be validated by testing the association with clinical outcomes of vertebral fracture, in particular the prediction of incident fractures.

Absorptiometry, Photon↗
PubMed2006

The comparative study of magnetic resonance angiography diagnosis and pathology of blunt vertebral artery injury.

STUDY DESIGN: Observational and comparative study of the vertebral artery injury detected by 2-dimensional (2-D) time-of-flight magnetic resonance angiography (MRA) for admitting patients. Construct a strike-induced flexion injury model of cervical spine with blunt vertebral artery injury in dogs. OBJECTIVES: To evaluate the value of MRA for diagnosing vertebral artery injury in cervical spinal trauma patients, and conduct a comparative study of MRA image and pathology of blunt vertebral artery injury in an animal experiment. SUMMARY OF BACKGROUND DATA: The 2-D time-of-flight MRA is the most important method for diagnosing vertebral artery injury. However, there is still controversy over MRA's accuracy in detecting vertebral artery injury of varying degrees. In addition, to our knowledge, no animal studies regarding this subject have been found in the literature so far. METHODS: In a clinical study, 319 patients with close cervical spinal trauma underwent 2-D time-of-flight MRA prospective examination. The 2-D time-of-flight MRA detected vertebral artery injury in 52 of the 319 subjects. Of the 52 patients, 51 had unilateral vertebral artery injuries, including 22 injuries on the left vertebral artery and 29 on the right vertebral artery. One case involved bilateral vertebral artery injury. In an animal experiment, the strike-induced flexion injury model of cervical spine was constructed based on an animal experiment with 26 adult dogs. A radiograph was taken immediately after injury, and 2-D time-of-flight MRA was taken in 24-36 hours. The vertebral artery sample was then harvested for pathologic examination. RESULTS: In the animal experiment, cervical facet dislocation occurred in 14 of the 26 dogs. Of the 26 dogs, 7 had unilateral vertebral artery injury as detected by MRA. There were 2 dogs that had incomplete blood flow imaging on one side of the vertebral artery, which MRA diagnosed as suspect positive. There were no vertebral artery injuries in the other 17 dogs. The vertebral artery sample of all 26 dogs underwent the pathologic study. Of the 7 dogs with positive MRA, 4 had disruption of the intima and media, and 3 had disruption of the intima. Of the 2 dogs with suspicious positive MRA diagnosis, 1 had no intima injury, while the other had intima disruption and late mural thrombus. There was no intima injury in the 17 dogs with negative MRA findings. CONCLUSIONS: The 2-D time-of-flight MRA is an effective diagnostic method for blunt vertebral artery injury. It may have difficulties differentiating spasm, small disruption of the intima from others under certain conditions.

Adolescent↗
PubMed2005

Anomalous vertebral artery at the extraosseous and intraosseous regions of the craniovertebral junction: analysis by three-dimensional computed tomography angiography.

STUDY DESIGN: This study examined the extraosseous and intraosseous anomalies of vertebral arteries in patients who underwent surgery of the craniovertebral junction. OBJECTIVES: To describe the usefulness of three-dimensional computed tomography angiography for evaluating vertebral artery anomalies before surgery. SUMMARY OF BACKGROUND DATA: Previous studies using catheter angiograms have identified anomalous courses of the vertebral artery at the craniovertebral junction. Studies using computed tomography reconstruction also showed deviation of the vertebral artery groove at the C2 isthmus, demonstrating a risk of vertebral artery injury for C1-C2 transarticular screw placement. These analyses provided us with useful information for identifying anomalies of the vertebral artery, but they could not visualize the artery and its circumferential osseous tissue simultaneously, nor could they analyze the reciprocal anatomy of both tissues. METHODS: Thirty-one consecutive patients who submitted to surgery at the craniovertebral junction were evaluated before surgery by three-dimensional computed tomography angiography. Eleven of the patients had congenital osseous anomalies at the craniovertebral junction including os odontoideum and ossiculum terminale. Anomalous vertebral arteries at the extraosseous region were visualized by three-dimensional reconstruction images, and the intraosseous deviation of the vertebral artery at the C2 isthmus was evaluated by multiplanar reconstruction images. RESULTS: Extraosseous and/or intraosseous vertebral artery anomalies were detected in 9 cases. Eight of the 9 cases had osseous anomalies at the craniovertebral junction. Abnormal courses of the vertebral artery at the extraosseous region were detected in 4 cases: 2 had fenestration and 2 had persistent first intersegmental artery. Asymmetry of bilateral vertebral arteries was found in 5 cases: the right was dominant in 3 cases and the left in 2 cases. A high-riding vertebral artery at the C2 isthmus was detected in 5 cases. Based on these findings, we modified our surgical approach and the screw placement; consequently, no vertebral artery injury occurred. CONCLUSIONS: In patients having osseous anomalies at the craniovertebral junction, the frequency of vertebral artery anomalies at the extraosseous and intraosseous regions is increased. With preoperative three-dimensional computed tomography angiography, we can precisely identify the anomalous vertebral artery and reduce the risk of intraoperative injury to the vertebral artery, in advance.

Adolescent↗
PubMed1987

Vertebral artery injury--diagnosis and management.

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.

Adolescent↗