Extension MRI is clinically useful in cervical myelopathy

INTRODUCTION

Cervical spine MRI with the neck in extension has been well described over the last 10 years, but its clinical value remains unknown.

METHODS

We performed extension imaging in 60 patients in whom the initial neutral study showed borderline cord compression. Images were assessed using a previously validated grading system for cord compression. Multiple linear and area measurements were also obtained. Images were scored blindly and randomly. Inter- and intra-rater variability were determined in a subset of 20 cases. Independent clinical assessment utilised the Ranwat criteria.

RESULTS

For most parameters inter/intra-observer variance of kappa/ICC > 0.6 was highly satisfactory. Standard MR was poor at discriminating between patients with and without myelopathy (ROC analysis, area under the curve (AUC), 0.52). This was considerably improved with extension imaging (AUC, 0.60), or by using the change in compression score between neutral and extension studies. Most measurements were not helpful; however, the ratio of cord area/CSF area at the level of maximum compression on extended images was the best discriminator (AUC, 0.71), as well as the presence of T2 change in cord substance (AUC, 0.68).

CONCLUSION

This is the first study to demonstrate added clinical value utilising extension MRI. In this cohort of difficult patients, when there was no T2 signal change in the cord, the presence of clinical myelopathy could only be predicted by utilising the data from extension imaging.

MRI of the cervical spine with neck extension: is it useful?

OBJECTIVES

Standard MRI of the cervical spine is performed in a different anatomical position to that utilised for traditional contrast myelography. Those well practised in myelography are familiar with the considerable changes in configuration of the bony and soft tissues of the cervical spine that may occur with changes in the degree of neck flexion and extension. We set out to compare the findings in a select group of patients with myeloradiculopathy who had undergone myelography and MRI in both standard and neck-extended positions. These findings were correlated with the clinical status.

METHODS

29 patients underwent myelography with CT (CTM) and MRI in neutral and neck-extended positions. The imaging was assessed for the degree of cord compression and neural foraminal narrowing, quantified using a simple grading scheme suitable for routine clinical practice. The degree of neck extension was assessed using an angular measurement.

RESULTS

For both CTM and MRI, scanning with the neck extended significantly increases the severity of cord compression compared with the standard supine position, to a degree similar to that shown during conventional prone myelography. The degree of perceived cord compression is related to the degree of neck extension achieved. Correlation of standard MRI findings and the clinical level of radiculopathy is poor. This correlation improves when the neck is extended.

CONCLUSIONS

The most appropriate position for routine MRI of the cervical spine in degenerative disease remains unknown, but in selected patients imaging with the neck extended may provide important additional information.

Focal dermal hypoplasia with subependymal heterotopia and hypoplastic corpus callosum

A case is reported with right-sided abnormalities involving the brain, eyelid, eye, face and chest. The features described are similar to those found in conditions including focal dermal hypoplasia, microphthalmia with linear skin defects, oculocerebrocutaneous syndrome and terminal osseous dysplasia and pigmentary defects. However, none of these conditions, fully explains the collection of abnormalities found in this patient.

Transient global amnesia in a patient with acute unilateral caudate nucleus ischemia

The pathogenesis and localization of neuronal dysfunction in transient global amnesia (TGA) is still disputed more than 40 years after the first description of this clinical entity. Previous studies have indicated that structural abnormality is rare in TGA. We report a case of TGA in a patient with acute ischemia in the body of right caudate nucleus. This provides evidence in support of an ischemic hypothesis as the possible etiology of TGA. The role of caudate nucleus in human memory is also reviewed.

Richter's syndrome: a novel presentation

Images