Treatment options in primary Ewing's sarcoma of the spine: report of seven cases and review of the literature.

Primary Ewing's sarcoma of the spine is reviewed, and seven cases are presented. Ewing's sarcoma of the spine is a rare condition that appears with a clinical triad of local pain, neurological deficit, and a palpable mass. The clinical picture, imaging characteristics, and management are discussed. The definitive management of Ewing's sarcoma of the spine, as in other locations, could include three main modalities: surgery, radiotherapy, and combination chemotherapy. In the presence of acute neurological decompensation, decompressive surgery via an appropriate approach should be performed. Because Ewing's sarcoma is usually sensitive to chemotherapy, initial chemotherapy, in neurologically stable patients, could be attempted first without surgical resection. Further management could then be gauged according to the response.     

Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with "cranial settling"

Lack of correlation between the severity of rheumatoid subluxation of the upper cervical vertebrae and supposed absence of neurological damage has led to the erroneous supposition that this finding is innocuous. Incomplete autopsy studies in rheumatoid arthritis have failed to recognize the cause of death, despite previously proven dramatic occipito-atlanto-axial dislocations. The most feared entity of rheumatoid basilar invagination, namely "cranial settling," is poorly understood. Between 1978 and 1984, the authors treated 45 rheumatoid arthritis patients who were symptomatic with "cranial settling." This consisted of vertical odontoid penetration through the foramen magnum (9 to 33 mm), occipito-atlanto-axial dislocation, lateral atlantal mass erosion, downward telescoping of the anterior arch of C-1 on the axis, and rostral rotation of the posterior arch of C-1 producing ventral and dorsal cervicomedullary junction compromise. Cervicomedullary junction dysfunction has mistakenly been called "entrapment neuropathy," "progression of disease," or "vasculitis." Occipital pain occurred in all 45 patients, myelopathy in 36, blackout spells in 24, brain-stem signs in 17, and lower cranial nerve palsies in 10. Four patients had prior tracheostomies. Four previously asymptomatic patients with "cranial settling" presented acutely quadriplegic. The factors governing treatment were reducibility and direction of encroachment determined by skeletal traction and myelotomography. Transoral odontoidectomy was performed in seven patients with irreducible pathology. All patients underwent occipitocervical bone fusion (with C-1 decompression if needed) and acrylic fixation. Improvement occurred during traction, implying that compression might be the etiology for the neurological signs. There were no complications. Thus, "cranial settling" is a frequent complication of rheumatoid arthritis; although it is poorly recognized, it has serious implications and is treatable.     

Sarcoma in Paget disease of bone: clinical, radiologic, and pathologic features in 22 cases

The clinical, radiologic, and histologic features of 22 cases of Paget sarcoma were reviewed to determine in which patients with Paget disease these tumors are most likely to develop and what radiologic findings suggest the diagnosis. Clinical findings at presentation included pain and/or a mass (11 patients), pathologic fracture (seven), and neurologic symptoms (four). Survival time in 20 patients ranged from 5 days to 2.5 years. Two patients were lost to follow-up: one at 2 years and one at 8 years. There were 16 high-grade osteosarcomas, three chondrosarcomas, two fibrosarcomas, and one malignant fibrous histiocytoma. The most common site was the femur. Tumors also were observed in unusual sites. In one case of multifocal osteosarcoma, the tumor involved only pagetic bone. In 15 patients, Paget disease was polyostotic, clinically significant, and had been documented previously. In four patients, a sarcoma developed near the site of a fracture that had occurred between 2 months and 15 years previously. All cases showed radiologic evidence of a destructive lesion; other findings included a mass and evidence of tumor mineralization. Periosteal reaction was not observed. All but one tumor developed in a site of osteoblastic or mixed osteoblastic and lytic Paget disease. Our results suggest that sarcomas can develop in any part of any bone affected by Paget disease but are more likely to occur with advanced disease and to present with a destructive lesion without periosteal reaction.     

MR imaging of patellar tendinitis.

To identify magnetic resonance (MR) imaging characteristics of normal patellar tendons and those affected by tendinitis, the authors evaluated MR images obtained in 10 healthy volunteers, in 50 patients who underwent MR imaging for evaluation of knee structures other than the patellar tendon, in 11 patients with patellar tendinitis, and in two athletes with patellar tendon injuries. Normal tendons had uniformly low signal intensity on T1-, T2-, and proton-density-weighted images and displayed distinct margins, and the anteroposterior (AP) diameter slightly increased proximally to distally. It was concluded that the AP diameter of a normal tendon, in its proximal portion, should not exceed 7 mm. In patellar tendinitis, the tendon showed increased signal intensity on T1-, T2-, and proton-density-weighted images and increased AP diameter proximally. The margins of affected tendons were indistinct, especially posterior to the thickened segment. In all groups studied, women had thicker proximal tendons than did men.     

Impact of clinical history on radiographic detection of fractures: a comparison of radiologists and orthopedists

Are the methods used by radiologists in interpreting imaging studies different from those of attending physicians? We evaluated the influence that knowledge of localizing clinical signs has on the accuracy of fracture detection by orthopedic surgeons and compared the results with those of an identical study of radiologists performed earlier. The orthopedists studied had the same degree of experience as the radiologists. Forty radiographs of the extremities were examined twice by seven orthopedic surgeons. In 26 cases, a subtle fracture was present; 14 cases were normal. During one interpretation of the radiographs of each case, the precise location of pain, tenderness, or swelling was provided; during the other, this information was withheld. Analysis of receiver-operating-characteristic parameters indicates that the clues regarding location of trauma facilitate detection of fractures by orthopedists (an 11% improvement in Az, the area under the ROC curve, F[1,12] = 49.67, p less than .001). This finding is similar to the results of the earlier study with radiologists (a 6% improvement in Az, F[1,12] = 14.77, p less than .005). Statistical comparison of the two experiments showed that orthopedists depend on this information much more than do radiologists, demonstrated by a statistically significant prompting-by-specialty interaction (F[1,12] = 5.13, p less than .05). Localization clues improve ability of orthopedic surgeons to detect fractures in the trauma patient even more than they improve the ability of radiologists. The accuracy of the radiologist will suffer less than that of the orthopedist when localization clues are unavailable. Nonetheless, the findings show that localizing clues are important to both orthopedists and radiologists when searching for fractures.     

An unusual cause of the quadrilateral space impingement syndrome by a bone spike

The quadrilateral space impingement syndrome is a clinical syndrome resulting from compression of the axillary nerve and the posterior circumflex humeral artery, with subsequent focal atrophy of the teres minor, with or without involvement of portions of the deltoid muscle. This entity has many etiologies. We are reporting a case of this syndrome caused by a bone spike from a malunited old scapular fracture following a motor vehicle accident. The bone spike impinged on the axillary nerve as it passes through the quadrilateral space, causing focal atrophy of the teres minor muscle. The abnormality was well demonstrated by MD-CT.