Coccygeal movement: Assessment with dynamic MRI

Differentiation of benign versus malignant indistinguishable vertebral compression fractures by different machine learning with MRI-based radiomic features

OBJECTIVES

To explore an optimal machine learning (ML) model trained on MRI-based radiomic features to differentiate benign from malignant indistinguishable vertebral compression fractures (VCFs).

METHODS

This retrospective study included patients within 6 weeks of back pain (non-traumatic) who underwent MRI and were diagnosed with benign and malignant indistinguishable VCFs. The two cohorts were retrospectively recruited from the Affiliated Hospital of Qingdao University (QUH) and Qinghai Red Cross Hospital (QRCH). Three hundred seventy-six participants from QUH were divided into the training (n = 263) and validation (n = 113) cohort based on the date of MRI examination. One hundred three participants from QRCH were used to evaluate the external generalizability of our prediction models. A total of 1045 radiomic features were extracted from each region of interest (ROI) and used to establish the models. The prediction models were established based on 7 different classifiers.

RESULTS

These models showed favorable efficacy in differentiating benign from malignant indistinguishable VCFs. However, our Gaussian naïve Bayes (GNB) model attained higher AUC and accuracy (0.86, 87.61%) than the other classifiers in validation cohort. It also remains the high accuracy and sensitivity for the external test cohort.

CONCLUSIONS

Our GNB model performed better than the other models in the present study, suggesting that it may be more useful for differentiating indistinguishable benign form malignant VCFs.

KEY POINTS

• The differential diagnosis of benign and malignant indistinguishable VCFs based on MRI is rather difficult for spine surgeons or radiologists. • Our ML models facilitate the differential diagnosis of benign and malignant indistinguishable VCFs with improved diagnostic efficacy. • Our GNB model had the high accuracy and sensitivity for clinical application.

Association of coccygodynia with pelvic floor symptoms in women with pelvic pain

BACKGROUND

Coccygodynia is a painful condition of the tailbone that occurs more commonly in females. The association of coccyx pain with pelvic floor symptoms and the prevalence of coccyx pain in women with pelvic pain has not previously been reported.

OBJECTIVE

To identify the prevalence of coccygodynia in women with pelvic pain and to describe the association of coccygodynia with pelvic floor examination findings and symptoms.

DESIGN

Retrospective cohort analysis.

SETTING

Tertiary medical institution.

PARTICIPANTS

One hundred twenty-seven women presenting for outpatient pelvic floor physical therapy treatment who underwent vaginal and rectal pelvic floor examination.

MAIN OUTCOME MEASURES

Prevalence of coccygodynia, pain scores, association of coccygodynia with other comorbidities and diagnoses, and association of coccygodynia with physical examination findings.

RESULTS

Sixty-three (49.6%) of 127 women with pelvic pain presented with coccygodynia and 64 (50.4%) did not. Women with coccygodynia had significantly higher rates of muscle spasm (50.8% vs. 31.2%, p = .025) higher visual analog scale pain scores (median 5 vs. 3, p = .014), higher rates of outlet dysfunction constipation (31.7% vs. 10.0%, p = .032), and higher rates of fibromyalgia (15.9% vs. 3.1%, p = .014). On pelvic examination, women with coccygodynia were significantly more likely to have sacrococcygeal joint hypomobility (65.1% vs. 14.1%, p < .001), coccygeus muscle spasm (77.8% vs. 17.2%, p < .001), anococcygeal ligament pain (63.5% vs. 9.4%, p < .001), external anal sphincter pain/spasm (33.3% vs. 13.1%, p < .001), and impaired pelvic floor muscle coordination (77.8% vs. 57.8%, p = .016).

CONCLUSIONS

Almost 50% of women seeking pelvic floor physical therapy for pelvic pain had coexisting coccygodynia. These women had higher pain scores, increased pelvic floor dysfunction, and significantly greater abnormal physical exam findings. This study demonstrates a strong link between coccygodynia, pelvic floor symptoms, and pelvic pain and highlights the importance of screening for and identifying coccyx pain when evaluating women with pelvic pain.

The interdisciplinary management of coccydynia: A narrative review

Pain that develops in the coccyx or surrounding tissues is known as coccydynia, which occurs as a result of many etiologies both traumatic and nontraumatic. Although coccydynia most commonly affects middle-aged women, it may be found in both sexes and in all age groups. The aim of this article is to provide an overview of the presentation, diagnostic imaging, and pathophysiology of coccydynia, and to comprehensively review the current treatment options. A review of publications from 1990 to 2020 using search words related to the treatment of coccydynia in PubMed and Google Scholar was completed. Level II evidence was found supporting stretching, manipulation, and extracorporeal shock wave therapy. There are no data from high-quality studies to support injection-based therapy including corticosteroids, prolotherapy, nerve blocks, and radiofrequency ablation, although there are small retrospective and prospective observational studies suggesting benefit. Level III evidence was found supporting coccygectomy for chronic/refractory coccydynia. There are no data from randomized controlled trials to support the use of neuromodulation (sacral burst and dorsal root ganglion stimulation), although there are case reports suggesting benefit. High-level, comparative studies are lacking to guide the treatment of coccydynia and should be a focus for future research studies.

Evaluation of Sanders Type 2 Joint Depression Calcaneal Fractures in 197 Patients from a Single Center Using Three-Dimensional Mapping

BACKGROUND This study aimed to evaluate Sanders type 2 calcaneal fractures in 197 patients from a single center using the 3D (three-dimensional) CT (computed tomography) mapping method. MATERIAL AND METHODS A consecutive series of 197 Sanders type 2 joint depression calcaneal fractures was used. The segment and split functions were used to create each calcaneal fragment using Mimics Research 20.0 software. The fracture fragments were reduced in 3-matic Research 12.0 software. In the E-3D Medical 18.01 software, after superimposing the fractured calcaneus entity with the calcaneus template, we drew the fracture line on the template. Finally, the heatmap was obtained by fracture statistical analysis function. Simultaneously, the distribution of the fracture lines in the anterior part of the calcaneus (APC) and middle talar joint was recorded. RESULTS There were 109 cases of Sanders type 2A, 46 cases of Sanders type 2B, and 42 cases of Sanders type 2C. Based on the data, we drew the characteristic fracture map of type 2A 2B and 2C. This study found that the most common types of Sanders type 2A in APC and middle talar articular surface are type AC and type AD. In Sanders type 2B, the most common type is type AC, and in Sanders type 2C it is type ACD. CONCLUSIONS The findings from this study showed that 3D CT imaging and reconstruction of the calcaneus was a useful diagnostic method to evaluate and classify joint depression calcaneal fractures. The calcaneal fracture map can be used to guide surgical planning and optimize the design of internal fixation.

Imaging Coccygeal Trauma and Coccydynia

The coccygeal region has complex anatomy, much of which may contribute to or be the cause of coccyx region pain (coccydynia). This anatomy is well depicted at imaging, and management is often dictated by what structures are involved. Coccydynia is a common condition that is known to be difficult to evaluate and treat. However, imaging can aid in determining potential causes of pain to help guide management. Commonly, coccydynia (coccygodynia) occurs after trauma and appears with normal imaging features at static neutral radiography, but dynamic imaging with standing and seated lateral radiography may reveal pathologic coccygeal motion that is predictive of pain. In addition, several findings seen at cross-sectional imaging in patients with coccydynia can point to a source of pain that may be subtle and easily overlooked. Radiology can also offer a role in management of coccygeal region pain with image-guided pain management procedures such as ganglion impar block. In addition to mechanical coccyx pain, a host of other conditions involving the sacrococcygeal region may cause coccydynia, which are well depicted at imaging. These include neoplasm, infection, crystal deposition, and cystic formations such as pilonidal cyst. The authors review a variety of coccydynia causes, their respective imaging features, and common management strategies.^©RSNA, 2020.

Three-dimensional evaluation of the coccyx movement between supine and standing positions using conventional and upright computed tomography imaging

Currently, no three-dimensional reference data exist for the normal coccyx in the standing position on computed tomography (CT); however, this information could have utility for evaluating patients with coccydynia and pelvic floor dysfunction. Thus, we aimed to compare coccygeal parameters in the standing versus supine positions using upright and supine CT and evaluate the effects of sex, age, and body mass index (BMI) on coccygeal movement. Thirty-two healthy volunteers underwent both upright (standing position) and conventional (supine position) CT examinations. In the standing position, the coccyx became significantly longer and straighter, with the tip of the coccyx moving backward and downward (all p < 0.001). Additionally, the coccygeal straight length (standing/supine, 37.8 ± 7.1/35.7 ± 7.0 mm) and sacrococcygeal straight length (standing/supine, 131.7 ± 11.2/125.0 ± 10.7 mm) were significantly longer in the standing position. The sacrococcygeal angle (standing/supine, 115.0 ± 10.6/105.0 ± 12.5°) was significantly larger, while the lumbosacral angle (standing/supine, 21.1 ± 5.9/25.0 ± 4.9°) was significantly smaller. The migration length of the tip of the coccyx (mean, 7.9 mm) exhibited a moderate correlation with BMI (r = 0.42, p = 0.0163). Our results may provide important clues regarding the pathogenesis of coccydynia and pelvic floor dysfunction.

Coccydynia-A comprehensive review on etiology, radiological features and management options

Coccydynia is a disabling condition characterized by pain in the coccyx region of the spine. The first description of the disease was given in as early as 1859. Since then a number of theories have been proposed by various researchers to explain the pathogenesis of the disease. Treatment options for coccydynia include ergonomic adaptation, manual therapy, injections and surgery. Despite being identified as a disease as early as 18th century, several uncertainties with respect to the origin of pain, predisposing factors and treatment outcomes of a wide range of treatment options persist till date. The current narrative review presents various aspects of the disease including pathoanatomy, clinical presentation, radiological features and management options for the disease.

Normal Preoperative Images Do Not Indicate a Poor Outcome of Surgery for Coccydynia

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

To evaluate the long-term outcomes after surgery for refractory coccygodynia in patients with normal imaging studies compared with patients where imaging shows an anomaly.

SUMMARY OF BACKGROUND DATA

Patients with coccydynia who do not respond to conservative treatment will often profit from coccygectomy. Most surgeons employ plain radiographs or magnetic resonance imaging (MRI) in their preoperative work-up. These will often show anomalies, but in some cases they do not. We investigated whether these patients do less well than those with abnormal images.

METHODS

We operated on 184 patients with coccydynia during a 7-year period and 171 (93%) responded to follow-up questionnaires after 37 (range: 12-85) months. Images of 33 patients were normal and 138 showed some coccygeal pathology. Surgery was considered to have been unsuccessful when respondents stated at review that they were somewhat better, unchanged, or worse.

RESULTS

There were no clinically or statistically significant differences in outcome between the groups. Surgery was unsuccessful in 24% of patients with normal images and in 32% among those with abnormal images. The median pain scores (0-10) during the week before review were two (interquartile range [IQR]: 0-3) and one (IQR: 1-5) in the two groups respectively. Similar proportions in the two groups stated that they would not have consented to surgery if they had known the outcome in advance.

CONCLUSION

Patients with severe coccydynia who have not responded to conservative treatment should not be denied surgery only because their radiographs or MRI studies look normal.

LEVEL OF EVIDENCE

4.

Image-guided percutaneous mechanical disc decompression for herniated discs: a technical note

Interventional radiology plays a key role in the treatment of symptomatic herniations of intervertebral discs. Through image-guided techniques, it is possible to use minimally invasive procedures with a percutaneous approach that are usually proposed before classic surgery. Thanks to imaging guidance, it is possible to significantly increase accuracy and decrease complication rates. The pivotal principle of these mini-invasive techniques is to remove a small amount of volume of the nucleus of the intervertebral disc which results in a significant reduction in intradiscal pressure; allowing for a consequent reduction in compression of the nervous structures that generate spinal pain. However, it must be considered that this type of treatment is only addressed to contained disc herniations previously diagnosed with a suitable neuroimaging examination. There are different types of treatment using a variety of chemical, thermal or mechanical processes that result in partial removal of the nucleus pulposus. The purpose of this technical note is to illustrate mechanical disc decompression treatment via a percutaneous approach using the DISKOM device (DISKOM percutaneous discectomy probe, Biopsybell, Mirandola, Italy). Indications, complications and various methods of use are described in relation to the different levels of the spine to be treated.

MAGNETIC RESONANCE IMAGING OF PELVIC FLOOR DYSFUNCTION, REVIEW

Pelvic floor dysfunction is an important medical and social problem in the female population. The impact of pelvic floor disorders (PFD) is likely to grow as the prevalence of these disorders increases with an aging population. Pregnancy and delivery are considered major risk factors in the development of POP and stress urinary incontinence. Pelvic floor dysfunction may involve pelvic organ prolapse and/or pelvic floor relaxation. Organ prolapse can include any combination of the following: urethra (urethrocele), bladder (cystocele), or both (cystourethrocele), vaginal vault and cervix (vaginal vault prolapse), uterus (uterineprolapse), rectum (rectocele), sigmoid colon (sigmoidocele),and small bowel (enterocele).Given the paucity of understanding of PFD pathophysiology ,multicompartmental pathology, the high rate of recurrence and repeat surgery imaging plays a major role in its clinical management.The magnetic resonance imaging (MRI) allows noninvasive, radiation-free, rapid, high-resolution evaluation the multicompartment defects in one examination.Findings reported at MR imaging of the pelvic floor are valuable for selecting candidates for surgical treatment and for indicating the most appropriate surgical approach.

The coccygeal pressure ulcer-does coccygectomy prevent recurrence?

STUDY DESIGN

This is a retrospective, non-randomized cohort study, with data collected during the regular annual visits between 2001 and 2019.

OBJECTIVES

The aim of this study was to evaluate the efficacy of coccygectomy for coccygeal pressure ulcers in individuals with paraplegia due to spinal cord injury or other neurological causes and to evaluate its role in the prophylaxis of ulcer recurrence.

SETTINGS

This study included inpatients and outpatients with a coccygeal pressure ulcer who were treated surgically at our Institution REHAB Basel and were followed with regular annual check-ups.

METHODS

Individuals with category 3 or 4 acute or chronic coccygeal pressure ulcer (classification according European Pressure Ulcer Advisory Panel (EPUAP)) received coccygectomy in addition to rotation flap surgery. The operative care was provided exclusively by the head of the plastic surgery department at REHAB Basel. Standardized follow-up treatment was carried out according to the "Basel Decubitus Concept" and thus allowed continuous and usually lifelong, regular follow-up care.

RESULTS

Forty-nine individuals underwent coccygectomy from 2001 to 2019 due to coccygeal category 3 or 4 pressure ulcers. The observation period was between 1.5 and 18.3 years. In 86% of the individuals, no relapse occurred during the first year. Over the next 5 years 78% remained relapse free.

CONCLUSIONS

In coccygeal pressure ulcer category 3 or 4, coccygectomy, in addition to sufficient rotation flap surgery, is a suitable method for recurrence prevention of pressure ulcer in this anatomic area.

Magnetic resonance enterography (MRE) and ultrasonography (US) in the study of the small bowel in Crohn's disease: state of the art and review of the literature

Crohn’s disease (CD) is a chronic idiopathic disease and its diagnosis is based on a combination of clinical symptoms, laboratory tests and imaging data. There isn’t a diagnostic gold standard: the ileocolonoscopy with mucosal biopsies represents the standard for luminal disease, while cross-sectional imaging such as Ultrasound (US), Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) can show transmural alterations and extraintestinal manifestations. CD is usually diagnosed in the young age and after baseline diagnosis, the patients have to undergo to variable follow-up depending on remission or active disease. The aim of our review is to compare Magnetic Resonance Enterography (MRE) to Ultrasonography (US) in the follow-up of CD. (www.actabiomedica.it)

Influence of adequate pelvic floor muscle contraction on the movement of the coccyx during pelvic floor muscle training

[Purpose] Pelvic floor muscle training is a first-line therapy for female stress urinary incontinence. Previous studies have suggested that the coccyx tip moves ventrally and cranially during pelvic floor muscle contraction. The study aimed to elucidate the influence of adequate pelvic floor muscle contraction on coccyx movement. [Subjects and Methods] Sixty-three females (57 patients with stress urinary incontinence and additional 6 healthy volunteers) were enrolled. Using magnetic resonance imaging, coccyx movement was evaluated during pelvic floor muscle contraction and strain. An adequate contraction was defined as a contraction with good Oxford grading scale [≥3] and without inadequate muscle substitution patterns. [Results] Inadequate muscle substitution patterns were observed in 33 participants (52.4%). No significant difference was observed in the movement of the coccyx tip in the ventrodorsal direction between females with and without inadequate muscle substitution patterns. However, a significant increase in the movement of the coccyx tip in the cranial direction was detected in the group without inadequate muscle substitution patterns. Compared to participants with inadequate pelvic floor muscle contraction, those who had adequate pelvic floor muscle contraction exhibited significantly increased cranial movement of the coccyx. [Conclusion] Adequate pelvic floor muscle contraction can produce cranial movement of the coccyx tip.

Calcaneal fractures: radiological and CT evaluation and classification systems

Background and aim of the work: The calcaneus, the more lower bone of the body, has the task of supporting the axial load from the weight of the body. Calcaneal fractures represent about 1-2% of all fractures and 60% of the tarsal bones fractures. The articular involvement has been associated with a poor functional outcome. The aim of this work is to describe the radiologic evaluation, the classification systems, the morphological preoperative diagnostic imaging features of calcaneal fractures, highlighting the correlation with the choice of treatment and predictive capacity for the fracture surgical outcome. Methods: A PubMed search was performed for the terms Imaging calcaneus fracture, selecting articles in English language, published in the last two years, where preoperatively diagnostic imaging of fractures of the calcaneus are described. Case reports have not been included. Results: We have collected a number of data that provide important help in preoperative evaluation of calcaneal fractures, such as the new classification system created by Harnroongroj et al, the association of calcaneal fractures with fractures of other bone structures or soft tissue impairment, the use of calcaneotalar ratio in assessing the length of heel. Conclusions: These data suggest an approach geared to the specific choice of treatment and to improving patient outcomes. (www.actabiomedica.it)

Imaging of metabolic bone disease

Osteoporosis is the most important metabolic bone disease, with a wide distribution among the elderly. It is characterized by low bone mass and micro architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. Identify bone weakening with an appropriate and accurate use of diagnostic imaging is of critical importance in the diagnosis and follow-up of osteoporotic patients. The aim of this review is to evaluate the detection rates of the different imaging modalities in the evaluation of bone strength, in the assessment of fracture risk and in the management of fragility fractures. (www.actabiomedica.it)

Magnetic Resonance Imaging in degenerative disease of the lumbar spine: Fat Saturation technique and contrast medium

Purpose: To examine both anterior and posterior elements of the lumbar spine in patients with low back pain using MRI T2-weighted sequences with Fat Saturation (FS) and contrast enhanced T1-weighted sequences with FS.Materials and methods: Two thousand eight hundred and twenty (2820) patients (1628 male, 1192 female, mean age 54) presenting low back pain underwent MRI standard examination (Sagittal T1w TSE and T2w TSE, axial T1 SE) with the addition of sagittal and axial T2w Fat Sat (FS) sequences. Among all the patients, 987 (35%) have been studied adding Contrast Enhanced (CE) T1w FS sequences after administration of contrast medium. Results: Among 987 patients studied with contrast medium, we found: active-inflammatory intervertebral osteochondrosis in 646 (65%) patients; degenerative-inflammatory changes in facet joints (facet joint effusion, synovitis, synovial cysts) in 462 (47%); spondylolysis in 69 (7%); degenerative-inflammatory changes of the flava, interspinous and supraspinous ligaments in 245 (25%); inflammatory changes of posterior perispinal muscles in 84 (8%) patients. Conclusions: In patients with suspected no-disc-related low back pain, the implementation of T2w FS and CE T1w FS sequences to the standard MR protocol could allow a better identification of degenerative-inflammatory changes more likely associated to the pain. (www.actabiomedica.it)

Weight-bearing MRI of the knee: a review of advantages and limits

Standard knee imaging with MRI is usually performed with patient in recumbent position under non-weight-bearing conditions. Recently, magnetic resonance imaging systems to scan the knee joint under weight bearing conditions has been proposed as an approach to improve the clinical utility of musculoskeletal MRI. Imaging under loading can be useful to understand the natural motion behavior of the knee joint and to identify conditions that are challenging to diagnose by using standard position. We reviewed the literature on weight-bearing MR imaging of the knee to describe the current state of use of such MRI technologies, evaluating the advantages and the potential limitations of these technologies.

Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department

Radiography remains the imaging standard for fracture detection after trauma. The radiographic diagnosis of most fractures and dislocations poses little difficulty to radiologists: however, occasionally these injuries are quite subtle or even impossible to detect on radiographs. Missed diagnoses of fracture potentially have important consequences for patients, clinicians, and radiologists. Radiologists play a pivot role in the diagnostic assessment of the trauma patients: emergency radiologists who are more practiced at seeking out and discerning traumatic fractures can provide an invaluable service to their clinical colleagues by ensuring that patients do not endure delayed diagnoses. This is a narrative review article aims to highlight the spectrum of fractures in adults potentially missed on plain radiographs, the causes of error in diagnosis of fractures in the emergency setting and the key elements to reduce misdiagnosis of fractures. (www.actabiomedica.it)

MRI of popliteo-meniscal fasciculi of the knee: a pictorial review

The popliteomeniscal fascicules (PMFs) provide the attachment of the lateral meniscus to the popliteus musculotendinous region, forming the floor and the roof the popliteal hiatus. In the second half of 1900’s, some anatomic studies claim the important function of the PMF as stabilizers of the lateral meniscus; these anatomical structures work in conjunction with the popliteus musculotendinous unit to prevent excessive lateral meniscal movement and possible meniscus subluxation. A correct diagnosis of the PMFs pathology is crucial to establish the suitable surgical treatment for each patient. MRI is a well-established imaging technique in the musculoskeletal system and the frequency of recognition of normal PMF in the normal knees is high in almost all MRI studies. At day, the gold standard for diagnosis is the arthroscopic evaluation that allows the direct visualization of the popliteo-meniscal ligaments at popliteal hiatus and evaluation of lateral meniscal movements. For this reason if unstable condition of meniscus was suspected, arthroscopic observation with probing into the popliteo-meniscal fascicle area is essential for the identification of the fascicle tears. Despite many treatments have being proposed in literature since now there is high recurrence of knee locking after repair and it is fundamental to develop new surgical techniques in order to achieve better outcome. (www.actabiomedica.it)

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study

BACKGROUND AND AIM

The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal.

METHODS

Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment.

RESULTS

In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn't change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn't change significantly.

CONCLUSIONS

Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It's not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree.

Dynamic MRI in the evaluation of the spine: state of the art

Introduction: Degenerative disease of the spine is a generic term encompassing a wide range of different disease processes, which leads to spinal instability; traumatic/neoplastic events can accelerate this aging process. Therefore, the dynamic nature of the spine and its mobility across multiple segments is difficult to depict with any single imaging modality. Methods: A review of PubMed databases for articles published about kMRI in patients with cervical and lumbar spinal desease was performed. We focused on the physiopathological changes in the transition from supine to upright position in spine instability. Discussion: Until a few years ago, X-ray was the only imaging modality for the spine in the upright position. Of the imaging techniques currently available, MRI provides the greatest range of information and the most accurate delineation of soft-tissue and osseous structures. Conventional MRI examinations of the spine usually are performed in supine position, in functional rest, but the lumbar spine instability is often shown only by upright standing. This can result in negative findings, even in the presence of symptoms. Regardless, the final result is distorted. To overcome this limitation, Kinetic MRI (kMRI) can image patients in a weight-bearing position and in flexed and extended positions, thus revealing abnormalities that are missed by traditional MRI studies. Conclusion: Despite some limitations, the upright MRI can be a complementary investigation to the traditional methods when there are negative results in conventional MRI in symptomatic patients or when surgical therapy is scheduled. (www.actabiomedica.it)

Imaging of pediatric foot disorders

Infants and children undergo imaging studies to evaluate a wide variety of congenital and acquired disorders. Imaging protocols have to consider the patient’s comfort, level of anxiety, and smaller size. The first imaging study is usually made with plain radiographs. The routine radiographic examination of the foot includes the anteroposterior (AP), lateral, and oblique projections. Magnetic Resonance Imaging (RMI) provides excellent anatomic detail of cartilage, vasculature and soft tissue thanks to superior soft tissue contrast and spatial resolution, so is valuable in many cases. According to the clinical and objective signs, guided by the radiographs images, we can be oriented to perform Computed Tomography (CT), CT imaging or MRI imaging. CT imaging is useful to observe the bones but it has the disadvantage of using radiation and doesn’t adequately define the bone’s non-ossified portions. On the contrary, MRI imaging is very useful in identifying the cartilaginous parts and vascular and soft tissues, thanks to its superior contrast and spatial resolution. Finally, it is important to orientate the diagnostic process keeping in mind the clinical sign of the patient and to use the most appropriate diagnostic technique. (www.actabiomedica.it)

Magnetic Resonance Imaging correlates of benign and malignant alterations of the spinal bone marrow

Background and aim of the work: Bone marrow (BM) abnormalities in the spine are a common, sometimes unexpected, finding on Magnetic Resonance Imaging (MRI), which is the most sensitive imaging modality to evaluate the marrow, and their interpretation can be difficult for the unexperienced radiologist. In this review, the MRI appearance of normal age-related BM changes, as well as the imaging features of benign and malignant diseases, are presented. Discussion: A large variety of BM signal alterations has been identified and described, including normal variants, BM reconversion, degenerative changes, infections, spondyloarthritis and osteonecrosis, trauma, neoplastic lesions (both primary or metastatic), post-radiation and chemotherapy sequelae. Conclusions: Knowledge of normal age-related BM appearance, normal variants and patterns of involvement in focal and diffuse bone diseases is essential, together with clinical and laboratory data, to narrow the list of the possible differential diagnoses. The radiologist should be familiar with these signal changes, as they can sometimes be discovered incidentally. In this context, it is equally important not to attribute pathological significance to benign alterations and to promptly detect signs of malignant diseases. (www.actabiomedica.it)

Magnetic resonance imaging of pelvic floor dysfunction - joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group

OBJECTIVE

To develop recommendations that can be used as guidance for standardized approach regarding indications, patient preparation, sequences acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for diagnosis and grading of pelvic floor dysfunction (PFD).

METHODS

The technique included critical literature between 1993 and 2013 and expert consensus about MRI protocols by the pelvic floor-imaging working group of the European Society of Urogenital Radiology (ESUR) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) from one Egyptian and seven European institutions. Data collection and analysis were achieved in 5 consecutive steps. Eighty-two items were scored to be eligible for further analysis and scaling. Agreement of at least 80 % was defined as consensus finding.

RESULTS

Consensus was reached for 88 % of 82 items. Recommended reporting template should include two main sections for measurements and grading. The pubococcygeal line (PCL) is recommended as the reference line to measure pelvic organ prolapse. The recommended grading scheme is the "Rule of three" for Pelvic Organ Prolapse (POP), while a rectocele and ARJ descent each has its specific grading system.

CONCLUSION

This literature review and expert consensus recommendations can be used as guidance for MR imaging and reporting of PFD.

KEY POINTS

• These recommendations highlight the most important prerequisites to obtain a diagnostic PFD-MRI. • Static, dynamic and evacuation sequences should be generally performed for PFD evaluation. • The recommendations were constructed through consensus among 13 radiologists from 8 institutions.

MR Imaging in Diagnosis of Pelvic Floor Descent: Supine versus Sitting Position

Introduction. Functional disorders of the pelvic floor represent have a significant impact on the quality of life. The advent of open-configuration systems allowed for the evaluation of defecation with MR imaging in sitting position. The purpose of the present study is to compare the results of static and dynamic pelvic MR performed in supine position versus sitting position, using a new MR prototype machine, in the diagnosis of pelvic floor descent. Materials and Methods. Thirty-one patients with pelvic floor disorders were enrolled, and underwent MR Defecography in supine position with 1.5 T closed magnet (MAGNETOM Symphony, Siemens, Germany) and in sitting position with a 0.25-Tesla open magnet system (G-Scan ESAOTE, Italy). Results. In rest and squeezing phases, positions of bladder, vagina, and ARJ were significantly different when the patient was imaged in supine versus sitting position. In the defecation phase, a significant difference for the bladder and vagina position was detected between the two exams whereas a significant difference for the ARJ was not found. A statistically significant difference exists when the pelvic floor descent is evaluated in sitting versus supine position. Conclusion. Our results show that MR Defecography in sitting position may represent a useful tool to correctly diagnose and grade the pelvic organ descent.

Computed tomography-based morphologic and morphometric features of the coccyx among Arab adults

STUDY DESIGN

Cross-sectional, retrospective.

OBJECTIVE

To identify morphological and morphometric features of the coccyx among adult Arabs.

SUMMARY OF BACKGROUND DATA

Different sacrococcygeal morphologic features were found to be associated with coccydynia.

METHODS

Review of 202 computed tomographic scans of adult Arab subjects was done (mean age: 47.98 ± 16.46 yr). Sacrococcygeal morphological features including number of coccygeal segments, type of coccyx, joint fusion, joint subluxation, coccygeal spicule, coccygeal sacralization, ventral angulation of the terminal sacral segment (S5), and lateral deviation of coccygeal tip were recorded. Moreover, morphometric measurements including lengths and angles of the sacrococcygeal region were measured. Analysis of data was carried out using P value of less than 0.05 as the cutoff level of significance.

RESULTS

Three coccygeal segments were present in 138 (68.3%) of individuals. The majority of the subjects had coccyx type I (96; 47.5%), II (70; 34.7%), or III (31; 15.3%); type I being more common among males (P = 0.004). Bony spicule was present in 109 (54.0%) individuals. Joint fusion, joint subluxation, coccygeal sacralization, ventral angulation of S5, and lateral deviation of coccygeal tip were present in 38.6%, 31.7%, 34.2%, 38.1%, and 38.6% of the subjects, respectively. Joint subluxation and ventral angulation of S5 were more significantly present among females (P = 0.015, P = 0.014, respectively). The mean straight and curved lengths of the coccyx were 3.3 ± 0.7 cm and 3.7 ± 0.8 cm, respectively. The sacrococcygeal structures were longer in males than in females. The mean sacrococcygeal joint angle was 149.2°± 28.1°. Based on the morphometric measurements, the coccyx was more ventrally angulated among females.

CONCLUSION

The coccygeal morphology and morphometry of Arab adults share some similarities and differences with individuals of other ethnic backgrounds. Future studies should investigate the relation between these anatomic features with coccydynia among this population.

LEVEL OF EVIDENCE

3.

Magnetic resonance imaging of pelvic floor disorders

Physical examination alone is often inadequate for evaluation of pelvic floor dysfunction. Magnetic resonance imaging (MRI) is a robust modality that can provide high-quality anatomic and functional evaluation of the pelvic floor. Although lack of standardized technique and radiologist inexperience may be relative deterrents in universal acceptance of pelvic floor MRI, the role of MRI is increasing as it is technically feasible on most magnets and offers some advantages over the traditional fluoroscopic defecography. This review focuses on the technical and interpretational aspects of anatomic and functional pelvic floor MRI.

Clinical decision making for the evaluation and management of coccydynia: 2 case reports

STUDY DESIGN

Case report.

BACKGROUND

Coccydynia is a painful condition of the sacrococcygeal region, with symptoms associated with sitting and rising from a seated position. There is no gold standard for diagnosis of this condition; however, coccyx mobility assessment, pain provocation testing, and imaging have been proposed as reasonable diagnostic approaches. Once correctly diagnosed, treatment options for coccydynia include conservative management and surgical excision. The purpose of this report is to describe the different but successful clinical management strategies of 2 patients with coccydynia.

CASE DESCRIPTION

Two women, 26 and 31 years of age, presented to physical therapy with persistent coccygeal pain that increased with prolonged sitting and intensified when transitioning from sit to stand. One patient had a traumatic onset of symptoms, in contrast to the other patient, for whom prolonged sitting was the precipitating factor. Both individuals were considered to have hypomobility of the sacrococcygeal joint, as assessed through intrarectal mobility testing, which also reproduced their symptoms. In both patients, examination of the lumbar spine was negative for alleviation or reproduction of symptoms. The patient with a traumatic onset of symptoms was referred to physical therapy at the onset of her symptoms, whereas the patient with a nontraumatic onset of symptoms was initially treated with a cortisone injection and, when symptoms returned 1 year later, was referred to physical therapy. Both individuals underwent manual therapy to the sacrococcygeal joint over 3 treatment sessions.

OUTCOMES

The patient with traumatic onset of symptoms had almost complete resolution of symptoms, whereas the patient with a nontraumatic onset only had temporary relief. This patient required further diagnostic examination and surgical excision.

DISCUSSION

Although the mechanisms of injury were different, both patients presented with similar clinical symptoms, and both were considered to have coccydynia through coccyx mobility assessment and pain provocation testing. Successful clinical outcomes were achieved in both cases; however, the interventions were significantly different. Level of Evidence Therapy, level 4.

MRI findings before and after prolapse surgery

BACKGROUND

Therapeutical outcome after prolapse surgery is evaluated using a standardized grading system based on maximum prolapse extent, which might not provide the full picture of the patient's subjective outcome. We therefore applied an evaluation method, which is detached from a grading system.

PURPOSE

To evaluate the impact of pelvic organ mobility in dynamic magnetic resonance imaging (MRI) before and after mesh-repair surgery in patients with symptomatic pelvic organ prolapse.

MATERIAL AND METHODS

To obtain measurements, we performed parasagittal T2-weighted turbo spin echo sequence at rest (TR, 3460 ms; TE, 85 ms; matrix, 512; slice thickness [ST], 5 mm), parasagittal T2-weighted true fast imaging with steady-state precession (TrueFISP) single-shot sequence during straining (TR, 397.4 ms; TE, 1.5 ms; matrix, 256; ST, 8 mm), and parasagittal T2-weighted TrueFISP sequence at maximum strain (TR, 4.3 ms; TE, 2.15 ms; matrix, 256; ST, 5 mm) at 1.5 T MRI. Pelvic organ prolapse (anatomical landmarks: bladder, cervix, pouch, rectum) was measured perpendicularly with reference to the pubococcygeal and the midpubic line. Pelvic organ mobility was defined as the difference between the measured distance at rest and at maximum strain for each anatomical landmark. All patients underwent mesh-repair procedure. Eighty patients could be included in this short-term follow-up study. Due to the physical diagnosis of pelvic organ prolapse, 51 underwent anterior mesh repair, 16 underwent posterior mesh repair, and 13 underwent total mesh repair. Surgery was performed by one surgeon, using mesh implants from several manufacturers.

RESULTS

Median values of maximum organ prolapse for bladder, cervix, pouch, and rectum preoperatively were 2.54 cm, 0.33 cm, 2.47 cm, and 0.32 cm, respectively, and 12 weeks postoperatively 0.87 cm, -1.79 cm, 1.49 cm, and 0.49 cm, respectively. Highly significant improvement (P < 0.001) of pelvic organ mobility was observed in the treated compartment at 4- and 12-week follow-up. Physical evaluation 12 weeks after mesh-repair showed an asymptomatic POP-Q stage I, if any.

CONCLUSION

Dynamic MRI is useful in visualizing the maximum extent of pelvic organ prolapse, as the evaluation of pelvic organ mobility documents the intraindividual therapeutic outcome detached from a grading system based on maximal prolapse values.

The anatomy of the sacrococcygeal cornual region and its clinical relevance

There has been no systematic study of the anatomy of the region between the sacral and coccygeal cornua. Reference texts describe an intercornual ligament connecting these structures. The aim of this study was to investigate the anatomy of this region, which may be relevant to unexplained cases of coccygeal pain (coccydynia) and local nerve blocks. The bony anatomy of the sacrococcygeal (SC) cornual region was analyzed in 33 CT scans obtained from supine adults of mostly European origin with no known SC pathology, 7 μCT scans of cadaver SC specimens, and 105 Asian Indian adult skeletons. A further five cadaver SC specimens were examined histologically. SC cornual fusion was seen in 45% of CT/μCT scans (mean age 67 years, 20 males) and in 20% of adult skeletons (78 males); there was no association with age or sex. In the absence of SC fusion, the mean intersacrococcygeal cornual gap was 7.1 ± 2.4 mm; this was bridged by an intercornual ligament composed of parallel vertical collagen fibers reinforced by elastin fibers on its anterior surface. Small nerve branches were observed adjacent to the ventral aspect of the intercornual ligament and, in one case, traversing the ligament. Ipsilateral sacral and coccygeal cornua are therefore normally bridged by an intercornual ligament that is probably innervated. The cornua are fused on one or both sides in 20-45% of adults. These findings may have implications for some cases of coccydynia and for anesthetists performing local nerve blocks.

Acute traumatic instability of the coccyx: results in 28 consecutive coccygectomies

INTRODUCTION

Coccygeal instability includes hypermobility, subluxation and fracture-dislocation. Surgical resection is still controversial, with intractable post-traumatic coccygodynia being an indication to surgery.

MATERIALS AND METHODS

From 2001 to 2010, we enrolled 31 patients with post-traumatic coccygodynia (19 females, 12 males; mean age 31 years, range 21-47). Conservative treatment failed in 28 patients, who underwent surgical resection of the coccyx. Twenty-one were total, while seven were partial coccygectomies. At follow-up (mean 33 months; range 24-70), clinical outcomes evaluation included measurement of complications rate, pain relief and satisfaction degree.

RESULTS

Nineteen patients experienced complete pain relief, while two had incomplete, and four had no relief. Partial coccygectomies were associated with poor results. Twenty-one patients were satisfied, whilst four were not.

CONCLUSIONS

Coccygectomy is the treatment of choice for post-traumatic instability. Patients' selection allowed excellent or good results. This study favors a more aggressive approach including total resection of the coccyx.

Role of conventional radiology and MRi defecography of pelvic floor hernias

Background

Purpose of the study is to define the role of conventional radiology and MRI in the evaluation of pelvic floor hernias in female pelvic floor disorders.

Methods

A MEDLINE and PubMed search was performed for journals before March 2013 with MeSH major terms 'MR Defecography' and 'pelvic floor hernias'.

Results

The prevalence of pelvic floor hernias at conventional radiology was higher if compared with that at MRI. Concerning the hernia content, there were significantly more enteroceles and sigmoidoceles on conventional radiology than on MRI, whereas, in relation to the hernia development modalities, the prevalence of elytroceles, edroceles, and Douglas' hernias at conventional radiology was significantly higher than that at MRI.

Conclusions

MRI shows lower sensitivity than conventional radiology in the detection of pelvic floor hernias development. The less-invasive MRI may have a role in a better evaluation of the entire pelvic anatomy and pelvic organ interaction especially in patients with multicompartmental defects, planned for surgery.

Imaging assessment of groin pain

Groin pain is a common condition in athletes, especially those who play certain sports, for instance soccer, ice hockey, fencing which request rapid acceleration and frequent changes of movement. This condition represents a diagnostic difficulty for the radiologist due to either the anatomical pubic region complexity than the many causes that can be a source of pain, because the groin pain can be determined by conditions affecting the bony structures, cartilage and muscle tendons that are part of the proper pubis but also from those involving the hip. The approach to the groin through diagnostic imaging is multidisciplinary: The study of the patient is performed by traditional radiographs, ultrasound examination, magnetic resonance imaging or computed tomography, based on clinical suspicion, and each of these methods provides different results depending on the disease in question. The purpose of this article is to examine what are the optimal imaging techniques to investigate the various diseases affecting the patient with groin pain.

Ankle fracture: radiographic approach according to the Lauge-Hansen classification

Ankle fractures account for 9 % of fractures (Clare in Foot Ankle Clin 13(4):593-610, 1) representing a significant portion of the trauma workload; proximal femoral fractures are the only lower limb fracture to present more frequently. Ankle fractures have a bimodal age distribution with peaks in younger males and older females (Arimoto and Forrester in AJR Am J Roentgenol 135(5):1057-1063, 2). There has been threefold increase in the incidence among elderly females over the past three decades (Haraguchi and Armiger in J Bone Joint Surg Am 91(4):821-829, 3). In 1950, Lauge-Hansen devised a classification of ankle fractures based on the position of the foot and the deforming force at the time of injury. This has been widely accepted by orthopedists, but is not in general use by radiologists. Identification of the fractures and classification of the type of injury allows diagnosis of the otherwise occult ligamentous injuries. Three radiographic views of the ankle (anteroposterior, mortise, and lateral) are necessary to classify an injury with the Lauge-Hansen system. Two additional criteria are also necessary: the position of the foot at the time of injury and the direction of the deforming force.

Atraumatic vertebral compression fractures: differential diagnosis between benign osteoporotic and malignant fractures by MRI

Atraumatic vertebral compression fractures are a common clinical problem, especially in elderly population. Metastases are the most frequent source of bone tumors, and the spine is a common site of metastatic disease; in case of cortical involvement or osteolysis, they may result in pathological compression fractures. Atraumatic compression fractures may result from other primary neoplasms of vertebrae and also from osteomyelitis, Paget's disease, hyperparathyroidism and other metabolic processes. Osteoporosis is a common source of vertebral compression fractures in elderly population, which may be indistinguishable from those of metastatic origin. The differentiation between osteoporotic compression fractures and malignant fracture is necessary to establish an appropriate staging and a therapeutic planning, especially in the acute and subacute stages. Anamnestic data about preexisting disease can be useful to individuate the potential cause of vertebral collapse. Plain radiography shows some difficulties in distinguishing whether the fracture represents a consequence of osteoporosis, a metastatic lesion or some other primary bone neoplasm. Computed tomography is one of the most suitable imaging techniques for the evaluation of bone structure and fragments and to establish the degree of cortical bone destruction; MR imaging (MRI) is the most helpful radiological investigation in order to provide the basis for the distinction between metastatic and acute osteoporotic compression fractures. The most relevant MRI findings to establish a differential diagnosis are described.

Rehabilitation and surgical management of ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease which, if untreated, may progress to severe damage of the spine with functional impairment, disability and poor quality of life. An increased mortality has been reported in AS patients compared to the general population. AS requires combined management (pharmacological and non-pharmacological) and advice by different health professionals. Even the pharmacological treatment in the last decade has dramatically changed the outcome, the severity of the disease might require a surgical approach for the hip involvement with total hip replacement, or the corrective spinal surgery. However, this surgery deserves some careful approaches since the complexity of the disease. Rehabilitation still represents a cornerstone of the global management of AS patients. The present review summarizes the state of art of surgical management of these two diseases.

Femoroacetabular impingement: role of imaging

The femoroacetabular impingement (FAI) is an impingement characterized by repetitive abutment between the femur and the acetabular rim during hip motion due to loss of joint clearance (Imam and Khanduja in Int Orthop 35(10):1427-1435, 2011; James et al. in AJR Am J Roentgenol 187(6):1412-1419, 2006). Femoroacetabular impingement (FAI) can be classified as either cam or pincer type, and it can be differentiated on the basis of a predominance of either a femoral or an acetabular abnormality (Pfirrmann et al. in Radiology 244(2):626, 2007; Ganz et al. in Clin Orthop Relat Res 466(2):264-272, 2008). In cases of cam FAI, the nonspherical shape of the femoral head at the femoral head-neck junction and reduced depth of the femoral waist lead to abutment of the femoral head-neck junction against the acetabular rim. In cases of pincer FAI, acetabular overcoverage limits the range of motion and leads to a conflict between the acetabulum and the femur. The most important role of preoperative MR evaluation in patients affected by FAI is the accurate assessment of the damage's extension.

CT morphology and morphometry of the normal adult coccyx

PURPOSE

Lack of data on the in vivo morphology and morphometry of the normal adult coccyx hampers understanding of radiological abnormalities in idiopathic coccydynia. The aim of this study was to investigate normal adult sacrococcygeal morphometry.

METHODS

Retrospective analysis of 112 adult CT scans (mean age 63 ± 14.6 years, 50 males) evaluated the following: number of coccygeal segments; joint fusion; coccygeal spicules, subluxation, sacralization, and scoliosis; sacrococcygeal straight and curved lengths and curvature indices; sacrococcygeal and intercoccygeal angles; and lateral deviation of the coccyx tip.

RESULTS

Four coccygeal segments were present in 76 % of scans. Sacrococcygeal fusion was present in 57 % and intercoccygeal fusion was increasingly common more caudally; there was no significant association with age or gender. A bony spicule was present in 23 %. Subluxation was rare. Nine of 12 coccyges with a retroverted tip were female. Mean coccygeal curved length was 4.4 ± 0.8 cm in men and 4.0 ± 0.8 cm in women (P < 0.01). Mean angle between first and last coccygeal segments was 138° ± 25° in men and 147° ± 25° in women (P = 0.08). There was no significant correlation between coccygeal length or curvature and stature, age or BMI.

CONCLUSIONS

In this first detailed study of the CT morphology and morphometry of the adult coccyx, sacrococcygeal and intercoccygeal joint fusion was common. Female coccyges were shorter, straighter, and may be more prone to retroversion, factors that may be relevant to the markedly higher prevalence of idiopathic coccydynia in women.

Semi-automated vectorial analysis of anorectal motion by magnetic resonance defecography in healthy subjects and fecal incontinence

BACKGROUND

Inter-observer variability limits the reproducibility of pelvic floor motion measured by magnetic resonance imaging (MRI). Our aim was to develop a semi-automated program measuring pelvic floor motion in a reproducible and refined manner.

METHODS

Pelvic floor anatomy and motion during voluntary contraction (squeeze) and rectal evacuation were assessed by MRI in 64 women with fecal incontinence (FI) and 64 age-matched controls. A radiologist measured anorectal angles and anorectal junction motion. A semi-automated program did the same and also dissected anorectal motion into perpendicular vectors representing the puborectalis and other pelvic floor muscles, assessed the pubococcygeal angle, and evaluated pelvic rotation.

KEY RESULTS

Manual and semi-automated measurements of anorectal junction motion (r = 0.70; P < 0.0001) during squeeze and evacuation were correlated, as were anorectal angles at rest, squeeze, and evacuation; angle change during squeeze or evacuation was less so. Semi-automated measurements of anorectal and pelvic bony motion were also reproducible within subjects. During squeeze, puborectalis injury was associated (P ≤ 0.01) with smaller puborectalis but not pelvic floor motion vectors, reflecting impaired puborectalis function. The pubococcygeal angle, reflecting posterior pelvic floor motion, was smaller during squeeze and larger during evacuation. However, pubococcygeal angles and pelvic rotation during squeeze and evacuation did not differ significantly between FI and controls.

CONCLUSION & INFERENCES

This semi-automated program provides a reproducible, efficient, and refined analysis of pelvic floor motion by MRI. Puborectalis injury is independently associated with impaired motion of puborectalis, not other pelvic floor muscles in controls and women with FI.

Dynamic MRI defecography vs. entero-colpo-cysto-defecography in the evaluation of midline pelvic floor hernias in female pelvic floor disorders

PURPOSE

The aim of this study was to compare the diagnostic efficacy of dynamic MR defecography (MR-D) with entero-colpo-cysto-defecography (ECCD) in the assessment of midline pelvic floor hernias (MPH) in female pelvic floor disorders.

METHODS

From August 2004 to August 2010, 3,006 female patients who required ECCD for the evaluation of pelvic floor disorders were enrolled in this study. All the 1,160 patients with ECCD findings of MPH were asked to undergo MR-D; 1,142 accepted to undergo MR-D and constituted the object of analysis. This study was approved by the Institutional Ethical Committee. All the patients gave their written informed consent to take part in the study.

RESULTS

Overall, the prevalence of MPH at ECCD was higher if compared with that at MR-D. Concerning the hernia content, there were significantly more enteroceles and sigmoidoceles on ECCD than on MR-D, whereas, in relation to the hernia development modalities, the prevalence of elytroceles, edroceles, and Douglas' hernias at ECCD was significantly higher than that at MR-D. In spite of a 100% specificity, the sensibility of MR-D in the detection of an omentocele, sigmoidocele, and enterocele was, respectively, 95%, 82%, and 65%, showing an inferior diagnostic capacity if compared with that of ECCD.

CONCLUSION

MR-D shows lower sensitivity than ECCD in the detection of MPH development. The less-invasive MR-D may have a role in a better evaluation of the entire pelvic anatomy and pelvic organ interaction especially in patients with multicompartmental defects, planned for surgery.

Fusion of coccyx to sacrum in humans: prevalence, correlates, and effect on pelvic size, with obstetrical and evolutionary implications

Humans do not have a tail, but we have four rudimentary coccygeal vertebrae. This study considers several issues pertaining to fusion of the coccyx to the sacrum, including prevalence, sexual differences, effect on pelvic size, and obstetrical and evolutionary implications. Previous research on sacral-coccygeal fusion has reported: (1) lower prevalence in females than males, (2) prevalence increases with age, (3) range in prevalence among 13 samples from 0 to 72%, and (4) obstetrical complications. This study uses a sample of 2,354 American skeletons of known sex, age 20 years and older to ascertain prevalence of sacral-coccygeal fusion and to evaluate some of its correlates. Results show that the sexes do not differ in prevalence of sacral-coccygeal fusion for five of seven decades of life, but that prevalence does increase with advancing age-from 24 to 47% from the third to eighth decades of life in females. Pelvimetric analysis of 132 females shows that those with sacral-coccygeal fusion have a shorter posterior sagittal diameter of the outlet compared to those without fusion; more than half of those with sacral-coccygeal fusion have an obstetrically contracted posterior sagittal diameter. Shortening of the posterior sagittal diameter is important, because its conjoint occurrence with a narrow subpubic arch may result in an obstetrically inadequate outlet. This study concludes that sacral-coccygeal fusion is a principal contributor to the evolution of sexual dimorphism in sacral angulation, which is a determinant of the length of the posterior sagittal diameter of the outlet.

Surgical treatment of coccygodynia: an analytic review of the literature

Coccygodynia is a pathological condition associated with pain-discomfort all around the bottom end of the spine. The aetiology and the intensity of the symptoms may defer significantly. The effectiveness of the surgical treatment remains obscure. Our purpose, through this systematic review is to evaluate the results of surgical treatment of coccygectomy. Literature retrieval was performed by the use of the PubMed searching engine utilising the terms 'coccygodynia-coccygectomy' in the English language from January 1980 to January 2010. Case reports and tumour related case series were excluded as well as articles published in other languages. In total 24 manuscripts were analyzed. Only 2 of them were prospective studies whereas 22 were retrospective case series; five were classified as Level III studies and the remaining as Level IV studies. In total, 671 patients with coccygodynia underwent coccygectomy following failed conservative management. The sex ratio, male/female was 1:4.4. The most popular aetiology for coccygodynia was direct trauma in 270 patients. 504 of the patients reported an excellent/good outcome following the procedure. There were 9 deep and 47 superficial infections. Other complications included two haematomas, six delayed wound healings and nine wound dehiscence. The overall complication rate was 11%. Patients with history of spinal or rectal disorders, as well as idiopathic or with compensation issues, had less predictable outcome than those with history of trauma or childbirth. Coccygectomy can provide pain relief to as high as 85% of the cases. The most common reported complication was wound infection.

Coccydynia

Coccydynia is a painful disorder characterised by coccygeal pain which is typically exaggerated by pressure. It remains an unsolved mystery because of the perceived unpredictability of the origin of the pain, some psychological traits that may be associated with the disorder, the presence of diverse treatment options, and varied outcomes. A more detailed classification based on the aetiology and pathoanatomy of coccydynia helps to identify patients who may benefit from conservative and surgical management.

This review focuses on the pathoanatomy, aetiology, clinical features, radiology, treatment and outcome of coccydynia.

Coccygectomy: an effective treatment option for chronic coccydynia: retrospective results in 41 consecutive patients

Between 1993 and 2008, 41 patients underwent total coccygectomy for coccydynia which had failed to respond to six months of conservative management. Of these, 40 patients were available for clinical review and 39 completed a questionnaire giving their evaluation of the effect of the operation. Excellent or good results were obtained in 33 of the 41 patients, comprising 18 of the 21 patients with coccydynia due to trauma, five of the eight patients with symptoms following childbirth and ten of 12 idiopathic onset. In eight patients the results were moderate or poor, although none described worse pain after the operation. The only post-operative complication was superficial wound infection which occurred in five patients and which settled fully with antibiotic treatment. One patient required re-operation for excision of the distal cornua of the sacrum. Total coccygectomy offered satisfactory relief of pain in the majority of patients regardless of the cause of their symptoms.

Whole-spine dynamic magnetic resonance study of contortionists: anatomy and pathology

OBJECT

Whole-spine magnetic resonance (MR) images were obtained using a cylindrical 3-T MR imaging system in 5 contortionists to assess the pathological changes possibly associated with the practice of contortion. Whole-spine dynamic MR images were obtained using a 1-T open MR imaging system in 2 of these contortionists with the purpose of defining the range of motion (ROM) achieved during extreme contortion. The range of spinal motion in this unique population was then quantified.

METHODS

The study included 5 female contortionists 20-49 years of age. Imaging was performed using open 1-T and cylindrical 3-T high-field MR imaging systems. Data were viewed and analyzed with DICOM-compliant tools. Real-time, dynamic, and standard MR imaging allowed for quantification of the contortionists' ROM.

RESULTS

There was a difference of 238 degrees between full spinal extension and full flexion. Three of the 5 contortionists had 4 anterosuperior limbus vertebrae at T-11 and the upper lumbar levels.

CONCLUSIONS

Whole-spine dynamic MR imaging is a valuable tool for the evaluation of the extreme ROM in contortionists, allowing for the quantification of extreme mobility. The limbus fractures present in 3 of the 5 contortionists is postulated to be due to avulsion on hyperextension. Future research may open the use of whole-spine dynamic MR imaging into such areas as pain management and traumatic spinal injuries.