Association between intervertebral disc degeneration and the Oswestry Disability Index

BACKGROUND

Low back pain and lumbar intervertebral disc degeneration (IDD) are common findings. Valid data on correlation between clinical pain scores and grades of IDD are not available.

OBJECTIVE

To investigate the correlation of intervertebral disc degeneration (IDD) at lumbar levels L4/5 and L5/S1 and the Oswestry Disability Index (ODI).

METHODS

The lumbar discs L4/5 and L5/S1 of 591 patients were evaluated according to the 5-point (Grade I to Grade V) grading system as published by Pfirrmann et al. Functional status was assessed using the Oswestry Disability Index. Spearman's coefficient of rank correlation was used for statistical analysis (p < 0.05).

RESULTS

The majority of patients revealed lumbar discs with Pfirrmann grade II to grade IV changes (93.3% at level L4/5; 89.8% at level L5/S1), while a relatively low percentage of lumbar discs presented with grade I (level L4/5: 1.5%; level L5/S1: 2.0%) or grade V (level L4/5: 5.1%; level L5/S1: 8.1%) changes, respectively. Patients' ODI scores ranged between 0 and 91.11% (arithmetic mean of 32.77% ± 17.02%). The largest group of patients (48.39%) had moderate functional disability (ODI score between 21 and 40%). There was a weak, but statistically significant positive correlation between IDD and ODI for both evaluated lumbar levels.

CONCLUSIONS

Increased lumbar IDD in MRI goes along with an increased ODI. Thus, MRI is a strong indicator of a patient's clinical appearance. However, low back pain cannot be explained by imaging alone. Clinical correlation is imperative for an adequate diagnostic advance in patients with low back pain.

Correlation of lumbar lateral recess stenosis in magnetic resonance imaging and clinical symptoms

AIM

To assess the correlation of lateral recess stenosis (LRS) of lumbar segments L4/5 and L5/S1 and the Oswestry Disability Index (ODI).

METHODS

Nine hundred and twenty-seven patients with history of low back pain were included in this uncontrolled study. On magnetic resonance images (MRI) the lateral recesses (LR) at lumbar levels L4/5 and L5/S1 were evaluated and each nerve root was classified into a 4-point grading scale (Grade 0-3) as normal, not deviated, deviated or compressed. Patient symptoms and disability were assessed using ODI. The Spearman’s rank correlation coefficient was used for statistical analysis (P < 0.05).

RESULTS

Approximately half of the LR revealed stenosis (grade 1-3; 52% at level L4/5 and 42% at level L5/S1) with 2.2% and 1.9% respectively reveal a nerve root compression. The ODI score ranged from 0%-91.11% with an arithmetic mean of 34.06% ± 16.89%. We observed a very weak statistically significant positive correlation between ODI and LRS at lumbar levels L4/5 and L5/S1, each bilaterally (L4/5 left: rho < 0.105, P < 0.01; L4/5 right: rho < 0.111, P < 0.01; L5/S1 left: rho 0.128, P < 0.01; L5/S1 right: rho < 0.157, P < 0.001).

CONCLUSION

Although MRI is the standard imaging tool for diagnosing lumbar spinal stenosis, this study showed only a weak correlation of LRS on MRI and clinical findings. This can be attributed to a number of reasons outlined in this study, underlining that imaging findings alone are not sufficient to establish a reliable diagnosis for patients with LRS.

Does therapist’s attitude affect clinical outcome of lumbar facet joint injections?

AIM: To investigate if the clinical outcome of intra-articular lumbar facet joint injections is affected by the therapist’s attitude.

METHODS: A total of 40 patients with facet joint-associated chronic low back pain were randomly divided into two groups. All patients received computed tomography-guided, monosegmental intra-articular facet joint injections. Following the therapeutic procedure, the patients of the experimental group (EG) held a conversation with the radiologist in a comfortable atmosphere. During the dialog, the patients were encouraged to ask questions and were shown four images. The patients of the control group (CG) left the clinic without any further contact with the radiologist. Outcome was assessed using a pain-based Verbal Numeric Scale at baseline, at 1 wk and at 1, 3, and 6 mo after first treatment.

RESULTS: The patient demographics showed no differences between the groups. The patients of the EG received 57 interventional procedures in total, while the patients of the CG received 70 interventional procedures. In both groups, the pain scores decreased significantly over the entire observation period. Compared to the CG, the EG showed a statistically significant reduction of pain at 1 wk and 1 mo post-treatment, while at 3 and 6 mo after treatment, there were no significant differences between both groups.

CONCLUSION: Our results show a significant effect on pain relief during the early post-interventional period in the EG as compared to the CG. The basic principle behind the higher efficacy might be the phenomenon of hetero-suggestion.

Association between facet joint osteoarthritis and the Oswestry Disability Index

AIM: To investigate the correlation of facet joint osteoarthritis (FJOA) at lumbar levels L4/L5 and L5/S1 and the Oswestry Disability Index (ODI).

METHODS: The study involved lumbar MRIs of 591 patients with a mean age of 47.3 years. The MRIs of the lumbar spine were performed on a 1.5 Tesla scanner (Magnetom^® Avanto, Siemens AG, Erlangen, Germany) using a dedicated receive only spine coil. After initial blinding, each dataset was evaluated by 2 board certified radiologist with more than 5 years experience in musculoskeletal imaging. In total 2364 facet joints were graded. Degenerative changes of the facet joints were evaluated according to the 4-point scale as proposed by Weishaupt et al Functional status was assessed using the ODI. The index is scored from 0 to 100 and interpreted as follows: 0%-20%, minimal disability; 20%-40%, moderate disability; 40%-60%, severe disability; 60%-80%, crippled; 80%-100%, patients are bedbound. Spearman’s coefficient of rank correlation was used for statistical analysis, with significance set at P < 0.05.

RESULTS: In total 2364 facet joints at lumbar levels L4/5 and L5/S1 were analysed in 591 individuals. FJOA was present in 97% (L4/L5) and 98% (L5/S1). At level L4/5 (left/right) 17/15 (2.9%/2.5%) were described as grade 0, 146/147 (24.7%/24.9%) as grade 1, 290/302 (49.1%/51.1%) as grade 2 and 138/127 (23.4%/21.5%) as grade 3. At level L5/S1 (left/right) 10/11 (1.7%/1.9%) were described as grade 0, 136/136 (23.0%/23.0%) as grade 1, 318/325 (53.8%/55.0%) as grade 2 and 127/119 (21.5%/20.1%) as grade 3. Regarding the ODI scores, patients’ disability had a minimum of 0% and a maximum of 91.11% with an arithmetic mean of 32.77% ± 17.02%. The majority of patients (48.39%) had moderate functional disability (21%-40%). There was no significant correlation between FJOA and ODI on both sides of lumbar level L4/5 and on the left side of lumbar level L5/S1. A weak positive correlation was evaluated between ODI and FJOA on the right side of lumbar level L5/S1.

CONCLUSION: The missing correlation of FJOA and ODI confirms our clinical experience that imaging alone is an insufficient approach explaining low back pain. Clinical correlation is imperative for an adequate diagnostic advance in patients with low back pain.

The value of putaminal diffusion imaging versus 18-fluorodeoxyglucose positron emission tomography for the differential diagnosis of the Parkinson variant of multiple system atrophy

Differentiating the Parkinson variant of multiple system atrophy (MSA-P) from idiopathic Parkinson's disease (PD) and other forms of atypical parkinsonism can be difficult because symptoms overlap considerably. 18-Fluorodeoxyglucose positron emission tomography (FDG-PET) is a powerful imaging technique that can assist in the diagnosis of MSA-P via detection of putaminal and cerebellar hypometabolism. Recent studies suggest that diffusion-weighted imaging (DWI) might be of similar diagnostic value, as it can detect microstructural damage in the putamen by means of an increased mean diffusivity (MD). The aim of this study was a direct comparison of DWI and FDG-PET by using both methods on the same subject cohort. To this end, combined DWI and FDG-PET were employed in patients with MSA-P (n = 11), PD (n = 13), progressive supranuclear palsy (n = 8), and in 6 control subjects. MD values and FDG uptake ratios were derived from volumetric parcellations of the putamen and subjected to further analysis of covariance (ANCOVA) and receiver operating characteristics analyses. MSA-P was found to be associated with an increased posterior putaminal MD (P < 0.001 in all subgroup comparisons) that correlated strongly with local reductions in FDG uptake (r = -0.85, P = 0.002). DWI discriminated patients with MSA-P from other subgroups nearly as accurately as FDG-PET (area under the curve = 0.89 vs 0.95, P = 0.27 [pooled data]). Our data suggest a close association between the amount of putaminal microstructural damage and a reduced energy metabolism in patients with MSA-P. The clinical use of DWI for the differential diagnosis of MSA-P is encouraged.

Paraneoplastic cerebellar degeneration associated with lymphoepithelial carcinoma of the tonsil

Background

Paraneoplastic cerebellar degeneration (PCD) is a classical tumor-associated, immune-mediated disease typically associated with gynecological malignancies, small-cell lung-cancer or lymphoma.

Case presentation

Here we present the case of a 38-year old male with an over 12 months rapidly progressive cerebellar syndrome. Extensive diagnostic workup revealed selective hypermetabolism of the right tonsil in whole-body PET. Histological examination after tonsillectomy demonstrated a lymphoepithelial carcinoma of the tonsil and the tongue base strongly suggesting a paraneoplastic cause of the cerebellar syndrome. To the best of our knowledge this is the first case of an association of a lymphoepithelial carcinoma, a rare pharyngeal tumor, with PCD.

Conclusions

In cases of classical paraneoplastic syndromes an extensive search for neoplasms should be performed including whole-body PET to detect tumors early in the course of the disease.

[The influence of cardiopulmonary bypass operation on the biodistribution of 99mTc-HMPAO-labelled granulocytes - Evaluation in pigs by planar scintigraphy and section-analyses]

AIM

of the study was to evaluate the influence of an extra corporal perfusion (cardiopulmonary bypass operation - cpb) on activation and biodistribution of (99m)Tc labelled granulocytes in pigs with and without inhibition of the granulocytes by a leukocyte inhibition module (LIM). The cpb is often related to an activation of granulocytes resulting in an inflammatory answer. The biological mechanisms are unsolved yet. First trials of our group showed that LIM may inhibit the activation of neutrophils and therefore antagonize a cpb-caused impairment of cardiac function. This study is the continuation of these experiments with a higher number of animals and the focus on scintigraphic imaging. ANIMALS, MATERIAL, METHODS: 39 German landrace pigs were subdivided into three groups: group A (control) median sternotomy without cpb, group B with cpb, group C with LIM in addition to cpb. After labelling with (99m)Tc-HMPAO autologues granulocytes were reinjected. Subsequently to cpb, the animals underwent scintigraphic imaging. Quantification was performed with ROI evaluation and with tissue samples (section analysis) examined in a well counter.

RESULTS

A high uptake of (99m)Tc-HMPAO was found in the liver. The count rates in brain, heart, lung, spleen and kidneys were far below. The amount of 99mTc-activity in the organ related to the half life corrected administered activity [%] was for the tissue samples (group A/B/C): brain 0.01/0.02/0.03; lung 12.1/8.3/11.5; heart 0.35/0.54/0.42; kidney 1.24/0.87/1.02; spleen 4.0/4.0/4.5, liver 16.8/20.9/19.6. The count rates determined by ROI-evaluation of the scintigraphic images related to the total count rate in the image [%] were (group A/B/C): brain 1.1/0.9/1.0; lung 15.6/10.4/12.2; heart 4.0/3.5/3.4; kidney 4.0/2.9/3.2; spleen 7.6/7.7/9.5, liver 23.1/36.7/31.4. A significant difference in the tracer uptake between the groups could neither be detected by scintigraphic imaging nor evaluation of tissue samples.

CONCLUSION

Scintigraphic imaging as well as section analysis showed a comparable biodistribution of the tracer. Therefore, the initial results of our group were not confirmed with a considerably higher number of animals. Neither cpb nor the use of the LIM influenced distribution of 99mTc-labelled granulocytes in pigs significantly.

Update on recent developments in the therapy of differentiated thyroid cancer

In the past decade, the management of differentiated thyroid carcinoma changed significantly and thus contributed to the improvement of the already favorable prognosis of this malignant disease. Surgical treatment techniques improved and the extent of initial surgery is more individualized. Radioiodine therapy is an essential part of therapeutic regimens in almost all cases, and the use of recombinant human thyroid-stimulating hormone has established for ablation of remnant tissue, treatment of iodine-positive cancer, and sensitive thyroglobulin measurement during follow-up. Risk stratification has become more important to plan treatment and follow-up individually, particularly to evaluate the need for thyroid-stimulating hormone suppression therapy. Especially for inoperable and radioiodine-negative thyroid carcinomas, novel treatment options such as tyrosine kinase inhibitor therapy have emerged. This article deals with the current options of optimal therapy regimens in differentiated thyroid carcinoma.

Initial experience with 18F-fluoroethylcholine PET/CT in staging and monitoring therapy response of advanced renal cell carcinoma

OBJECTIVE

The use of 18F-fluoroethylcholine (FEC) PET/ CT in staging and monitoring therapy response of advanced renal cell carcinoma (RCC) was prospectively analysed.

METHODS

Preliminary results of two patients with metastatic RCC who underwent tumour nephrectomy as well as FEC PET/CT before and 10 weeks after two cycles of tyrosine kinase inhibitor therapy are presented.

RESULTS

All in all, 18 tumour lesions were detected by baseline PET/CT, of which 10 (56%) were positive in FEC PET and 17 (94%) visible on contrast-enhanced computed tomography (ceCT). Mainly, small lung metastases resulted in the lower detection rate of FEC PET compared with ceCT. In follow-up PET/CT of the first case, progressive disease (PD) occurred with increase in tumour diameters of all metastases but non-uniform metabolic response. In the second case, partial response (PR) was achieved with concordant results of PET and CT. These results were confirmed by further CT in the course of disease.

CONCLUSIONS

In this small sample more than half of the RCC metastases were evident in baseline FEC PET. Monitoring therapy, FEC PET showed heterogeneous results in the first case with PD and was consistent with ceCT in the second one displaying PR.

Comparison of positron emission tomography with [(18)F]FDG and [(68)Ga]DOTATOC in recurrent differentiated thyroid cancer: preliminary data

AIM

The aim of this study was to retrospectively analyse the value of positron emission tomography (PET) with a radiolabelled somatostatin analogue, [(68)Ga]DOTATOC, in recurrent radioiodine positive and negative differentiated thyroid cancer (DTC) compared to [(18)F]FDG PET.

METHODS

Seventeen patients with known or suspected recurrent DTC were enrolled in this study. All patients underwent PET with [(68)Ga]DOTATOC and [(18)F]FDG under TSH suppressive therapy and whole-body scintigraphy (WBS) after administration of [(131)I] following TSH stimulation. The total number of tumour lesions was defined as the sum of the lesions detected by at least one of these three imaging techniques. Pathologic findings were confirmed histopathologically or by follow-up and conventional radiological imaging.

RESULTS

Both PET tracers consistently detected metastases in 12 patients. In two cases, only [(131)I] WBS and computed tomography revealed metastatic disease; in the remaining three patients with an increased thyroglobulin no correlate could be found. From a total of 104 tumour lesions, [(18)F]FDG PET showed only slightly higher detection rate than [(68)Ga]DOTATOC PET in radioiodine positive patients (28/31 versus 25/31), whereas significant differences were seen in the group with negative [(131)I] WBS (70/73 versus 26/73, P<0.01). Three out of 104 lesions were only visible using [(68)Ga]DOTATOC PET.

CONCLUSIONS

[(68)Ga]DOTATOC and [(18)F]FDG PET showed comparable diagnostic performance in recurrent, radioiodine positive DTC. Due to much higher lesion detection rates, [(18)F]FDG PET should be preferred to [(68)Ga]DOTATOC PET in the work-up of radioiodine negative DTC relapse. These preliminary results have to be confirmed by more extensive data in further studies.