The crowned dens syndrome. Evaluation with CT imaging

PURPOSE

The purpose of this study was to verify the value of computed tomography (CT) in the diagnosis of the "crowned dens" syndrome, not only in crystal deposition diseases, but also in other rheumatic or nonrheumatic conditions.

MATERIALS AND METHODS

Thirty-eight patients (15 men and 23 women; mean age 55 years; age range 35-79) with neck pain were examined and divided into two groups: (1) patients already identified as rheumatic and referred for further investigation of the atlantoaxial region; (2) patients with symptoms confined to the cervical spine, with inconclusive radiographic findings. Unenhanced CT of the cervical spine (Tomoscan SR 7000 Philips, Eindhoven, Netherlands) was performed in all patients. There were 11 cases of rheumatoid arthritis (ten women and one man), two calcium pyrophosphate dihydrate crystal deposition disease (both women), one of systemic sclerosis (a woman), one of osteoarthritis (a man), one of seronegative arthritis (a man), four of neoplasm (one woman and three men) with suspected cervical involvement, one (a man) of haematological disease (lymphoma), one (a woman) of menopausal osteoporosis, ten (five men and five women) of recent or previous trauma with suspected involvement of the skull base and first cervical vertebrae and six of unknown painful cervical dysfunction (three men and three women).

RESULTS

CT demonstrated calcific deposits around the dens in 12 patients (three men and nine women), in the transverse and alar ligaments, and in the anterior atlantooccipital membrane. CT revealed horseshoe- or crown-like calcification surrounding the odontoid process. In our series, other rheumatic diseases, especially rheumatoid arthritis, showed similar irregular calcifications of the atlantoaxial joint. Discussion. In calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, the spine may be the only site of involvement, generally asymptomatic. Crystals located in the transverse ligament of the atlas give rise to the crowned dens syndrome, usually in patients affected by severe degenerative lesions of the atlantoaxial joint and peripheral chondrocalcinosis. Symptoms may be absent, or a neurological compressive syndrome may develop. Symptoms tend to worsen with age. The diagnosis is not always easy, as the symptoms are similar to those of other diseases, such as meningitis, cervicobrachial pain, occipitotemporal headache, calcific tendinitis of the longus colli muscle, spondylodiscitis and retropharyngeal abscess.

CONCLUSION

CT is the gold standard in identifying crowned dens syndrome, as it is able to depict the shape and site of calcification and any bone erosions. Radiography of other joints (wrist, knee, pubic symphysis) may help to ascertain whether the disease is due to calcium pyrophosphate dihydrate or hydroxyapatite crystals, and is therefore recommended for routine patient management. Magnetic resonance imaging (MRI) is indicated for the study of neurological complications.

The value of computed tomography in the diagnosis of low back pain. A review of 2,012 cases

AIM

The aim of this study was to establish the effective role of CT in the diagnosis of low back pain, and whether CT features correlate with clinical signs and symptoms.

METHODS

Two thousand and twelve consecutive patients, of which 866 males and 1,146 females, aged 22 to 91 years, affected by generic painful back, have been studied in the period between January 2000 and October 2002. Volumetric CT of the lumbo-sacral column was performed on all the patients, employing a Philips Tomoscan SR 7000 (Eindhoven, The Netherlands). Sections of 3 mm in thickness were obtained, employing window and level of window both for bone and soft tissues. Contrast medium was not injected.

RESULTS

Regarding the distribution of lesions, 172 males were affected by one, 586 from 2 to 4, 102 more than 4 lesions; 6 subjects were without. On the contrary, 196 females had a single lesion, 611 from 2 to 4, 331 more than 4 and 8 did not have any one. In females, the age group most involved is encompassed between 51 and 80 years; the more frequent alterations, in decreasing order, were: bulging disc, synovial facet syndrome, disc herniation and vacuum phenomenon. In males incidence age related and frequency of various pathologies were overlapped to that observed in females; however the incidence of disc herniation in males is greatest between 41 to 50 years.

CONCLUSIONS

Low back pain, with or without radiation to the sciatic and femoral nerves, is one of the most common diseases, involving approximately 2/3 of the adult population sooner or later in life. Anatomically the center of pain is the lumbar column (from L3 to L5), the lumbo-sacral junction, the sacrum, the sacro-iliac joints, and the sacral-coccygeal region. Generally, it is a benign syndrome; however, since a pathologic condition is recognized in 15% of cases, then this condition must always be diagnosed. The list of events producing lumbar pain seems to be endless: therefore differential diagnosis must be based on appropriate anatomic and etiologic factors, also considering that pathogenesis (due to mechanical, compression, inflammatory, and neuropathic factors) is directly influenced by social and psychologic factors. Initially a conventional X-ray was used for the diagnosis of images, subsequently, arthrography and myelography were used; today CT is useful in the detection of bone and soft tissue structures, especially using multiplanar reformatted images. It is a noninvasive procedure that usually reveals the cause of radicular compression and demonstrates lateral and intraforaminal pathologic condition well. MRI represents the last technical development. The characteristics of all these techniques are such as to achieve a full diagnosis. Their reconciled use is in relation to the current clinical question, and it also depends on various considerations, not only technical matters, but availability of equipment and costs too, even if conventional radiography must always precede every other survey.

[Metastatic bone disease. Strategies for imaging]

Skeletal metastases represent the most common malignant bone tumor. They occur mainly in adults and even more frequently in the elderly. The most common metastases in men are from prostate cancer (60%) and in women from breast cancer (70%). Other primitive tumors responsible for bone metastases are: lung, kidney, thyroid, alimentary tract, bladder, and skin. The spine and pelvis are the most common metastatic sites, due to the presence of red (haematopoietic active) bone marrow in a high amount. As a general rule, the radiographic pattern was lytic type; other aspects were osteosclerotic, mixed, lytic vs mixed and osteosclerotic vs lytic patterns. The main symptom is pain, although many bone metastases are asymptomatic. The most severe consequences are pathologic fractures and cord compression. Clinical evaluation of patients with skeletal metastases needs multimodal diagnostic imaging, able to detect lesions, to assess their extension and localization, and eventually drive the biopsy (for histo-morphological diagnosis). These techniques give different performances in terms of sensitivity and specificity; but none of the modalities alone seems to be adequate to yield a reliable diagnostic outcome. Therefore multidisciplinary cooperation is required to optimize the screening, clinical management and follow-up of the patients. In other terms, what is the efficacy of these new diagnostic tests compared to the "older" diagnostic tests? Frequently the new procedures do not replace the older one, but it is added to the diagnostic workup, thereby increasing costs without impacting the "patient's condition". The aim of the present work is to propose an "algorithm" for the detection and diagnosis of skeletal metastases, which may be applied differently in symptomatic and asymptomatic oncologic patients. Bone scintigraphy remains the first choice technique in the evaluation of asymptomatic patients, in whom skeletal metastases are supposed. Although it has a high sensitivity, scintigraphy is unspecific. So that a negative scan response has to be re-evaluated with other methods: if clinical status remains "negative", the diagnostic route can stop. On the contrary, in patients with "positive" scan or with local symptoms and pain, the screening of metastatic lesions must be accomplished by a combination of radiography and CT: the result may be negative (for low sensitivity of conventional radiology), not conclusive (in this case bone biopsy is necessary) or symptoms are not due to metastatic lesions (i.e., osteoarthritis). CT represents an excellent mean of defining the extent of any metastatic lesions, especially those located at sites difficult to evaluate (vertebral column and pelvis). Before bone biopsy is carried out, MRI must be performed, because it is the only technique that makes it possible to distinguish between bone marrow components. It has been used most extensively in the evaluation of spine metastases. The limitation of MRI is the unspecificity of its findings, which may lead to an equivocal diagnosis, and because only part of the skeleton can be studied.

[Diagnostic imaging of bone metastases]

PURPOSE

To present an "algorithm" for detection and diagnosis of skeletal metastases, which may be applied differently in symptomatic and asymptomatic cancer patients.

MATERIAL AND METHODS

February to March 1999 we randomly selected and retrospectively reviewed the clinical charts of 100 cancer patients (70 women and 30 men; mean age: 63 years, range: 55-87). All the patients had been staged according to TNM criteria and had undergone conventional radiography and bone scan; when findings were equivocal, CT and MRI had been performed too.

RESULTS

The primary lesions responsible for bone metastases were sited in the: breast (51 cases), colon (30 cases: 17 men and 13 women), lung (7 cases: 6 men and 1 woman), stomach (4 cases: 2 men and 2 women), skin (4 cases: 3 men and 1 woman), kidney (2 men), pleura (1 woman), and finally liver (1 men). The most frequent radiographic pattern was the lytic type (52%), followed by osteosclerotic, mixed, lytic vs. mixed and osteosclerotic vs lytic patterns. The patients were divided into two groups: group A patients were asymptomatic and group B patients had local symptoms and/or pain.

DISCUSSION

Skeletal metastases are the most common malignant bone tumors: the spine and the pelvis are the most frequent sites of metastasis, because of the presence of high amounts of red (hematopoietic active) bone marrow. Pain is the main symptom, even though many bone metastases are asymptomatic. Pathological fractures are the most severe consequences. With the algorithm for detection and diagnosis of skeletal metastases two different diagnostic courses are available for asymptomatic and symptomatic patients. Bone scintigraphy remains the technique of choice in asymptomatic patients in whom skeletal metastases are suspected. However this technique, though very sensitive, is poorly specific, and thus a negative bone scan finding is double-checked with another physical examination: if the findings remain negative, the diagnostic workup is over. On the contrary, in patients with a positive bone scan or with local symptoms and pain, radiography and CT are used for screening of metastatic lesions: results may be negative (for low sensitivity of conventional radiology) or questionable (in which case bone biopsy is necessary), or else symptoms may be due to different causes than metastatic lesions (i.e., osteoarthritis). Before bone biopsy is made, MRI must be performed, because it is the only technique that allows to distinguish between bone marrow components. The limitation of MRI is the poor specificity of its findings, which may provide misleading findings.

[Non-hodgkin's lymphomas of extranodal localization. Strategies for imaging diagnosis]

PURPOSE

To evaluate the diagnostic workup proposed by the UICC (International Union against Cancer) Flow charts for diagnosis and staging of lymphomas in developed and developing countries (1998).

MATERIAL AND METHODS

Our series consists of 134 patients with early non-Hodgkin's lymphoma (NHL). The patients, 75 men (56%) and 59 women (44%), ranging in age 14-80 years (mean: 56.8), were examined with chest radiography and thoracoabdominal CT. Abdominal US was used only in the follow-up of low-grade NHL. The patients were classified according to the Working Formulation criteria (1981) and staged as proposed by the Ann Arbor Conference guidelines (1971).

RESULTS

At diagnosis, 5 patients (3.7%) were in stage I, 32 (23.8%) in stage II, 46 (34%) in stage III and 51 (38%) in stage IV. Extranodal involvement was seen in 59 patients (44%), which was present at disease onset in 49 of them (80%) and developed later on in 10 (20%). Gastrointestinal tract and respiratory system were the most frequent sites of extranodal involvement (15 cases, 25%), followed by liver (12%), genitourinary system (including the ovary), adrenal glands, the craniocervical region, muscles and finally the breast. The parotid gland, thyroid and bone were involved in one case only each.

DISCUSSION AND CONCLUSION

In agreement with previous literature reports, our study confirms that the best technique currently available for diagnosis, staging and follow-up of malignant lymphoma is chest-abdomen CT. Indeed, even though extranodal involvement exhibits extremely variable patterns, there are some typical findings at CT, such as homogenous structural hypodensity, low contrast enhancement, frequent plurivisceral involvement and/or local lymph node involvement. Our study followed the 1998 UICC guidelines for cancer diagnosis and staging in developed countries, based on the histology of lymph node biopsy material and on imaging techniques such as CT, MRI and PET. As for developing countries, lymph node biopsy is the most easily available, and thus preferred, examination, while imaging diagnosis features chest radiography and abdominal US.

Rheumatoid arthritis: sequences

OBJECTIVE

Rheumatoid arthritis (RA) is an autoimmune disorder of unknown etiology characterized by symmetric, erosive synovitis and sometimes multisystem involvement. It affects 1% of the adult population and exhibits a chronic fluctuating course which may result in progressive joint destruction, deformity, disability and premature death. We review the literature data relative to the peculiar pathologic features of the disease shown by diagnostic imaging techniques.

METHODS

All our patients were classified according to the diagnostic criteria of the American Rheumatism Association (1987). Plain radiography remains the diagnostic technique of choice, but ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are also used.

RESULTS

Clinically articular involvement presents as pain, swelling, stiffness and motion impairment. The patients with positive rheumatoid factor are > 70% likely to develop joint damage or erosions within 2 years of disease onset. Any joint can be involved, but the proximal interphalangeal and metacarpophalangeal joints of the hand and the wrist are preferential sites, as well as the metatarsophalangeal joint of the foot, the knee and the joints of the shoulder, the ankle and the hip. Symmetry is the hallmark of joint involvement. The synovium of bursae and tendon sheaths is also affected. Soft tissue (subcutaneous nodules), muscles (weakness and atrophy) and vessels (vasculitis) may also be involved. Systemic involvement may result in Felty's syndrome, metabolic bone disorders (i.e. osteoporosis), Sjögren syndrome and pleuropulmonary abnormalities (pleural effusion, fibrosing alveolitis, constrictive bronchiolitis). The earliest abnormalities consist in synovial proliferation, soft tissue swelling, and osteoporosis. At a slightly later stage, the inflamed synovial tissue ('pannus') extends across the cartilage surface, leading to chondral erosions and small bone erosions at the joint margin (bare areas). Marginal and central erosions follow in advanced stages and finally fibrous ankylosis, joint deformities (subluxations and dislocations), fractures and fragmentations are typical findings of more advanced RA.

CONCLUSION

RA is a frequent joint disorder with a characteristic radiographic picture. Joint involvement patterns are sufficiently common to permit accurate diagnosis, especially when fusiform soft tissue swelling, regional osteoporosis, marginal and central erosions and diffuse loss of interosseous space are present. Conventional radiography remains the standard imaging technique for joint studies in the patients with suspected RA. US is recommended to diagnose soft tissue involvement (joint effusion). CT is very useful for showing abnormal processes in complex joints (sacroiliac and temporomandibular joints and craniocervical junction) which are difficult to depict completely with conventional radiography. Magnetic resonance applications include the assessment of disease activity: in particular, this technique may be the only tool differentiating synovial fluid and inflammatory pannus.

[Role of computerized tomography in the diagnosis of bone disease in multiple myeloma]

PURPOSE

To assess the role of CT in the diagnosis and management of multiple myeloma (MM) and to investigate if CT findings can influence the clinical approach, prognosis and treatment.

STUDY DESIGN AND PATIENTS

We reviewed the findings relative to 273 MM patients submitted to CT June, 1994, to December, 1996. The patients were 143 men and 130 women (mean age: 65 years): 143 were stage I, 38 stage II and 92 stage III according to Durie and Salmon's clinical classification. All patients were submitted to blood tests, spinal radiography and CT, the latter with serial 5-mm scans on several vertebral bodies. The CT unit was a Philips Tomoscan SR 7000.

RESULTS

CT showed lysis foci in some vertebral bodies (4 cases) where conventional radiography had shown only aspecific osteopenia. CT also depicted vertebral arch and process involvement in 3 cases with the vertebral pedicle sign. Moreover, CT proved superior to radiography in showing the spread of myelomatous masses into the soft tissues in a case with solitary permeative lesion in the left pubic bone, which facilitated subsequent biopsy. As for extraosseous localizations, CT demonstrated thoracic soft tissue (1 woman) and pelvic (1 man) involvement by myelomatous masses penetrating into surrounding tissues. In our series, only a case of osteosclerotic bone myeloma was observed in the pelvis, associated with lytic abnormalities.

DISCUSSION AND CONCLUSIONS

The role of CT in the diagnosis and management of MM has not been assessed, because this technique demonstrates tumor extent more accurately than radiography but CT findings do not seem to improve the clinical approach and therapeutic management of the disease. Nevertheless, we recommend CT for some myelomatous conditions, namely: a) in the patients with focal bone pain but normal skeletal radiographs; b) in the patients with M protein, bone marrow plasmocytosis and back pain, but with an inconclusive MM diagnosis; c) to assess bone spread in the regions which are anatomically complex or difficult to study with radiography and to depict soft tissue involvement; d) for bone biopsy.

[Periodontal disease in patients with HIV infection. Radiographic study]

A painful and rapidly progressive form of periodontitis--involving both soft tissue and bone, with gingival bleeding and loss of teeth--was observed in HIV-patients in the mid-80's. Today, there are few reports regarding the real incidence of periodontitis in HIV populations: however, it seems not as high as first supposed on discovering the disease, and bacterial plaque is moderate, compared with "conventional" periodontitis. Since there are few radiologic studies, the Authors report on the clinical-radiographic patterns of periodontitis in 20 HIV patients, compared to 20 normal controls. All the subjects were submitted to clinical-instrumental investigations (clinical tests, periodontal sampling, DMF index), and panoramic radiography. To assess periodontal disease severity, bone pocket depth is investigated radiographically, defined as the distance between the highest point of alveolar bone and root apex, at the mesial and distal aspects of all the teeth. We measured four alveolar quadrants, from the first premolar to the second molar. Statistical analysis was carried out with one way ANOVA test and non-parametric Kruskal-Willis's test; statistical significance is accepted at the probability level p < 0.05. Clinical-radiographic results demonstrated minimal bone loss and little teeth mobility, in the early stage of disease; involvement of total gingival attachment with partial bone sequestration at muco-gingival line, in the moderate stage; severe bone loss with soft tissue necrosis and risk of teeth exfoliation, in the advanced stage. Gingival tartar was also found. A significant statistical difference was demonstrated between the two examined populations. HIV-related periodontitis may represent one of the various features of the clinical picture of HIV infection, which must not be underestimated and mistaken for "conventional" adult periodontitis. If the diagnosis of periodontic disease is essentially clinic, radiography remains nevertheless important, because it yields data on bone status, integrity of lamina dura and morphology of roots, which data help make diagnosis and prognosis more reliable.

[Radiographic manifestations in teeth and jaws in chronic kidney insufficiency]

Forty-five patients affected with chronic renal failure (29 men and 16 women; mean age: 47.8 years), treated with hemodialysis for 4 to 245 months (mean: 66.9 months) were examined with panoramic and skeletal radiographs-the latter of the skull, hands, shoulders and clavicles, pelvis and spine. The control group (45 subjects with no renal diseases) was examined only with panoramic radiography. Dental and skeletal radio-graphs were given an 0-6 score and then compared to assess a possible relationship between skeletal and dental changes at radiography. Twenty-six dialysis patients (57.7%) had radiographic abnormalities in the maxillary bones-i.e., osteoporosis (100% of patients), focal osteosclerosis adjacent to the roots (11.5%), lamina dura reduction or loss (26.9%), calcifications of soft tissues or salivary glands (15.3%) and brown tumors (7.6%). In the teeth of dialysis patients, the dental pulp chamber was narrowed in 11.1% and hypercementosis of the roots was observed in 4.5%. Radiographic abnormalities in the hand, shoulder and pelvis were depicted in 51.1% of dialysis patients-in 86.9% of them with maxillary lesions. In the control group, 15.5% had mandibular bone lesions-i.e., osteopenia, cortex reduction at the mandibular angles and cyst-like lesions -but the evidence of caries and periodontal disease did not differ from that in the dialysis group. The diagnosis and follow-up of dialysis patients are currently made with serum biochemistry, radiography and histology. The purpose of skeletal radiology is to monitor the progression or regression of musculoskeletal abnormalities. Panoramic radiography might be useful in monitoring renal osteodystrophy, especially to assess the response to therapy-i.e., parathyroidectomy, calcium or vitamin-D therapy and renal transplant.

[Diagnostic imaging of osteoid osteoma]

Conventional radiography, bone scintigraphy and Computed Tomography (CT) are the most useful tools to identify osteoid osteomas. We examined 26 patients (14 men and 12 women) with osteoid osteoma in different skeletal sites (13 femora, 3 tibiae, 3 hands, 2 peroneal bones, 2 humera, 2 spines and 1 talus) and compared the diagnostic yield of the above techniques. The fundamental radiographic findings in this benign bone lesion are the presence of a "nidus", with or without calcifications, perilesional sclerosis and periosteal new bone formation. Four patients in our series had soft tissue edema. In the majority of cases, conventional radiography is the imaging method of choice, because it is easily available and its diagnostic yield is adequate (17 patients in our series), especially if combined with bone scintigraphy-whose high diagnostic sensitivity was proved in all of our patients. CT is recommended for its better spatial resolution, in view of surgery, especially when soft tissues are involved. MRI is a highly valuable tool in bone tumor staging because it demonstrates cortical involvement and intramedullary and soft tissue spread. However, MR findings might be misinterpreted as indicating a more aggressive pathologic process.

[Monoarthritis]

By definition, monoarticular arthritis means one-joint involvement, even though, in fact, such a condition is often an oligoarthritis because as many as two or three separate joints will be involved. Arthritis is often limited and may regress, so that it is frequently misdiagnosed. Sometimes, a monoarticular condition may be a polyarthritis onset (i.e., rheumatoid arthritis). Monoarticular arthritis can be caused by many factors, such as infections (septic arthritis), nonspecific inflammatory processes (reactive arthritis), crystals deposition (gout, CPPD crystal deposition disease), trauma, neoplasm (pigmented villonodular synovitis), immunologic conditions (amyloidosis) and hormonal changes (parathyroid disease). Its onset is usually acute and sometimes dramatic, with fever, pain and joint swelling, so that a decision must be made promptly to stop rapid illness evolution and to prevent the irreversible destruction of cartilage and bone (especially in septic arthritis). Diagnostic studies are performed with mono-bilateral radiographs of the joint. Radiographic findings (i.e., soft tissue swelling, joint effusion, widening and thinning of joint spaces, bone erosions and destruction of bone surface) are typical of the disease, but some findings (e.g., type of evolution and progression), laboratory tests, synovial biopsy and arthroscopy can differentiate infectious from inflammatory forms. Scintigraphy can depict isotopic joint uptake, before articular abnormalities are demonstrated with radiography, thanks to its high sensitivity; nevertheless, because of its low specificity, scintigraphy may miss some kinds of lesions (including osteoarthritis) and cannot easily differentiate osteomyelitis from septic arthritis. CT and MRI play a secondary, though not negligible, role, especially to study such deep infections as psoas abscesses, which may mimic arthritides.

Association between diffuse idiopathic skeletal hyperostosis and multiple myeloma

OBJECTIVE

To determine whether an association exists between multiple myeloma and diffuse idiopathic skeletal hyperostosis (DISH).

DESIGN AND PATIENTS

Radiologic studies were performed over a 26-month period in a series of 97 consecutive patients with multiple myeloma (56 male and 41 female, aged 42-91 years).

RESULTS

Both myelomatous bone lesions and hyperostosis similar to DISH were found in these patients. The prevalence of DISH in association with multiple myeloma (21 male and 8 females patients) was higher (29.8%) than in our control group (973 patients, 449 male and 524 female) or in the general population (15-20%). The involved segments of the column were thoracic in 11 males and 7 females, cervical in 8 males and 2 females, and lumbar in 5 males and 4 females. Ossifying enthesopathy in the pelvis ("whiskering") was observed in 7 males and 1 female.

CONCLUSIONS

The pathogenesis of hyperostosis remains unknown. It is possible that the coexistence of DISH and multiple myeloma is merely an association. For this reason, it is important for the real prevalence of DISH in the general population to be defined.

[Significance and usefulness of SPECT with Tc-99m HMPAO in the diagnosis of hemicrania with aura]

It is generally agreed upon that the attacks of migraine with aura are indicative of abnormal cerebral perfusion, while the permanence of such perfusion abnormalities during the pain-free intervals of migraine remains debated. This study was aimed at assessing: 1) the presence of cerebral perfusion abnormalities also during the interictal phase and 2) the role of SPET with 99mTc HM-PAO to diagnose migraine. Twenty-eight patients (22 women and 6 men), diagnosed as having migraine with aura according to the International Headache Society (Headache Classification Committee criteria), were submitted to SPET studies, within 10 days of the last attack. 99mTc HM-PAO was used as perfusion tracer and a single head rotating gamma camera equipped with a high-resolution collimator was used for data acquisition. The qualitative analysis of SPET images showed slight hypoperfusion areas in 22 of 28 patients (79%). In 12 of 22 patients (55%) a regional correlation was observed between hypoperfusion areas and the neurologic symptoms of aura. The results of the present study are in agreement with the current physiopathologic interpretation of migraine with aura, confirming the instability of cerebral perfusion control, even with instrumental evidence of perfusion abnormalities in the interictal period. Moreover, SPET with 99mTc Hm-PAO seems to be a useful tool in the diagnostic assessment of migraine.

[Skeletal changes in the kidney transplant patient]

The skeletal status was investigated with noninvasive diagnostic procedures in 44 renal transplant patients (mean time since intervention: 5 to 195 months) treated with steroid and azathioprine (21 cases) or with steroid, azathioprine and cyclosporine (23 cases). 38.6% of the patients had reduced renal function (creatininemia: 1.6-3.0 mg/dl). Our patients underwent biochemical and hormonal tests of bone metabolism, digital radiographs of the skeleton and bone mineral density measurement with dual-energy X-ray absorptiometry (DXA, Hologic QDR 1000). All the patients exhibited moderate to severe osteopenia at both radiographic and densitometric investigations; the risk of fracture was high in 47% of cases. Radiographic signs of vertebral fractures were observed in 4.5% of cases. Other major radiographic patterns were the aseptic necrosis of femoral head (9%), of carpal bone (4.5%) and of humeral head (2.2%). Fibrous osteitis was demonstrated in three patients. Geodes in the wrist were also observed. The correlation of bone densitometry values and time since renal transplantation was statistically significant (r = 0.381; p < 0.01). Moreover, the grade of osteopenia correlated with serum levels of calcitonin and calcitriol--the latter especially in the patients with severe osteopenia.

Platyspondyly in treated beta-thalassemia

Flattening of the vertebral bodies with a platyspondyly appearance is described in 14 patients selected for evaluation of short stature from 106 patients affected by thalassemia major, who received an intensive transfusion regimen combined with continuous chelation therapy. The vertebral body height/width ratio was decreased at the level of all the investigated tracts, namely, cervical and/or dorsal and/or lumbar. The flattening of the vertebral bodies may be due to suppression of intramedullary hematopoiesis by a high transfusion regimen. The reduced intravertebral pressure due to disturbed hemopoiesis could cause weight-bearing and other biological stresses to provoke a reduction in vertebral body height.

[Anomalies of the masticatory apparatus in beta-thalassemia. The present status after transfusion and iron-chelating therapy]

Fifty-four homozygous beta-thalassemic patients (26 men and 28 women) aged 7 to 24 years, who had been treated with high transfusion regimen (Hb levels = 9-10 g/dl) and chelation therapy (desferrioxamine, 35-50 mg/kg), underwent clinical and radiographic investigations. This study was aimed at assessing the clinical and radiographic changes in the stomatognathic system (teeth, mandible and maxilla, occlusion relationship and dental bases). All patients underwent orthopantomography and teleradiography of the skull, in the lateral view. Twenty thalassemic patients (13 men and 7 women) of the same age but treated with low transfusion regimes (Hb levels = 5-6 g/dl) were examined as a control group. Our results indicate that: 1) in the control group, osteopenia is the specific lesion of anemia, in both the alveolar process and the mandible, following marrow expansion. Consequently, diastema of incisors and several types of malocclusion follow--i.e., overjet, anterior open-bite and crossbite, nearly all of them associated with II dental and skeletal patterns of Angle's classification. 2) In adequately transfused patients, no lesions are observed in 55% of cases, in both the teeth and the facial skeleton. This means that current treatment methods can prevent bone abnormalities, especially if transfusions begin at birth. Nevertheless, osteopenia of the mandible (31.4%) and dental and/or skeletal malocclusions (40.7%) remain in many cases, because of persistent marrow expansion, which usually follows incorrect treatment. 3) General dental diseases--e.g., caries, paradentosis, gingivitis, etc.--affect both populations with the same incidence.

[The evolutionary effects of therapy on the skeletal lesions in beta-thalassemia]

Up to the mid-1960s, beta-thalassemia was treated with blood transfusions as frequent as needed to keep symptoms under control and to prevent transfusional hemosiderosis. In the following years, high transfusion regimens and iron chelation therapy with desferrioxamine were used. Because of these different treatment modalities, skeletal findings in thalassemia have markedly changed. In the past, thalassemic patients treated with a low transfusion regimen and without chelation therapy developed osteopenia--with widened medullary spaces, cortical thinning and trabecular atrophy--secondary to chronic expansion of red marrow, due to increased erythropoietin response to chronic anemic hypoxia. Typical radiographic patterns in the skull included widened diploic space, atrophic-especially outer--tables and, in some patients, the "hair-on-end" pattern. As for the face, obliteration of the paranasal sinuses and the typical "rodent facies" were observed. In the ribs, bulbous expansion of the posterior and anterior segments and the "rib within a rib" patterns were observed. As for the spine, coarse trabecular arrangement was seen. The "cobweb" pattern was seen in the pelvis and finally the lack of the normal concave outline was observed in the long bones. In the patients treated with high transfusion regimens and iron chelation therapy over the last 30 years, both skull anomalies and disfigurement are less frequent. The skull is almost normal, with the exception of osteopenia and thickened diploic space in the frontal bone only; the paranasal sinuses are usually not obliterated. The hands and rib are normal, just like long bones, pelvis, scapulae and vertebral bodies. Nevertheless, in some adequately treated patients new skeletal features have been recently observed in the long bones, which are similar to those occurring in rickets and/or scurvy, and in the vertebral bodies, resembling platyspondylia. These abnormal features might be caused by several factors--i.e., marrow expansion, transfusion regimens, direct/indirect effects of desferrioxamine, iron load, endocrine abnormalities, deficiency of some minerals and finally dysvitaminoses. Nevertheless, osteopenia remains the main negative factor of thalassemia.

[Cephalometry and digital radiography. Technical note]

Conventional and digital lateral teleradiographs of the skull were performed on 6 consecutive patients (3 men and 3 women). The study was aimed at comparing the diagnostic capabilities of the two imaging techniques to measure points and angles, as derived from different cephalometric analyses (see text for details). These variables were analyzed by three different operators: for both techniques, 18 cephalometric tracings were made, including a total of 414 points and 36 angles. Correlation coefficients between the two types of measurements (points and angles) were calculated; Wilcoxon's non-parametric test was also used. This study demonstrates digital radiography to be superior to conventional radiography to detect cephalometric landmarks, which is especially evident in the evaluation of the so-called "questionable" landmarks: the latter were 15 of 23 with conventional radiography and 9 of 23 with digital radiography. On the other hand, correlation coefficients and significance of the values of the considered angles were in close agreement with the two techniques. Therefore, its simultaneous demonstration of anatomical structures of different thickness--i.e., bone and soft tissues--and its lower exposure dose make digital radiography the diagnostic procedure of choice in cephalometrics, especially in the pediatric age, as well as in monitoring the patients.

[The hand in hematologic diseases]

Radiography of the hand often reflects the picture of generalized diseases, affecting both the muscolo-skeletal system and the others. Some of the most common hematologic disorders may be detected in roentgenograms of the hand, especially in the anemias, but also in plasma cell dyscrasias and proliferative malignant diseases (i.e., lymphomas and leukemias). On the basis of their experience, the authors have reviewed and discussed the radiographic "pattern" of the hand in several hematologic conditions (i.e., anemias; thalassemias; sickle-cell disease; lymphomas; multiple myeloma; etc.), and their pathogenesis. Radiographies of both the hands, in antero-posterior view, were performed using Kodak-Min R film; xeroradiography was performed--in the same projection--using Rank Xerox plate, developed always in "positive mode" in 125 Rank Xerox System, conditioned with contrast "D", for emphasizing osseous details. Recently, digital radiography--employing PCR system--has substituted xeroradiography, because of its well-known properties and diagnostic advantages: in this manner, changes in bone and soft tissue are demonstrated on the same image, with augmentation of diagnostic information, with reduced dose to patient. In our series, hand is always involved (100% of cases) in thalassemias: lesions are characterized by diffuse osteopenia (washed out melted appearance), with widening of bone marrow space, diaphyseal convex aspect of the long bones, thinning of the cortex, and cyst-like changes (rain drops). Lesions disappear completely after the hypertransfusion regimen (HTR). Following chelation therapy, lesions of the wrist and hand are similar to those described in rickets and/or scurvy. Sometimes, the hand is characteristically affected in sickle-cell disease--particularly in the so called hand-foot syndrome--as "cone-deformity". In multiple myeloma incidence of hand involvement is 2.9%: lesions reflect general abnormalities observed in other skeletal sites, and they consist in multiple well-circumscribed lytic lesions. In amyloidosis, poorly defined radiolucent areas may be discovered. In non-Hodgkin lymphoma, incidence of hand involvement is less frequent, approximately 0.2%: the radiographic pattern is aspecific (mottled lytic lesions), sometimes simulating multiple myeloma and/or leukemias. In hemophilia, swelling of soft tissues, around the interphalangeal joint, related to intra-articular and/or per-articular hematoma, is observed. The other conditions reflect general radiographic features of anemias, which are of three main types: 1. the over active marrow (i.e., polycythemia); 2. the infarction of bone (i.e., sickle-cell disease); 3. non-specific findings, resulting from chronic illness (delays of maturation; dwarfism; osteopenia; tendency to infection).

[The temporo-mandibular joint in pathologic conditions: rheumatoid arthritis and seronegative spondyloarthritis]

Pain and dysfunction of the temporomandibular joint (TMJ) are major clinical problems, especially in arthritides and allied conditions. In the last 10 years, such new imaging methods as arthrography, CT and MRI have been developed, but many problems are still to be solved. This study was aimed at reporting the radiographic patterns of lesions in TMJ rheumatoid arthritis and seronegative spondyloarthropathies and at investigating the role of conventional radiology in the assessment of these disorders. Digital hypocycloidal tomography of the TMJ was performed on 44 patients affected with rheumatoid arthritis, on 2 with Sjögren's syndrome, 2 with ankylosing spondylitis, 4 with psoriatic arthritis and 1 with Reiter's syndrome. CT, with sagittal and coronal scans, was performed only on 9 patients (18 joints) whose clinical and radiographic findings were particularly severe. The radiographic features of the lesions--i.e., erosions, osteophytes, subchondral bone sclerosis and condylar-glenoid fossa remodelling--cannot be distinguished from one another and from the so-called allied conditions; nevertheless, in rheumatoid arthritis abnormalities are usually bilateral and symmetric, whereas in seronegative arthropathies joint involvement is usually unilateral. In the first stage of the disease, these lesions are better demonstrated by CT than by tomography, thanks to better contrast and spatial resolution of the former, especially on the lateral and medial aspects of the joint. The most common findings were: erosions (68.2%), osteophytes (31.8%), subchondral bone sclerosis (28.6%) and condylar-glenoid fossa remodelling (9.1%). In the clinical practice sagittal multidirectional tomography remains today the method of choice because it can demonstrate several areas on the condylar surface, with finer anatomical detailing, and it can solve most diagnostic problems in TMJ disorders. Thus, CT is recommended only in the patients whose diagnosis remains questionable with the above techniques.

[Bone disease in multiple myeloma. Analysis of 253 controlled cases, with reappraisal of diagnostic criteria and current imaging techniques]

Two hundred and fifty-three multiple myeloma patients (136 males and 117 females; mean age 66 years) classified by the clinical criteria of Durie and Salmon underwent skeletal radiography; 148 of them had total body bone scintigraphy, and 130 bone marrow scintigraphy. A selected group of them (18 patients, both males and females) had densitometric bone examination, employing both quantitative computed tomography (QCT) and dual energy X-ray absorptiometry (DXA). The results can be summarized as follows: 29.7% of patients exhibited no skeletal abnormalities at early staging. Spine (49%), skull (35%), pelvis (34%), ribs (33%), humeri (22%), femora (13%), and mandible (10%) were the most frequently involved locations. The main pattern is osteolysis as a characteristic "punched-out" multiple lesion (43.3%), but the most frequent lesion is osteopenia (43.9%), particularly evident in the spine; pathologic fractures (54%) are seen in the ribs, vertebral bodies, limbs; typical radiographic associations of features and sites are observed, which sometimes make diagnosis easier. Total body scintigraphy, revealing aspecific uptake only in the presence of pathologic fractures, is not recommended in the first staging of the disease, but it is considered as an important technique in the follow-up, when the patients become symptomatic. Bone marrow scintigraphy, especially in the "marrow expansion" pattern, might be considered as a form of compensating attempt to recover the lost central space, destroyed by myelomatous involvement, of which it defines the pathologic and prognostic status. Bone densitometry, as it confirms the grade of osteopenia, reveals that osteoporosis is a peculiar characteristic pattern of bone disease in multiple myeloma, not only due to age. Conventional skeletal radiography is the main support in the diagnosis of lytic areas of multiple myeloma, and it remains--today--irreplaceable. The other diagnostic techniques (i.e., CT and MRI) may be used to detect the extent of bone and soft tissue involvement, in areas of complicated anatomy, and to define the degree of marrow involvement.

[Osteoporosis and the thalassemia "trait"]

The authors evaluated the prevalence of the thalassemia trait in a general population affected with femoral neck fractures. Our research was aimed at assessing whether hemoglobinopathy might affect osteoporosis, which is responsible for femoral fractures. Two hundred and thirty-eight patients admitted to St. Anna Hospital, Ferrara, for proximal femoral fractures, were retrospectively studied. The patients were 68 males and 170 females, aged 58 to 83 years (mean age: 70.4 years). The thalassemia trait was seen in 11.76% of cases, versus in 7-8% of the general population. The high prevalence of heterozygous beta-thalassemic subjects probably means that the beta-thalassemia condition is a further "variable" which is responsible for the more frequent occurrence of fractures of the proximal femur and is certainly related to an osteopenic condition much more severe than usual.

[Platyspondylisis+ in beta-thalassemia major]

Platyspondylia was observed in 14 patients affected with thalassemia major (7 males and 7 females, age range: 10-18 years) who received an intensive transfusion regimen combined with continuous chelation therapy (desferrioxamine: 50-80 mg/kg daily). Height/width ratio was decreased at all the investigated tracts--i.e., cervical and/or dorsal and/or lumbar spine. The range of height/width ratio values was 0.41-0.55 at the 5th cervical body, 0.33-0.53 at the 8th dorsal body, 0.43-0.56 at the 12th dorsal body and 0.47-0.62 at the 2nd lumbar body. The flattening of the vertebral bodies seems to be due to the depletion of hematopoetic tissue determined by the high transfusion regimen. The reduced intramedullary pressure is thought to counteract neither weight-bearing nor other biological stresses, which might ultimately provoke the thinning of vertebral bodies.

[The radiology of osteogenesis imperfecta]

The term "osteogenesis imperfecta" refers to a heterogeneous group of hereditary diseases characterized by osteopenia, increased bone fragility, blue sclerae and dentinogenesis imperfecta. The abnormal synthesis of type-I collagen is responsible for the pathologic changes occurring not only in bone, but also in skin, tendons and ligaments, sclerae and teeth. The clinical and radiographic features of 5 cases (2 males and 3 females; age range: 1 month to 29 years) were analyzed. The patients were unrelated with each other. The diagnosis of the different types of osteogenesis imperfecta is as difficult as the identification of the various genotypes which are responsible for the different clinical pictures. The most characteristic radiographic pattern--which is observed in any type of the disease--consists in osteopenia associated, in most cases, with multiple fractures and deformities--e.g., micromelia, large metaphysis, archon long bones. Typically, "pop corn" calcifications are observed in both epiphysis and metaphysis of long bones. Dentinogenesis imperfecta is one of the most significant clinical patterns, and it can be the only bone abnormality. The prognosis of osteogenesis imperfecta is as varied as its genetics--i.e., the fractures discovered at birth are not necessarily a negative prognostic sign.

Bone marrow imaging in plasma cell dyscrasias: review of 130 cases

Skeletal radiography, bone and bone marrow scintigraphy have been performed in 130 patients with plasma cell dyscrasias (119 multiple myeloma, 9 MGUS and 2 Waldenström disease). Our results confirm: 1) that radiography is much more sensitive than scintigraphy in the identification of the lesions typical of myeloma, but in the first stage bone scintigraphy and especially bone marrow scintigraphy are more sensitive than x-ray for the detection of regions affected by focal lesions; 2) that bone scintigraphy is of particular value in detecting some abnormalities in specific sites not fully visualized by x-ray; 3) that bone marrow scintigraphy is a valuable diagnostic tool in the early stage of myeloma, especially for evaluating the progression of the disease, because it is able to demonstrate not only focal lesions, but also bone marrow expansion. We believe that bone marrow scintigraphy may be a useful technique in the early diagnosis and follow-up of multiple myeloma, particularly in the detection of unusual forms (i.e., "smouldering" myeloma), but it remains only an "additional" technique for bone imaging.

[Diffuse idiopathic skeletal hyperostosis. Review of diagnostic criteria and analysis of 915 cases]

DISH is a common systemic skeletal disease, probably of dysmetabolic and/or degenerative origin, yet of unknown etiology. It is observed in middle-aged or elderly patients of both sexes, and is characterized by ossification of the anterior longitudinal ligament on the antero-lateral aspect of the spine, and by ossifying enthesopathy, in both the central and the peripheral skeleton. Diagnosis is solely based on radiographic abnormalities, according to the so-called Resnick criteria. In the present study, the spines of 915 patients (414 males, 501 females, mean age: 65 years) were considered, and the peripheral entheses (heel, patella and elbow) of 494 of them (234 males and 260 females). The incidence of DISH was 14.09% (129 cases): 17.6% in males (73 cases) and 11.7% in females (56 cases). DISH strikes in the VI and VII decades of life most. The most affected sites of the spine were: the dorsal portion (100%), especially in the D7-D11 segment (93%); the lumbar spine in L1-L3 (81%), and the cervical spine, in the C5-C7 segment (69%). Peripheral areas of involvement were: pelvis (90%), heel (76%), elbow (46%) and knee (29%). The symptoms of DISH must be promptly detected: the disease is not asymptomatic, but presents with pain and stiffness in the spine, recurrent tendinitis and bursitis, and myelopathy.

[Bone disease in multiple myeloma. A study of 237 cases]

From 1984 to 1990 the authors reviewed the radiologic-clinical charts of 237 patients affected with multiple myeloma (MM). The series included 127 males and 110 females (mean age: 66 years) who had been classified according to Durie and Salmon clinical criteria. All the patients underwent X-rays of the skeleton, as recommended in international literature; moreover, 148 subjects underwent whole-body bone scintigraphy, and 130 bone marrow scintigraphy. A selected group of cases (18 male/female patients) were submitted to bone densitometry employing both quantitative computed tomography (QCT) and dual-energy X-ray absorptiometry (DXA). The results follow: 1) in the first stage of the disease, a high number of patients (29.5%) exhibits no skeletal abnormalities on X-rays; the most common lesion locations include the spine (49%), skull (35%), pelvis (34%), ribs (33%), humeri (22%), femora (13%) and mandible (10%); 2) the most frequent pattern is osteolysis, as a characteristic "punched-out" multiple lesion; the second most frequent lesion is osteopenia (43%), especially in the spine; pathologic fractures are common (54%) in the ribs, vertebral bodies, limbs; typical associations of features and sites are seen on X-ray images, which sometime make diagnosis easier; 3) whole-body scintigraphy, revealing aspecific uptake only in the presence of pathological fractures, is not recommended in the first staging of the disease, but is considered as a valuable technique in the follow-up, when the patients become symptomatic; 4) bone marrow scintigraphy, especially in the "marrow expansion" pattern, might be considered as an attempt made by the body to recover the central space which was destroyed by myelomatous involvement. The prognostic value of this technique is still to be assessed; 5) bone densitometry, by confirming the grade of osteopenia, reveals that osteoporosis is a peculiar pattern of bone disease in MM, which is not related to age only; 6) conventional radiography of the skeleton is the method of choice in the diagnosis of lytic areas of MM, and remains, as yet, irreplaceable. The other diagnostic techniques--i.e., CT and MRI--can be used to evaluate the extent of bone and soft tissue involvement, in the cases with questionable diagnosis, and to assess the degree of marrow involvement.

[Mandibular lesions in multiple myeloma]

A review was made of 237 cases of multiple myeloma seen at the Institute of Radiology and Hematology of the Ferrara University from 1984 through 1990. The results showed skeletal involvement of the mandible to be present in 25 patients (10.54%). The diagnosis of multiple myeloma was based on the following criteria: 1) increased number of abnormal, atypical or immature plasma cells in the bone marrow; 2) the presence of a monoclonal protein in the serum or urine; 3) bone lesions consistent with those of myeloma. Symptoms include pain and swelling of the oral cavity, tooth mobility and loss, numbness along the inferior dental nerve, and paresthesia of the lower lip. The typical radiographic appearance is a well-defined "punched-out" lytic defect, solitary or multiple; sometimes, the defect enlarges and appears "bubbly" or septated. Permeative lytic areas, with blurred outlines, are a rare pattern, which is radiologically indistinguishable from skeletal metastases. The involvement of the oral cavity and jaw in multiple myeloma has been often reported in literature: nevertheless, if radiographs of the jaws had been systematically taken in all the cases, its incidence would probably have been much higher than previously suspected.

Growth plate injury of the long bones in treated beta-thalassemia

In 12 patients affected by thalassemia major who received an intensive transfusion regimen combined with continuous iron chelation therapy (desferrioxamine 50-80 mg/kg daily), radiologic abnormalities of the long bones were observed similar to those observed in rickets and scurvy. These abnormalities were associated with a growth retardation. The pathogenesis of these lesions is uncertain, but probably the toxic effect of desferrioxamine plays an important role in their development. A relative deficiency of vitamins D and/or C cannot be entirely excluded.

[Normal ranges of bone mineral content of the distal radius determined with single photon absorptiometry. Study of 1521 cases]

The normal ranges and mathematical equations of bone mineral content (BMC), normalized to radial width (BMC/W) vs. age at the distal radius, were obtained by single photon absorptiometry (SPA), and compared in two different normal populations, one of postmenopausal females and the other of control males. The female population included 1359 postmenopausal women, aged 35 to 75 years; normal control males were 162, of the same age. The results obtained in the two groups of patients show a statistically significant (p less than 0.001) correlation between age and BMC/W, expressed in a polinomial third-degree regression. The slope of the regression curves is quite different between males and females: the mean decrement, evaluated from regression polinomial fits, results 0.5% per year for normal females, and 0.3% per year for normal males. The maximum decrement (1% per year) is observed at the mean age of 51 years, which is the average age of peri-menopausal women in our province (Ferrara). The authors believe SPA to be a simple and reliable technique in measuring peripheral bone loss rate. SPA may be useful in the diagnosis and treatment of postmenopausal women, but is not recommended in the short-term follow-up of osteoporosis.

[Role of triphasic bone scintigraphy in the diagnosis of osteonecrosis of the femur head]

Twelve patients affected by idiopathic osteonecrosis of the femoral head underwent X-ray, triphasic bone scintigraphic (TBS) and CT tests on the femoral head on both sides. TBS revealed arterial hypoperfusion and an area of hypocaptation in the caput femoris in 3 coxofemoral joints which were radiologically "negative" (and of which one was also CT negative); these are scintigraphical signs which are typical of aseptic necrosis. In line with published data, TBS was found to be a more sensitive test in comparison with traditional X-ray techniques and CT, and in the early stages of disease it is more specific in recognising aseptic necrosis of the femoral head. Lastly, it is underlined that magnetic resonance is currently considered to be most sensitive (88%) and most specific (100%) imaging technique in the diagnosis of osteonecrosis of the femoral head.

[Radiology of osteoarticular changes in patients undergoing periodic hemodialysis for more than 15 years]

Osteoarticular complications, which are characterized by osseous pain, pathologic fractures, and decreased articular mobility, represent one of the major problems affecting long-term (over 15 years) hemodialysis patients. These changes seem to have a multifactorial etiology; they include osteomalacia, secondary hyperparathyroidism, and dialysis-related amyloidosis. Ten patients (5 males and 5 females, mean age 55 +/- 7 years) on long-term (over 15 years) hemodialysis were submitted to X-ray examinations of the skull, spine, shoulders, wrists, pelvis, and knees. Serum calcium, phosphorous, parathyroid hormone, alkaline phosphatase, and basal aluminium levels were also calculated. Osteopenia was demonstrated in all patients. Seven of them had alterations due to hyperparathyroidism. Six patients exhibited signs related to dialysis spondyloarthropathy; in 9 cases amyloid lesions, geodes, and erosions were present in wrists, humeral heads, or hips. One patient exhibited osteomalacic changes. Most long-term dialysis patients presented multifactorial osteoarticular changes due to hyperparathyroidism, osteomalacia, and dialysis-related amyloidosis. Clinical symptoms and decreased articular mobility appeared to be due mainly to amyloid osteoarthropathy.

[Plasma cell dyscrasias and diffuse idiopathic skeletal hyperostosis. Is it a merely accidental association?]

The radiologic staging of a series of 144 patients (88 males and 56 females) affected with plasma-cell dyscrasias and observed over a 26-month period, revealed both the well-known bone myeloma-related abnormalities and hyperostotic lesions similar to those described in diffuse idiopathic skeletal hyperostosis. The incidence of skeletal hyperostosis was 31.94%, much higher than that reported in literature for the general population (5%). Typically, the axial skeleton is the most common location for abnormalities in multiple myeloma (MM) as well as in DISH: involvement of the dorsal spine was observed in 65% of cases, the cervical spine was involved in 34.8% of patients, and the lumbar spine in 28.3%. Peripheral ossifying enthesopathy, considered as "whiskering" in the pelvis, was found in 12 cases (8.2%), 7 males and 5 females. DISH was indifferently present in both MM (23 cases), with severe osteolysis (stage III) or simple osteoporosis (stage I), and monoclonal gammopathy of undetermined significance (MGUS) (17 cases), usually without any myeloma-related bone lesions, and in Waldenström disease (4 cases). Many hypotheses are discussed as to the possible pathogenesis (e.g.: accidental, dysmetabolic, or degenerative) of hyperostosis in dysgammaglobulinemias, but, to date, they are no more than mere guesses. DISH is a disorder the etiology of which is still unknown: it is likely to be an ossifying diathesis, but its incidence in both illnesses--which are both plasma-cell dyscarsias--is too high for the association to be accidental. Thus, a pathogenetic factor produced by multiple myeloma can be hypothesized, capable of increasing the so-called idiopathic hyperostosis.

[Course of radiologic changes in spondyloarthropathy caused by dialysis]

Destructive spondyloarthropathy (DSA) has been observed in patients undergoing long-term hemodialysis. The pathophysiology of this condition is still unknown, but there is evidence that amyloid depositions play an important role in its development. Despite several reports, the radiological evolution of these lesions is poorly known. The authors report the results of the radiographic follow-up (12-18 months) of 9 cases (7 female and 2 male patients; age 63 +/- 6 years) hemodialyzed for over 60 months (mean: 126 +/- 33). In 7 cases, radiographic patterns of destructive arthropathy were seen in peripheral joints as well. X-ray pictures demonstrated: 1) increased erosion of vertebral end plates (in all cases); 2) increased narrowing of intervertebral spaces (in 5 cases); 3) increased collapse of vertebral bodies (in 5 cases); 4) increased malalignment of the involved segments (in 4 cases). In 3 autopsied cases beta 2-microglobulin amyloid depositions were found in disc and ligamentous paravertebral tissue. These results confirm that: 1) DSA is progressive in long-term hemodialysis patients; 2) radiographic evolution is often very quick; 3) the cervical spine is the most frequently involved location and the one where lesions are quickest to develop; 4) severe malalignment of the involved spine may be present, with subsequent neurological complications.

[Rickets- and/or scurvy-like bone lesions in beta-thalassemia major]

Recently, a new type of skeletal lesions has been described in Cooley's anemia as a possible complication secondary to therapy. In 12 children affected with thalassemia major, who received an intensive transfusional regimen combined with continuous iron chelation therapy (desferoxamine-B: 50-80 mg/kg/day), some radiological abnormalities of the long bones were observed similar to those described in rickets and scurvy. These rickets and/or scurvy-like lesions had never been reported before the introduction of high-dose desferoxamine therapy. The pathogenesis of these lesions is uncertain, but the toxic effect of desferoxamine probably plays an important role in their development. The association of growth retardation and rickets and/or scurvy-like skeletal lesions in Cooley's anemia patients may be used as a valuable clinical criterion in long-term chelation management.

[Radiodiagnosis of orthodontic and dysfunctional anomalies of the stomatognathic system: analysis of a sample of 204 patients]

Two hundred and four subjects (86 males and 118 females), aged 8 to 35 years, with different types of malocclusion, underwent panoramic dental radiography and skull teleradiography. This study was aimed at investigating advantages and limitations of the two radiographic techniques, in view of their use as screening methods. On orthopantomography, inferior interincisive point, menthon (Me), and, bilaterally, gonion (Go) and condilion (Co), were localized so as to allow a model of the right and left jaws to be made. On teleradiography of the skull, in lateral view, Steiner's cephalometric analysis allowed skeletal classes to be evaluated according to ANB angle values. Moreover, major postural parameters relative to the relationship between skull and cervical spine were analyzed: atlanto-occipital distance, cranio-vertebral angle, cervical lordosis, and hyoid triangle. Orthopantomography, though not a reproducible technique, can be considered as a valuable screening method for it allows right and left hemi-jaws to be comparatively measured. Cephalometric analysis of postural data confirmed the frequency of wrong postures in orthodontic patients. From the correlation of mandibular asymmetries and cranio-cervical parameters, the authors observed that asymmetrical patients have many postural problems, just like class II skeletal and dolico-facial types. This finding seems to confirm the mixed (functional and skeletal) etiopathogenesis of mandibular asymmetries.

[Changes in the small and large intestines in systemic sclerosis]

A series of 21 subjects (2 males and 19 females) affected with systemic sclerosis, was examined by small bowel (oral and intubation methods) and colon enema. The underlying process responsible for abnormalities in the small bowel and colon in systemic sclerosis is a variable and pacthy destruction of the muscularis propria, that produces the structural and functional changes detected on X-ray. Pathologic condition is the same affecting the esophagus. The scout film of the abdomen often reveals colonic distension and fecal impaction, so that it may be quite difficult to prepare adequately the patients for a barium enema. Peristalsis may be virtually absent in short segments, and transit time may be several time longer than that in normal patients. For these reasons, intestinal pseudo-obstruction may appear in systemic sclerosis. The observed radiographic changes are: 1) in the small bowel: a) dilatation of the gut, especially in its proximal portions (duodenum and jejunum), in which the valvulae conniventes are straightened, normal or thinned; b) presence of diverticula, 2-4 cm in diameter, with hemispherical shape without the neck-like opening into the bowel lumen; 2) in the colon, the characteristic finding is an increase in size of individual haustra, forming sacculations or pseudo-diverticula, usually on the antemesenteric border of the transverse colon, better demonstrated on post-evacuation film. Moreover, loss of colonic haustration is also observed associated to colonic elongation and dilatation.

[Quantitative analysis of bone density in multiple myeloma]

Bone lesions are the main sign of neoplastic proliferation of multiple myeloma (MM), a disseminated malignant disease which originates in, invades and replaces normal bone marrow. The most characteristic radiographic pattern is a focal lytic lesion, well-defined or "punched-out", generally with no surrounding bone reaction. The association is confirmed between MM and osteoporosis, as reduced bone density (osteopenia) and pathologic fractures (ribs, spine). This paper is aimed at evaluating the importance of osteopenia in both diagnosis and prognosis of MM. Eighteen patients affected with MM were examined with quantitative computed tomography (QCT) and dual-energy X-ray absorptiometry (DEXA) for bone densitometry in lumbar spine and proximal femur. The patients (12 males and 6 females) were classified according to Durie's clinical criteria and to the radiographic patterns suggested by Merlini. The results indicate the patients with an advanced clinical stage (III) and scintigraphic expansion of bone marrow to have low densitometric values on both QCT and DEXA. There was substantial agreement between the 2 methods, but DEXA had a higher number of false positives. Instrumental diagnostic protocol may be thus planned as follows: 1) conventional radiography; 2) bone marrow scintigraphy; 3) bone densitometry of lumbar spine, with QCT. The patient is then to be followed with conventional and/or digital radiography in symptomatic locations, and with bone scintigraphy.

Destructive spondyloarthropathy and radiographic follow-up in hemodialysis patients

Nine patients undergoing regular dialytic treatment for more than 60 months showed clinical and radiologic features of a noninfective and destructive spondyloarthropathy. The cervical spine was most affected (100%), followed by the dorsal (three patients, 33.3%) and the lumbar spine (two patients, 22.2%). Typically, radiographs and CT scans revealed narrowing of intervertebral spaces, with destruction or sclerosis of the subchondral bone of the vertebral plate. Autopsy was performed on three patients; histologic study demonstrated the presence of large amyloid deposits containing beta 2-microglobulin (beta 2-m) in the discs and peridiscal ligaments. A radiographic follow-up of the cervical spine was performed in seven patients after a period of 12 months and showed that the bone destruction in DSA is very rapid and progressive. The lower biocompatibility of the cuprophan membranes of dialyzers is probably the factor most responsible for hyperproduction of beta 2-m and subsequently osteoarticular deposition of a new type of amyloidosis.

[Synopsis of wrist pathology. Xeroradiography vs digital radiology]

Pathologic conditions of the wrist involve both musculoskeletal structures (bones and joints) and soft tissues, of which fat pads are an important diagnostic aid to recognize various disorders. The authors report their 5-year experience with Xeroradiography in the diagnosis of various pathologic conditions (e.g., inflammatory, degenerative, and tumoral conditions) of the wrist. The importance of Xeroradiography was emphasized, in the past, because of its characteristic technical properties, especially in demonstrating lower-density tissues tumors. The main advantage of Xeroradiography is the physical phenomenon known as edge effect, which increases image contrast at the borders. Other differences between xeroradiography and conventional radiography are: broader recording latitude of the former, together with its higher resolution power (100 lines/mm), and high exposition power (which makes repeats useless). Thus, Xeroradiography allows the contemporary depiction of various and different structures and densities--e.g., bones and soft tissues. Unfortunately, radiation dose to the patient is higher during Xeroradiography than during conventional radiography. That is why digital radiography has nowadays replaced Xeroradiography. In fact, the former provides images that are comparable with those obtained by means of conventional radiography and--sometimes--even with xeroradiographic images. Moreover, the use of digital radiography allows radiation dose to the patient to be markedly reduced, whereas recording latitude remains the same.

[Involvement of the temporomandibular joint in rheumatoid arthritis]

A tomographic investigation was performed on 51 randomly-selected rheumatic patients, according to American Rheumatism Association criteria. Fourteen males and 37 females, aged 26 to 73 (mean age 50.9) were examined in order to identify the prevalence of temporo-mandibular joint involvement. By means of a special examination form, a contemporary clinical survey of both signs and symptoms of mandibular dysfunction was also conducted: the data were used for calculating the Helkimo anamnestic and clinical dysfunction indices. As for X-ray diagnosis, and original linear and angular analysis was proposed to measure the relationship between condyle and fossa in intercuspal position and during opening: the anterior joint space often increased and protrusive condylar path was reduced in more than 41% of patients. Structural changes were also evaluated by classifying the shape of both the condyle and the glenoid fossa (rounded, wedge-shaped and flattened). A special score was used to quantify these morphological features: only 4% of the whole of joints resulted uninjured. The most involved joint portions were the articular tubercle and the anterior condylar pole. Many cases were demonstrated of marked resorption and remodelling of the condyle, of increased joint space and erosion of the fossa; in other instances, reduced joint spaces and sclerosis were observed, depending on associated degenerative arthritis (usually more painful). Sex and age differences were not significant. Severity of clinical dysfunction and seriousness of the lesions coincided, whereas subjective symptoms were relatively independent. At any rate, the survey demonstrated a clear prevalence of structural, as well as functional, involvement of the temporo-mandibular joint in rheumatoid arthritis and suggested a more careful and multimodal therapeutic approach.

The "lamellated" skull in beta-thalassaemia

The skull in homozygous beta-thalassaemia may present several abnormalities, such as osteopenia, widening of the diploic space, and a "hair-on-end" appearance. In some cases it presents also a particular stratified appearance caused by a variable number of osseous lamellae, parallel with the inner table. This "lamellated skull" was observed in 16 out of 150 patients affected by the disease (10.6%). Possible mechanisms are discussed. The lamellar osseous changes could be due to repeated periosteal osteoblastic reactions to the sinusoidal neovascularization associated with marrow hyperplasia in poorly transfused patients.

[Echographic diagnosis of Peyronie's disease]

Thirty-six patients with Peyronie's disease were evaluated with diagnostic sonography. Radiographic and/or xeroradiographic examinations were also performed on 23 patients. Sonography could demonstrate the presence of the plaques characteristic of the disease in the majority of cases (94.5%), whereas only calcified lesions were depicted by conventional X-rays. Sonography is therefore recommended for its well-known advantages over other techniques, not only as the diagnostic methodology of choice, but also in the follow-up of the disease.

[The "lamellar cranium": a particular radiologic feature of Cooley's disease]

The skull in homozygous beta-thalassemia (Cooley's anemia) may present with several abnormalities, such as osteopenia, widening of the diploic space, and a "hair on end" appearance. In some cases it presents also a particular stratified aspect owing to a variable number of osseous lamellae, arranged so as to be parallel to the inner table. This "lamellated skull" was observed in 16 patients, selected from 150 patients with Cooley's anemia (10.6%). The possible mechanisms are discussed. The pluristratified lamellar osseous production could be brought about by repeated periosteal osteoblastic reaction to the sinusoidal neovascularization associated with marrow hyperplasia in poorly or not at all transfused patients.

The radiographic appearances following adequate transfusion in beta-thalassaemia

The main lesions of the skull and hand, observed in a group of hypertransfused beta-thalassaemic patients, are compared with a control group of low-transfused patients. Bony abnormalities reflect the relationship between proliferating bone marrow and bone cortex, and hypertransfusion therapy will prevent development of lesions only if established early in life. If this is done, the diploë in the skull may become normal, overgrowth of facial bone is moderate, pneumatisation of the paranasal sinuses is not completely prevented, and the "hair-brush" pattern may disappear completely. A normal appearance of the hand in adequately treated patients differentiates between prepubertal patients and adults.

[Radiology of the foot in chronic alcoholism]

The authors have reviewed the radiographic patterns of the foot in 28 patients affected by neuropathic joint disease complicating alcoholism, out of a series of 82 chronic alcoholic patients. Sixteen of them were also affected by diabetes mellitus. On the basis of X-ray findings, lesions were divided into three groups, reflecting the evolution of the disease: 1) early changes, especially affecting the soft tissues and joints; 2) definite lesions, consisting of fractures, osteolysis, bone destruction and amputation, periarticular debris; 3) "healing" signs, simulating degenerative joint disease, which cause severe and weakening deformities. Tabes dorsalis and diabetic osteoarthropathy must be differentiated from alcohol-induced syndrome. Even though a correct differential diagnosis is often difficult to reach, it must be kept in mind that focal/diffuse osteopenia is the most characteristic manifestation of alcoholic osteopathy, whereas different radiographic findings simulate chronic degenerative arthropathies.