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Marked hypertrophy of the psoas muscle in a bodybuilder produced a unilateral extrinsic mass effect upon the medial cecum and adjacent small bowel. The patient had presented with right lower quadrant pain and leukocytosis. Routine contrast studies of the abdomen were misleading, but a computed tomogram suggested the correct diagnosis.
Four cases of diffuse xanthogranulomatous pyelonephritis (XPN) in young children are presented. In three patients the clinical picture was one of weight loss, anaemia and neutrophilia with a large renal mass. The fourth presented with haematuria. Ultrasound (US) and CT findings were almost identical in all four patients. US showed the affected kidney was massively enlarged but retained a reniform shape. Dilated fluid spaces containing calculi were present. CT confirmed the US findings and revealed peripheral enhancement without contrast excretion, with dilated calyceal spaces producing the "bear paw sign". Extrarenal extension into abdominal wall and psoas muscle is typical and was well demonstrated by CT. The affected kidneys were non-functioning and nephrectomy was required. Typical US and CT features allow a confident diagnosis of XPN and appropriate early treatment.
Malignant fibrous histiocytomas are uncommon retroperitoneal soft tissue tumors. We report a case of a malignant fibrous histiocytoma of the retroperitoneum that was anmgiographically hypervascular and indistinguishable from renal cell carcinoma. Computerized tomography of the abdomen demonstrated extensive psoas muscle infiltration by tumor. This feature may be useful in differentiating a renal cell carcinoma from a primary retroperitoneal sarcoma.
Magnetic resonance imaging (MRI) represents the most recent development in imaging of the retroperitoneum. This article discusses the utility of MRI in evaluating the abdominal aorta, inferior vena cava, lymph nodes, and psoas muscle.
Three cases are reported where continuous lumbosacral block was performed using a catheter through an epidural needle technique. Good unilateral lower limb surgical anaesthesia was achieved in all three cases with successful blockade of the lumbar and sacral plexuses. A 17-gauge Tuohy needle was positioned between the transverse processes of L4 and L5 and an epidural catheter inserted into the space between the quadratus lumborum and psoas muscles. Forty to seventy millilitres of local anaesthetic were injected and resulted in good surgical anaesthesia within 12-20 min. Radiographic studies in these patients confirmed placement of the catheter in close proximity to the lumbosacral plexus. Experience in a further 12 cases is also reported. There were no side-effects. The technique is successful and is recommended when unilateral lower limb anaesthetic is required and when spinal and epidural anaesthesia are contraindicated.
PURPOSE: To report the successful perioperative anaesthetic and analgesic management of a spinal trauma patient with a surgically placed epidural catheter. CLINICAL FEATURES: A 15-yr-old adolescent woman sustained an unstable spinal column injury with an incomplete neurological deficit following a high speed motor vehicle accident. She was scheduled for spinal decompression and stabilisation through a left thoracoabdominal approach. Balanced general anaesthesia was undertaken. Prior to closure, a multi-orifice epidural catheter was surgically placed under direct vision 5 cm into the anterior epidural space. The catheter was then tunnelled out through the psoas muscle and secured in place. Combined epidural-general anaesthesia was then initiated for the duration of the case using 5 ml bupivacaine 0.25% after an initial test dose of 3 ml lidocaine 1.5% with epinephrine. An infusion of bupivacaine 0.10% and fentanyl 5 micrograms.ml-1 at 8 ml.hr-1 using patient controlled epidural analgesia (PCEA) provided excellent postoperative pain control for four days. She had an uncomplicated postoperative course. CONCLUSION: A surgically placed epidural catheter provided excellent, safe, perioperative anaesthesia and analgesia in this patient with unstable spinal trauma.
The authors present a case of extensive soft-tissue radioactivity visualized on both 99mTc-MDP and 201Tl-chloride scintigrams in a patient with dermatomyositis and colon cancer. Incidentally, diffuse and intense uptake of 99mTc-MDP was observed in the shoulder girdles, anterior chest wall, psoas muscles, both proximal thighs and right lower limb, corresponding to the sites of symptomatic muscles, even though skin lesions were limited and no calcification was detected on radiographs. Moreover, 201Tl-chloride was also intensely accumulated in nearly the same sites as the symptomatic muscles as shown on the 99mTc-MDP bone scintigrams. Whole-body scintigraphy with 99mTc-MDP and 201Tl-chloride is a useful tool to detect occult muscle lesions with dystrophic calcification and hyperemia in dermatomyositis.
BACKGROUND: Recent experience indicates that unstable spine fractures should be stabilized dorsoventrally. To avoid the high morbidity associated with the common anterior approach-i.e., thoraco-phreno-lumbotomy-we developed a technique that allows the anterior fusion of lumbar spine fractures using an endoscopic retroperitoneal (lumboscopic) approach. METHODS: Lumboscopic anterior fusion was performed a few days after the initial dorsal stabilization. The retroperitoneal space was accessed endoscopically via a suprailic incision and enlarged using a balloon spacer and CO(2) insufflation. The peritoneum and the kidney were gently pushed ventrally. Mobilization of the psoas muscle dorsally then allowed exposure of the fractured spine bodies. Via two additional trocars placed opposite the fractured level, the damaged disc and bone were removed, and anterior spondylodesis was performed with an iliac crest bone block and a titanium plate. RESULTS: The technique was applied successfully in 12 patients with fractures of L1 (n = 6), L2 (n = 4), L3 (n = 1), and L4 (n = 1) as a mono- or bisegmental fusion, requiring instrumentation from T12 to L5. No major complications (including neurological problems) were encountered. Blood loss was minimal. None of the patients required conversion to open surgery. Patients were mobilized early, starting regularly at the second postoperative day. CONCLUSIONS: Lumboscopic instrumentation of the lumbar spine is a safe, minimally invasive method for the treatment of spine fractures. The patients benefit from reduced pain, low morbidity, and excellent cosmetic results.
We assessed the longitudinal changes in renal vein blood flow (RVBF) and kidney volume in response to neonatally induced partial unilateral ureteral obstruction (PUUO) in rats with a magnetic resonance imaging (MRI) technique. During anesthesia, either the upper third or two thirds of the left ureter was embedded into the psoas muscle in newborn rats, creating either a mild (n=20) or a severe (n=9) partial obstruction. Control groups consisted of sham-operated (n=12) and non-operated (n=15) rats. During the following 24 weeks, RVBF and kidney volume were measured sequentially every 2-6 weeks with MRI, beginning 9 days after the operation. Both mild and severe obstruction caused a time-dependent decrease in RVBF. At week 24, the mean RVBF had decreased to 79% of the controls in the mildly obstructed kidneys (mean+/-SE: 1.45+/-0.14 vs 1.84+/-0.08 ml/min/100 g body weight, P<0.05) and to 57% of controls in the severely obstructed kidneys (1.05+/-0.10 vs 1.84+/-0.08 ml/min/100 g body weight, P<0.05). The renal pelvis volume increased and the renal parenchymal volume decreased significantly in the severely obstructed kidneys compared to the mildly obstructed kidneys. A good correlation was found between kidney volume measured in vivo using MRI and that measured in vitro (r>0.8, P<0.05), and between RVBF and renal parenchymal volume (r=0.758, P<0.01). In conclusion, the degree of reduction in RVBF depends on the severity and the duration of the PUUO. MRI can safely and reliably be used to monitor the longitudinal changes in RVBF and kidney volume in rats from early life.
Ureteral obstruction (UO) is one of the most common problems confronting the urologist. Although large amounts of animal and clinical research have been done, the pathophysiologic mechanisms accompanying UO are not fully elucidated. Most of our knowledge on UO has been derived from experimental studies in a variety of animal models. Both antenatal and postnatal UO models have been developed mainly by ligation of the ureter or by burying the ureter into the psoas muscle. Most experimental studies have focused on short-term complete ureteral obstruction. The long-term effects of partial ureteral obstruction have been less intensively studied. It is now clear that obstructive nephropathy is not a simple result of mechanical impairment to urine flow but a complex syndrome resulting in alterations of both glomerular hemodynamics and tubular function caused by the interaction of a variety of vasoactive factors and cytokines that are activated in response to UO. Leukocyte infiltration appears to play an important role in obstructive nephropathy suggesting that UO also has an immunological component. Growth factors such as platelet-derived growth factor, transforming growth factor-beta, epidermal growth factor and insulin-like growth factor I may all play a role in the development and progression of fibrotic and sclerotic changes in the obstructed kidney. At present, the selection of patients with congenital hydronephrosis for operative treatment is controversial. Studies in animals and patients have shown that partial unilateral UO does not always cause a loss of renal function or progression in urinary tract dilation during long-term follow-up. The implications of UO continue to raise many questions and further work is necessary to achieve a better understanding of the pathogenesis in obstructive nephropathy.
BACKGROUND: Infantile myofibromatosis is the most common fibrous tumor of infancy. It can involve the skin, muscle, bone, and viscera. This uncommon entity is subdivided into solitary and multicentric forms, with or without visceral involvement. OBJECTIVE: To describe the imaging characteristics of extracranial myofibromatosis. MATERIALS AND METHODS: Six infants, aged 1 day-1 week, were evaluated by imaging. All six patients had evaluation of one of the masses by US; four patients had CT evaluation of at least one of the masses; and five patients had evaluation by MRI. RESULTS: The US appearance of the myofibromas included a mass with a purely anechoic center with a thick wall, a mass with a partially anechoic center, and a mass without anechoic components. On enhanced CT, the masses had lower or similar attenuation compared to adjacent muscle, with some masses exhibiting peripheral enhancement. The MR appearance consisted of low signal on T1-weighted imaging. On T2-weighted imaging, two had low signal of the center and the other three had high signal. All masses showed peripheral enhancement after gadolinium administration. CONCLUSIONS: Myofibromas have variable appearance on US, with a mass with an anechoic center being the most common feature. On CT, the mass can exhibit peripheral enhancement, calcifications, and erosion of adjacent bone. The MR appearance consisted of low signal on T1-weighted imaging and high or low signal of the center on T2-weighted imaging. All masses showed peripheral enhancement after gadolinium administration.
OBJECTIVE: Cold abscesses, although common in spinal tuberculosis, are usually localized to the level of infection, follow tissue planes, and may extend into the spinal canal at any level. They may cause symptoms resulting from neurovascular compression, hemorrhage, and direct mass effect. DESIGN AND PATIENTS: We present an unusual case of cervical tuberculous spondylodiscitis in a 25-year old man with a cold abscesses involving the retropharyngeal, mediastinal, and retroperitoneal areas bilaterally. The abscess tracked from the neck to the psoas muscles bilaterally. Following the diagnosis the patient received 9 months of antituberculous therapy. RESULTS: MRI showed resolution on medical treatment alone. CONCLUSIONS: Even in the presence of massive paravertebral cold abscesses medical treatment alone may well suffice for this common worldwide disorder. MRI is ideal for monitoring regression of massive abscesses in deep anatomical locations.
We report two cases of acutely infected pseudoaneurysms of the iliac arteries, successfully treated with endovascular stent-grafting. Two patients underwent stent-graft treatment for erosive rupture of the iliac artery caused by surrounding infection. The first case is that of a 61-year-old man who had undergone Miles' operation for an advanced rectal cancer. Postoperatively, he developed intrapelvic abscess formation, from which methicillin-resistant Staphylococcus aureus was cultured, followed by rupture of the right external iliac artery. The second case is that of a 60-year-old man who had a pseudoaneurysm of the left common iliac artery, which was contiguous with a left psoas muscle abscess, from which Streptococcus agalactiae was cultured. Both patients were successfully treated with only a stent-graft and antibiotic therapy, and remained symptom-free 12 months and 10 months later. Although endovascular stent-grafting should not be considered standard therapy for infected aneurysms, our cases suggest that it can result in repair of infected aneurysms even in the uncontrolled active stage.
The purpose of this study was to assess the efficacy and safety of percutaneous radiofrequency (RF) ablation therapy combined with cementoplasty under computed tomography and fluoroscopic guidance for painful bone metastases. Seventeen adult patients with 23 painful bone metastases underwent RF ablation therapy combined with cementoplasty during a 2-year period. The mean tumor size was 52 x 40 x 59 mm. Initial pain relief, reduction of analgesics, duration of pain relief, recurrence rate of pain, survival rate, and complications were analyzed. The technical success rate was 100%. Initial pain relief was achieved in 100% of patients (n=17). The mean VAS scores dropped from 63 to 24 (p<0.001) (n=8). Analgesic reduction was achieved in 41% (7 out of 17 patients). The mean duration of pain relief was 7.3 months (median: 6 months). Pain recurred in three patients (17.6%) from 2 weeks to 3 months. Eight patients died and 8 patients are still alive (a patient was lost to follow-up). The one-year survival rate was 40% (observation period: 1--30 months). No major complications occurred, but one patient treated with this combined therapy broke his right femur 2 days later. There was transient local pain in most cases, and a hematoma in the psoas muscle (n=1) and a hematoma at the puncture site (n=1) occurred as minor complications. Percutaneous RF ablation therapy combined with cementoplasty for painful bone metastases is effective and safe, in particular, for bulky tumors extending to extraosseous regions. A comparison with cementoplasty or RF ablation alone and their long-term efficacies is needed.
Severe retroperitoneal hemorrhage represents an infrequent and serious complication of bone marrow biopsy. A 53-year-old man, diagnosed with polycythemia vera 12 years earlier, was submitted to a bone marrow biopsy due to the appearance of anemia with clinical and hematological features suggesting myelofibrotic transformation, a diagnosis that was confirmed by the marrow study. At 2 h of a right anterior iliac bone marrow trephine biopsy, the patient suddenly developed severe pain in the area of the biopsy, with antialgic flexion of the right leg. Computed tomographic (CT) scan of the abdomen showed a 5 x 9.5 cm hematoma in the right iliac and psoas muscles. The patient was initially managed with analgesics and transfusional support, but the pain persisted and a continuous fall in the hematocrit was observed in the following days. Angiographic examination of the right external iliac artery showed contrast extravasation arising from the circumflex iliac branch, which was embolized using polivinyl alcohol particles and one coil. Following such procedure, the patient recovered uneventfully and was discharged in good condition a few days later. This case illustrates the effectiveness of an endovascular approach in providing a fast and minimally invasive treatment for this life-threatening complication of bone marrow trephine biopsy.
Spinal infections typically involve vertebrae as well as discs, and for this reason they are called septic spondylodiscitis. Magnetic resonance imaging is the most sensitive imaging method for the evaluation of this group of spinal diseases. The use of contrast-enhanced T1-weighted sequences with fat suppression, if correctly applied, may increase information provided by MRI. Firstly, this technique allows the primary vertebral focus, which often precedes disc involvement, to be identified at a very early stage. When the disease spreads, T1-weighted fat-suppressed gadolinium dimeglumine (Gd-DTPA) enhanced images provide macroscopic details of the primary vertebral focus, disc involvement patterns, and pathways of infection diffusion. All this information, when correlated with laboratory tests, may be useful in identifying the infectious agents (tuberculous vs piogenic forms), thus enabling a suitable therapy to be started. This technique is also useful in the assessment of the real extension of the disease, providing a clear depiction of paravertebral space involvement and of psoas muscle abscesses. Dangerous complications, such as meningitis, myelitis, and epidural abscesses, may be more promptly diagnosed and fully evaluated with fat-suppressed post-contrast T1-weighted images. Finally, this imaging technique may help to differentiate infectious processes from degenerative disorders, extradural neoplastic processes, and rheumatic diseases.
The aim of this study was to examine the feasibility of a hybrid interventional MR system, which combines a closed bore magnet with a C-arm fluoroscopy unit for percutaneous drainage of abdominal fluid collections. During the past 2 years, we have performed four drainage procedures in four patients (mean age 47 years). Three patients had abscesses (psoas muscle, kidney, subphrenic location) and the fourth patient had a recurrent splenic cyst. All procedures were performed on an interventional MR system consisting of a 1.5-T ACS-NT scanner combined with a specially shielded C-arm. The drainages were guided by T1-weighted fast gradient-echo images, T2-weighted single-shot turbo spin-echo images or both. A standard 18 G (1.2 mm) nonferromagnetic stainless steel needle with a Teflon sheath was used for the punctures following which a 0.89 mm nitinol guidewire was inserted into the fluid collection. Thereafter, the patient was positioned in the immediate adjacent fluoroscopy unit and a drainage catheter was placed under fluoroscopic control. All drainage catheters were successfully placed into the fluid collections, as proven by fluid aspiration and resolution of the collection. The mean time needed for the entire drainage procedure (MR and fluoroscopy) was 110 min. No procedure-related complications occurred. It is feasible to perform drainage procedures on a closed-bore MR scanner. The multiplanar imaging capabilities of MR are particularly helpful for fluid collections in the subphrenic location.
Renal cancer is diagnosed in 27,000 Americans and accounts for 12,000 deaths per year. Fortunately, improvements in imaging technology have resulted in earlier detection and longer survival. Although computed tomography (CT) and ultrasound (US) have accounted for much of this success, magnetic resonance (MR) imaging can offer several improvements in renal cancer imaging. MR imaging has demonstrated increased detection of tumor thrombus in the renal vein and IVC with better delineation of the superior extent of the tumor thrombus in the IVC, especially in the region of the right atrium. This information potentially impacts the surgical approach in cases where CT or US is equivocal. Visualization of tumor extension to the liver, spleen, and psoas muscle is also improved with MR imaging, increasing staging accuracy in selected cases. In addition, because of the relatively low nephrotoxicity and allergic potential of gadolinium chelates, contrast-enhanced MR imaging remains the study of choice for patients who cannot tolerate iodinated contrast agents. Although the current role of MR in renal cancer imaging is complementary to that of CT and US, its future role has not yet been completely defined. Recent developments in rapid MR imaging techniques have suggested the possibility of improved detection and characterization of renal masses relative to CT. In addition, as MR spectroscopic imaging of the kidney evolves, the possibility of future identification and characterization of renal masses on a biochemical basis may provide completely new insight into our understanding of renal cancer.