Primary disorders of bone with 'spinal block'.

Two hundred and thirty-two cases of compression of the spinal cord or cauda equina included 11 cases where compression was entirely due to a primary bony disorder and 20 further cases where developmental spinal stenosis was the main cause of compression. The former group consisted of two cases of Paget's disease and one each of polyostotic fibrous dysplasia, chondrosarcoma, achondroplasia, spondylo-epiphyseal dysplasia, Klippel--Feil syndrome, haemangioma of bone, primary bone reticulosarcoma, osteoporotic fracture and vertebral osteomyelitis. Three patients, with fibrous dysplasia, chondrosarcoma and Paget's disease with recurrent compression respectively, are described and the relevant literature is reviewed. The large number of primary disorders of bone which can cause cord compression are tabulated. Cord compression is a rare complication in most of these disorders but collectively they caused 13% of the cases of spinal block in this series.     

Urographic findings in adults with chronic pyelonephritis

The radiological findings in a cohort of 138 adults with chronic pyelonephritis are presented and the following conclusions made. Scarring is commoner in the right kidney than the left and is found in the upper, middle and lower poles with decreasing frequency from above down. Agreement between observers in the grading of scarring in urograms taken without standardisation or routine tomography, is sufficiently high to justify the continued use of the intravenous urogram as a screening test but is not high enough to detect any progression of scars in the group over a 6.5-year period. Repetition of urograms seldom reveals the development of calculi or other new abnormalities and is not justified as a clinical routine. The combination of extensive bilateral renal scarring and proteinuria is associated with the worst renal function.     

Sclerosing-cholangitis-like changes in pancreatic disease

In a retrospective analysis of endoscopic cholangiograms in 66 patients with pancreatic disease we found sclerosing-cholangitis-like changes in 83% of cases. Excluding patients with intrapancreatic constriction of the distal common bile duct, 70% of patients with chronic pancreatitis, 60% with acute pancreatitis and 100% with pancreatic cancer had these abnormalities. The possible significance of these changes, which are unlikely to be secondary to pancreatic disease, are discussed with reference to the published literature on sclerosing cholangitis.     

99Tcm-Sn pyrophosphate scanning in suspected acute myocardial infarction using a mobile rectilinear scanner

99Tcm stannous pyrophosphate injected intravenously gives a positive image of freshly damaged myocardium but not of normal or scarred myocardium. It is safe, cheap and generally available. One hundred and forty patients admitted to hospital with possible myocardial infarction were scanned with a mobile rectilinear scanner of the type available in most district general hospitals. When the diagnosis of infarction was definite on clinical, electrocardiographic and enzyme criteria the anterior scan was positive in 31 out of 36 patients (86%); and when it was probable, the scan was positive in 28 out of 41 (68%) and when it was doubtful the scan was positive in 23 out of 63 (37%). The optimum time for scanning was between the second and seventh days. Pyrophosphate scanning is a very valuable investigation even though it is not an absolute discriminator of myocardial infarction. It is useful in assessing patients with atypical or doubtful symptoms of infarction where the ECG is already abnormal or where there are other causes of raised enzyme concentrations. False negative scans are not common, but a negative scan does not outweigh strong alternative evidence of infarction. Positive scans occur in some patients with unstable angina without confirmatory evidence of infarction. Positive scans due to extracardiac lesions are distinguished readily.     

Scintigraphic evaluation of the painful prosthetic joint: a comparison of gallium-67 citrate and indium-111 labelled leucocyte imaging

The radiopharmaceuticals gallium-67 and indium-111 labelled leucocytes have been compared in 15 patients with a painful joint prosthesis in an attempt to identify those patients with periprosthetic infection. Gallium-67 images were abnormal in five out of six patients with periprosthetic infection and normal in seven out of nine without evidence of infection. Indium-111 leucocyte images were abnormal in three out of six patients with infection and normal in all nine patients without infection. Indium-111 labelled leucocyte imaging is technically more difficult to perform than gallium-67 imaging. This, combined with the higher sensitivity of gallium-67 imaging for infection around a prosthetic joint, leads us to conclude that gallium-67 imaging is superior to indium-111 leucocyte imaging in identifying infection as a cause of a painful prosthetic joint.     

Ultrasonic and radionuclide scanning in pancreatic disease

Ultrasonic examination of the pancreas is rendered difficult by the echogenic characteristics of the organ, by its depth, by the overlying gas, and by bony structures and anatomic variations. The reintroduction of gray-scale imaging promises to simplify the technique and expand its usefulness. The 75Se-/-selenomethionine scan is a reliable test when performed after effective pancreatic stimulation with a scintillation camera that permits the angulation required to separate pancreas from liver. Gallium-67-citrate may be important for both mapping inflammatory processes and imaging some tumors. Retrograde pancreatography has developed into a rather reliable and sensitive method of visualizing pancreatic duct abnormalities. Angiography remains the most reliable technique for finding small lesions, while computerized axial tomography appears a promising modality in the near future. In acute pancreatitis, gallium scanning may find a place alongside plain films, GI series, and echography. Chronic pancreatitis appears best studied by pancreatography, possibly with selenomethionine scanning as a function study and echography to find associated mass lesions. Pseudocysts are most easily located by ultrasound examination. Screening for pancreatic carcinoma is done most effectively with selenomethionine scanning when the index of suspicion is low and with pancreatography or arteriography when it is high. Echography is useful for localization for aspiration biopsy and for sequential evaluation of therapeutic response. Islet-cell tumors are best found by angiographic studies.     

The scintigraphic findings in Paget's disease of bone.

Bone scans and radiographic skeletal surveys have been done in 41 patients who had Paget's disease. The scintigraphic findings are consistent with what is known of the pathophysiology of Paget's disease. Diseased bone demonstrates increased vascularity, an increased degree of uptake of bone-seeking radiotracers and, in appropriate bones, evidence of marrow replacement. The bone scintiscan is a more sensitive indicator of the extent of polyostotic Paget's disease than conventional radiograph, demonstrating 34% more lesions. Because it reflects shorter term changes in osteoblastic activity the bone scan is of some value in providing immediate objective evidence of the therapeutic effectiveness of Mithramycin which has been used in this study in the treatment of the minority of patients with pain in Pagetoid bone. A technique for documenting alterations in uptake by diseased bone numerically is presented. Upon treatment with Mithramycin the ratio of abnormal uptake in relation to normal bone fell from 8.7 to 3.9.     

Rationale for the use of bone scans in selected metastatic and primary bone tumors

Since the introduction of bone scans in 1951, there have been many studies comparing biologic and physical characteristics of new bone-imaging agents and the results of scintigraphy and radiology in large numbers of patients. Relatively speaking, there have been fewer studies detailing the health benefits and financial cost associated with the use of skeletal scintigraphy. This review concerns these aspects in patients with malignancies of various sites and stages. About 2% of patients with stage I or II breast cancer have bone metastases at the time they first present, whereas nearly 28% of patients with stage III disease have bone metastases. A large percentage of patients with initially negative scans develop bone metastases during the first 3--4 yr; many of them develop them within the first 12--18 mo after initial diagnosis. For patients with lung cancer, the use of bone scans in staging their disease is somewhat controversial. Several studies indicate that the yield of positive bone scans may range from as low as 2% to as high as 35%. Data on the use of bone scans in staging prostatic cancer initially are similar to those in patients with breast cancer, that is, yields of 7% in patients with stage I or II disease and a yield of about 20% with stage III disease. Children with osteosarcoma or Ewing's sarcoma rarely have bone disease distant from the site of their primary bone lesion at presentation. However, a large percentage of them (30%--40% or so) develop bone metastases during the follow-up period. As in the case with patients with breast cancer, about half of these bone metastases are evident by 12--18 mo.