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Radiology


A New Look at Adolescent Idiopathic Scoliosis
Radiology
Written by Mark Sanna, D.C.   
Thursday, 23 September 2010 13:17

A New Look at Adolescent Idiopathic Scoliosis

by Mark Sanna, D.C.

 

Scoliosis comes from the Greek word skoliosis which means crookedness. Adolescent Idiopathic Scoliosis (AIS) is a deformity of the spinal column with an onset between the ages of ten and eighteen. Most types of scoliosis are classified as idiopathic, meaning that the reasons for this type of deformity of the spine are unknown. Many assumptions concerning the causative factors for the dysfunction have developed. These include: birth trauma, visceral tensions, psychological problems, unilateral shortening of the psoas muscle, nutrition, genetic factors, and so on.

 
Soft Tissue Neoplasm or Hematoma?
Radiology
Written by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C.   
Wednesday, 22 September 2010 15:42

Soft Tissue Neoplasm or Hematoma?

by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C.

 

History: This 25 year old female has recently noticed a palpable mass in the upper inner thigh. She doesn’t recall any fall but does ride her horse on a regular basis.

Diagnosis: Post-traumatic myositis ossificans. Note the calcific mass near the lesser trochanter which was caused by chronic trauma to the adductor muscles while horseback riding. (Prussian’s disease)

General considerations:

Traumatic myositis ossificans (myositis ossificans posttraumatica, ossifying hematoma, traumatic ossifying myositis, or heterotopic posttraumatic bone formation) is a condition characterized by heterotopic bone formation in the soft tissues following trauma. The process occurs most often in muscle but may also occur in fascia, tendons, joint capsules, and ligaments. Most occur following any local injury sufficient to cause bruising of the muscle or a frank hemorrhage within it. The most common sites are the brachialis anterior (elbow), quadriceps femoris (thigh), adductor muscles of the thigh, medial collateral ligament of the knee (Pellegrini-Stieda disease), and in cases of rupture of the coracoclavicular ligament of the shoulder.1 The constant pressure of the saddle against the adductors in riders may cause ossification in the adductor magnus and is known as Prussian’s disease, or erroneously, as a saddle tumor.1 Bedridden and wheelchair-confined patients frequently produce heterotopic bone at areas of gravitational stress, most commonly found at the ischial tuberosities. Up to 50 percent of paraplegic and quadraplegics exhibit paravertebral ossification.1,2

Radiologic Features:

The ossifying hematoma may be visible radiographically within three to four weeks after the initial injury.1 Magnetic resonance imaging may show the intramuscular hematoma from an early stage. Initially, the roentgen appearance is a fine, lacy radiopacity, which is followed later by a cloudy ossification within a well-defined mass. Its size depends upon the degree of initial trauma and the overall size of the hematoma. Eventually, sequential studies demonstrate a bony mass that is very radiopaque in its peripheral margins, with the center of the lesion appearing relatively radiolucent. The bony mass usually measures 4 to 5 cm but may be as large as 25 cm on occasion. The soft tissue osseous mass distinctively has no direct connection with the closest bone.

Radiologic diagnosis is essential, since biopsy of this mass in its early stages may show what would appear to be a sarcomatous change centrally. A radiologic sign important in making the distinction between this and a bone neoplasm is the characteristic lucent zone (cleavage plane) between the calcified mass and the subadjacent cortex.1,2 The mass is usually located adjacent to the diaphysis of a tubular bone, but the cortex of the bone is intact. Other important confirmatory properties are a dense periphery with a more lucent center and decrease in volume with time. Increased uptake of bone-seeking radionuclide may be noted which diminishes with maturity and inactivity of the lesion.1

3101_yochum

 

Differential Diagnosis:

Extraskeletal sarcoma may be difficult to differentiate from myositis ossificans. This condition is rare and tends to occur in older adults. Synovioma, in one third of cases, may calcify and can be located remote from the joint due to its association with tendon sheaths; therefore, this tumor must be given consideration when evaluating a calcified soft tissue mass. A parosteal sarcoma may have a similar appearance, but no lucent zone between it and the diaphysis should be visible. Other soft tissue calcifications such as tumoral calcinosis may present as a densely calcified mass but have an amorphous calcific rather than maturely ossific nature.2

Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 1-303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 1-303-690-8503 or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it

 

Reference

1. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 3rd ed., Williams & Wilkins, Baltimore, Maryland, 2005.

2. Goldman AB: Myositis Ossificans, A Benign Lesion with a Malignant Differential Diagnosis: AJR 126:32, 1976.

 
What Is The Vacuum Sign?
Radiology
Written by Terry R. Yochum   
Wednesday, 15 September 2010 15:48

by Terry R. Yochum, D.C., D.A.C.B.R., Fellow, A.C.C.R., and Chad J. Maola, D.C.

 

History:  
An adult male patient with a long history of low back pain.

Discussion:
The vacuum sign (of Knutts en) is an important early radiographic finding.  Essentially, this represents collections of nitrogen gas in nuclear and annular fissures and  presents as an area of linear radiolucency in the disc space.1   Studies have show n this to be a comm on sign of disc aging and  degeneration, with an incidence of 2-3% in the general population.1 The collection of nitrogen in the discal fiss ures is th ought to originate from adjacent extracellular fluid. 

 
SPONDYLOLYSIS AND/OR SPONDYLOLISTHESIS: LET'S GET IT RIGHT AND STIR THINGS UP
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Radiology
Written by Terry R. Yochum, D.C., D.A.C.B.R.   
Saturday, 26 June 2010 10:00

The topic of spondylolysis and/or spondylolisthesis has been clouded with confusion for many years. To understand the true etiology as a stress fracture rather than an inherited congenital anomaly or predisposition has been a lifelong quest for me. The normally developing pars interarticulares is a fully ossified structure at birth and without a local synchondrosis to undergo nonunion. There has never been a patient born with a lumbar spondylolysis and/or spondylolisthesis. The true etiology of spondylolysis (pars defects) is that of a stress fracture, which is, in fact, a fatigue fracture where repetitive stress on normal bone allows the bone to fatigue, much like you see in the metatarsal bones and tibia with marathon runners and gymnasts.

To fully understand the concept of the pain-generating factors associated with spondylolysis and/or spondylolisthesis, one must look beyond plain films and computed tomography to more physiological imaging. In the past, I have stressed the importance of determining the presence/absence of increased physiological activity at the pars interarticularis as an aid to developing an accurate diagnosis and appropriate treatment plan for patients who have or are at risk for spondylolysis, coining the term "PENDING SPONDYLOLYSIS" for those who have a developing stress fracture without frank separation. Historically, two modes of diagnostic imaging have been used to assess whether physiologic activity is present and associated with existing pars defects. Radionuclide bone scan imaging, particularly SPECT (Single Photon Emission Computed Tomography), has often been the examination of choice, however suffers from two drawbacks; it does expose the patient to ionizing radiation and it provides very little anatomical information. Fortunately, these concerns have been addressed with the advent of MR imaging.

 http://www.theamericanchiropractor.com/images/spondylolysis-yocum1.jpg

Having reviewed thousands of cases, often with sports related back pain and/or spondylolysis, I have had the opportunity to see proven value of MR imaging for evaluation of the physiological activity that occurs adjacent to a pars defect, or that which is hidden in the region of the pars interarticularis when the defect is, in fact, "PENDING". I feel, at this point in time, that SPECT imaging is probably no longer the exam of choice, since there is so much more information obtained with the physiological imaging of magnetic resonance. Additionally, the exquisite anatomical information that MR imaging provides can be invaluable in demonstrating other possible causes of back pain in those individuals whose MR findings are negative for spondylolysis. The ability to evaluate the spinal canal, exiting nerve roots and the integrity of the discs, along with the surrounding paraspinal musculature, offers so much more information in the evaluation of a young athlete with persistent back pain with what is often repetitive hyperextension.

Let’s STIR Things Up in the Evaluation of Spondylolysis and/or Spondylolisthesis

I have seen many cases where bone marrow edema adjacent to the pars or hidden within an intact pars on its way to becoming a pars defect (PENDING SPONDYLOLYSIS) has been missed on standard T2-weighted images, where a STIR imaging sequence clearly provides this information. At this point in time, I offer to the profession that an MRI scan should be the exam of choice, with the proviso that the MR protocol includes a strongly fluid sensitive pulse sequence, such as STIR (short-tau inversion recovery) or other strong fat-suppression protocol. When appropriate clinical management depends on whether the spondylolysis and/or spondylolisthesis is active and/or inactive, only physiological activity will provide that information. If your local imaging center does not include STIR or other fat-suppressed (FatSat) pulse sequence as part of their routine lumbar MRI scan, requesting a sagittal STIR imaging will definitively answer the question of normal or increased physiological activity in the region of the pars interarticularis. When ordering this additional study to the standard lumbar spine MRI scan, it will only add a few minutes to the overall imaging time and should add no additional expense to the study.

 http://www.theamericanchiropractor.com/images/spondylolysis-yocum2.jpg

Spondylolysis should be included in the differential for any patient who complains of low back pain due to repetitive hyperextension, be it sports or industrial related. Physical exam findings such as a positive Stork (single leg hyperextension) test, often positive in acute facet syndrome and/or hot pars abnormality, may further indicate the need for more physiological imaging of the region of the lower lumbar pars interarticularis. When repeating an MRI scan to evaluate whether the bone marrow edema adjacent to the pars has subsided and the patient can be removed from the standard Boston overlap brace that the patient has been placed in, the only imaging sequence really required to determine that the active pars defect has become inactive is the sagittal STIR fluid-sensitive imaging sequence. This should be performed after the patient has been in a Boston overlap brace for a minimum of three to four months and, if the imaging study shows no evidence of persistent edema, one can allow the patient to slowly go back to their sports or work related physical activities. Core stabilization exercises and physical activity back to their normal routines should occur slowly, and some common sense should be used by the clinician in not allowing the athlete to go back at full performance too quickly. For a more detailed discussion of this condition, see Chapter 5 of the new edition of Essentials of Skeletal Radiology, published in 2005 by Lippincott Williams & Wilkins. Included there are some positive treatment protocols for patients with active spondylolysis and/or spondylolisthesis.

As a final comment, it is always appropriate and very useful to the radiologist for the referring clinician to clearly state on the imaging request form the working diagnosis. Tell the radiologist why imaging is being performed and what questions you are trying to answer. This is particularly important in the evaluation of spondylolysis, so that right imaging sequences are performed and the sometimes subtle changes in marrow signal are not overlooked. Including a copy of the material in Chapter 5 of my textbook covering "Active versus Inactive Spondylolisthesis" and perhaps a copy of the article which I have referenced in this text along with your imaging request may also be useful for emphasis. The additional information may help the medical radiologist to provide you the right report and ensure proper and complete evaluation of the patient’s presenting complaint.

Thanks to Dr. Jeff Thompson, Professor and Chairman, Department of Radiology, Texas Chiropractic College, Houston, Texas, for his help in preparation of the text and images for this article.

Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado Schoolof Medicine, Denver, CO. Dr. Yochum can be reached at 1-303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

1. Yochum, TR, Rowe, LJ: Essentials of Skeletal Radiology, 3rd ed., Chapter 5,Williams & Wilkins, Baltimore, Maryland, 2005

2. Yochum, T.R., et al., Active or Inactive Spondylolysis and/or Spondylolisthesis: What’s the Real Cause of Back Pain? J.N.M.S: Journal of the Neuromusculoskeletal System, Vol. 10, No. 2, Summer 2002.

 
Idiopathic Wrist Pain
Radiology
Written by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C.   
Tuesday, 25 May 2010 00:00

History

This young adult male patient complains of wrist pain after physical activity. Plain film radiographs showed no abnormalities of any of the bones of the wrist, nor was there any joint disease in the carpal bones. Because of persistent pain, an MRI scan was performed.

http://www.theamericanchiropractor.com/images/Yochum-1.jpgDiagnosis: Kienbock's Disease

 Osteonecrosis may occur at any carpal bone as a result of traumatic disruption of the blood supply. The scaphoid and the lunate are the most frequently affected carpal bones (Kienböck’s disease).1 Osteonecrosis of the scaphoid is usually the sequela of a traumatic injury to the waist or proximal pole and occurs in 10-15% of all scaphoid fractures.1 MRI demonstrates the extent of the necrotic process more accurately than does conventional radiography and is equal in sensitivity to nuclear scintigraphy. When only T1-weighted sequences are used, the MRI sensitivity in diagnosing necrosis is about 87.5%; with the addition of the T2-weighted sequences, the specificity is 100%.1 Therefore T1- and T2-weighted coronal and axial images should be used to best display the characteristics of the lesion. In the early stages, T2-weighted sequences demonstrate regions of increased signal intensity. This area can be surrounded by hypointense signal, which is believed to represent the interface between non-viable (dead) bone and reparative granulation tissue. In advanced cases the necrotic zone has a homogeneous, hypointense signal on both T1- and T2-weighted images.

 

Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado Schoolof Medicine, Denver, CO. Dr. Yochum can be reached at 1-303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Chad Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is available for post-graduate seminars. He may be reached at 1-727-433-0153 or by email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

1. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 3rd ed., Williams & Wilkins, Baltimore, Maryland, 2005.

 
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