Diskography

Diskography has become a vital study in the evaluation of spinal pain, particularly in patients who are considered candidates for possible surgical intervention. It has been the author's experience that when diskography is performed with appropriate clinical indication by skilled and experienced practitioners who are thoroughly familiar with spinal pathology, the results lead to improved clinical outcomes. Diskography is a study ideally suited for procedural radiologists.     

Temporomandibular Joint: MR Fast Scanning

Eleven hundred ninety temporomandibular joints (TMJ) in 662 patients were studied with high field strength surface coil magnetic resonance using high resolution T1-weighted closed-mouth and short partial flip angle closed- and open-mouth images to evaluate internal derangement. Partial flip angle (gradient recalled acquisition in the steady state, or GRASS) images using image acquisition times as short as three seconds in most cases provided reliable information on disk position, morphology, and intrinsic signal. Abnormalities of disk function may be studied using sequential GRASS scans during incremental degrees of mouth opening. Joint effusions may be delineated by T2* effects, and avascular necrosis (AVN) of the mandibular condyle is demonstrated. Fast GRASS scans provide accurate information and may be employed alone or in conjunction with standard T1-weighted images in studies of the TMJ. Combined studies using both T1-weighted closed- and short GRASS open-mouth scans provide greater information than is obtained from either T1-weighted or GRASS scans alone, and examination times are short compared to T2-weighted pulse sequence techniques.     

Photodynamic therapy of gynecologic neoplasms after presensitization with hematoporphyrin derivative

Five patients with various gynecologic neoplasms were treated with photodynamic therapy using 630-nm light delivered from an argon dye laser system following the intravenous injection of hematoporphyrin derivative (HpD). A patient with multifocal squamous cell cancer of the vagina had no evidence of disease 15 months after her first photodynamic therapy treatment. Autopsy nine months after the first treatment of another patient with multifocal invasive cancer of the vagina and parametrium showed no evidence of tumor on the surface of the vagina. Eight months after treatment of an 8 X 12 cm area of Bowen's disease of the vulva and thigh, there was no evidence of disease. Vaginal bleeding from breast cancer metastatic to the endometrium was controlled by one treatment until the patient expired five months later from her disease. Adenocarcinoma metastatic to the vaginal cuff showed partial response when vaginectomy was performed five weeks after photodynamic therapy.     

Prognostic factors and the significance of cytologic grading in invasive squamous cell carcinoma of the vulva: a clinicopathologic study

Clinical staging, tumor size, histologic differentiation, cytologic grading, depth of stromal invasion, and vascular channel involvement by tumor cells were studied in 42 patients with invasive squamous cell carcinoma of the vulva who were treated with radical vulvectomy and inguinal-femoral lymphadenectomy. All parameters were found to correlate well in predicting groin node metastasis. Cytological grading was found to be more significant compared to histologic grading in regard to nodal metastasis (P less than 0.02). No patient with cytologic or histologic grade 1 tumor and less than 5 mm stromal invasion was found to have nodal metastasis.     

Vaginal reconstruction after total pelvic exenteration using a modification of the Williams' procedure.

The complete rehabilitation of women who have been subjected to ultraradical pelvic surgery should include the reconstruction of a functional vagina. The creation of a vaginal pouch as described by Williams for patients with congenital absence of the vagina or vaginal stenosis may be considered in some of these patients. The principle of his operative procedure can be applied to anatomic conditions in which the vagina and vulva have been resected utilizing perineal tissue structures and skin grafts. This is demonstrated in two patients with different postoperative perineal defects.     

Facial skeleton remodeling due to temporomandibular joint degeneration: an imaging study of 100 patients

One hundred patients with recently acquired, externally visible mandibular deformity and no history of previous extraarticular mandible fracture were selected for retrospective analysis. All had been investigated clinically and with radiography, tomography, and high-field surface-coil MR imaging to determine the presence or absence and extent of temporomandibular joint degeneration. Temporomandibular joint degeneration was found in either one or both joints of each patient studied. Chin deviation was always toward the smaller mandibular condyle or more diseased joint, and many patients either complained of or exhibited malocclusion, often manifested by unstable or fluctuating occlusion disturbances. Three radiologically distinct forms of degenerative vs adaptive osteocartilaginous processes--(1) osteoarthritis, (2) avascular necrosis, and (3) regressive remodeling--involving the mandibular condyle and temporal bone were identified in joints most often exhibiting meniscus derangement. Osteoarthritis and avascular necrosis of the mandibular condyle and temporal bone were generally associated with pain, mechanical joint symptoms, and occlusion disturbances. Regressive remodeling was less frequently associated with occlusion disturbances, despite remodeling of the facial skeleton, and appears to result from regional osteoporosis. Forty patients (52 joints) underwent open arthroplasty procedures, including either meniscectomy or microsurgical meniscus repair, at which time major radiologic diagnoses were confirmed. Surgical and pathologic findings included meniscus displacement, disk degeneration, synovitis, joint effusion, articular cartilage erosion, cartilage healing/fibrosis, cartilage hypertrophy, osseous sclerosis, osteophyte formation, osteochondritis dissecans, localized or extensive avascular necrosis, and decreased mandibular condyle mass and vertical dimension. We conclude that temporomandibular joint degeneration is the principal cause of both acquired facial skeleton remodeling and unstable occlusion in patients with intact dentition and without previous mandible fracture.     

Selective cervical nerve root blockade: experience with a safe and reliable technique using an anterolateral approach for needle placement

BACKGROUND [corrected] AND PURPOSE: Our aim was to evaluate the safety and clinical utility of a fluoroscopically guided anterolateral oblique approach technique for outpatient diagnostic and therapeutic selective cervical nerve root blockade (SCNRB). MATERIALS AND METHODS: During a 13-year period (1994 through February 2007), 4612 patients underwent fluoroscopically guided diagnostic and/or therapeutic extraforaminal SCNRB by using an anterior oblique approach at affiliated outpatient imaging centers. Each procedure was performed by 1 of 6 procedural radiologists, all highly experienced in and actively performing spinal injections on a full-time basis in clinical practice. All of the proceduralists were thoroughly experienced with lumbar injections before endeavoring to perform SCNRBs. Nonionic contrast was injected in nearly all patients (except isolated patients with contrast allergy), and a minimum of 2 projection filming procedures were performed to document the accuracy of needle placement and contrast dispersal before the injection of therapeutic substances. All clinically significant complications beyond skin discoloration and temporary exacerbation of symptoms were recorded. RESULTS: There were no serious neurologic complications, such as stroke, spinal cord insult, or permanent nerve root deficit. One life-threatening anaphylactic reaction occurred and was attributed to the injected materials and not the specific procedure itself. Another patient had a 3- to 4-minute grand mal seizure, from which he fully recovered within 30 minutes. There were no infections. CONCLUSION: The technique we describe for fluoroscopically guided SCNRB is a useful and safe outpatient procedure when performed by skilled and experienced proceduralists.     

Permanent Proplast temporomandibular joint implants: MR imaging of destructive complications

We studied the radiologic and pathologic changes in 30 patients (34 joints) in which there were locally destructive bone and soft-tissue complications associated with previously inserted permanent temporomandibular joint (TMJ) Proplast-Teflon implants. The cases were selected as representative examples of patients with failed Proplast interpositional arthroplasty, in whom images of the TMJ were obtained with conventional radiography, tomography, and MR, and in whom both surgical and histologic findings were available. Clinical indications for imaging included joint pain, restricted joint motion, crepitus, preauricular swelling, regional lymphadenopathy, malocclusion either acquired or changed since implant surgery, and facial deformity. Surgery was then performed for the purposes of implant retrieval and joint debridement because of destructive soft-tissue and osseous changes observed from the imaging analysis in conjunction with significant clinical signs and symptoms. The pathologic changes, observed 4-54 months after implant surgery, included a destructive foreign-body-type granuloma and avascular necrosis of the mandibular condyle and condylar neck. Our findings suggest that MR is useful in the detection and evaluation of destructive complications that may accompany failed Proplast-Teflon implants in the TMJ. MR is superior to conventional radiography and tomography in detecting soft-tissue lesions and avascular necrosis of bone. Tomography more accurately delineates soft-tissue calcifications and cortical margins of osseous structures.