MR Neurography and Quantitative Muscle MRI of Parsonage Turner Syndrome Involving the Long Thoracic Nerve

BACKGROUND

Parsonage-Turner syndrome (PTS) is characterized by severe, acute upper extremity pain and subsequent paresis and most commonly involves the long thoracic nerve (LTN). While MR neurography (MRN) can detect LTN hourglass-like constrictions (HGCs), quantitative muscle MRI (qMRI) can quantify serratus anterior muscle (SAM) neurogenic changes.

PURPOSE/HYPOTHESIS

1) To characterize qMRI findings in LTN-involved PTS. 2) To investigate associations between qMRI and clinical assessments of HGCs/electromyography (EMG).

STUDY TYPE

Prospective.

POPULATION

30 PTS subjects (25 M/5 F, mean/range age = 39/15-67 years) with LTN involvement who underwent bilateral chest wall qMRI and unilateral brachial plexus MRN.

FIELD STRENGTH/SEQUENCES

3.0 Tesla/multiecho spin-echo T2-mapping, diffusion-weighted echo-planar-imaging, multiecho gradient echo.

ASSESSMENT

qMRI was performed to obtain T2, muscle diameter fat fraction (FF), and cross-sectional area of the SAM. Clinical reports of MRN and EMG were obtained; from MRN, the number of HGCs; from EMG, SAM measurements of motor unit recruitment levels, fibrillations, and positive sharp waves. qMRI/MRN were performed within 90 days of EMG. EMG was performed on average 185 days from symptom onset (all ≥2 weeks from symptom onset) and 5 days preceding MRI.

STATISTICAL TESTS

Paired t-tests were used to compare qMRI measures in the affected SAM versus the contralateral, unaffected side (P < 0.05 deemed statistically significant). Kendall's tau was used to determine associations between qMRI against HGCs and EMG.

RESULTS

Relative to the unaffected SAM, the affected SAM had increased T2 (50.42 ± 6.62 vs. 39.09 ± 4.23 msec) and FF (8.45 ± 9.69 vs. 4.03% ± 1.97%), and decreased muscle diameter (74.26 ± 21.54 vs. 88.73 ± 17.61 μm) and cross-sectional area (9.21 ± 3.75 vs. 16.77 ± 6.40 mm2). There were weak to negligible associations (tau = -0.229 to <0.001, P = 0.054-1.00) between individual qMRI biomarkers and clinical assessments of HGCs and EMG.

DATA CONCLUSION

qMRI changes in the SAM were observed in subjects with PTS involving the LTN.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 1.

[Neuralgic amyotrophy: an inflammatory neuropathy and its surgical treatment]

BACKGROUND

Neuralgic amyotrophy (NA) is a monofocal or oligofocal inflammatory neuropathy whose incidence has been significantly underestimated. A connection between constrictions and torsions of peripheral nerves with this disease has been increasingly established in recent years. Modern imaging techniques such as high-resolution nerve ultrasound and MR neurography have contributed to a better understanding of the pathophysiology and a better assessment of the prognosis of the disease. This has led to the concept of treating patients with such focal changes surgically in order to improve the prognosis. This review presents current ideas on the pathophysiology, clinical presentation, diagnosis and treatment of the disease.

PATIENTS AND METHODS

In a retrospective study, pre-, intra- and postoperative findings of 22 patients with 23 constrictions/torsions of peripheral nerves of the upper extremity were analysed. The patients underwent surgery at a nerve surgery centre over a period of 3.5 years (Dec. 2019-May 2023). The median nerve was most frequently affected (N=9), followed by the suprascapular nerve (N=6) and radial nerve (N=4). The axillary nerve (N=3) and the accessory nerve (N=1) were also involved. Surgical exploration revealed nerve torsions (N=9), nerve constrictions (N=5), fascicular torsions (N=12) and fascicular constrictions (N=9). Depending on the intraoperative findings, epineuriotomies (N=1), epi- and perineuriotomies (N=33), end-to-end sutures (N=2), and one epi- and one perineural suture were performed.

RESULTS

After an average follow-up of 10 months (3-28 months), 17 patients were re-examined. All of them reported a clear subjective improvement in motor deficits. Clinically and electromyographically, a reinnervation and significant increase in strength from a pre-existing strength grade of M0 to at least M3 in the vast majority of affected muscles was demonstrated in these patients.

SUMMARY

The incidence of NA continues to be underestimated and, in a significant proportion of patients, leads to permanent motor deficits, most likely due to constrictions and torsions of affected nerves. Surgical treatment is recommended as early as possible. Very good results can usually be achieved with epi- and perineuriotomy. In rare cases, end-to-end neurorrhaphy or nerve grafting is required.

[MR neurography reveals fascicular constriction of the median nerve in a patient with neuralgic amyotrophy]

Diagnosing neuralgic amyotrophy can be challenging in clinical practice. Here, we report the case of a 37-years old Japanese woman who suddenly developed neuropathic pain in the right upper limb after influenza vaccination. The pain, especially at night, was severe and unrelenting, which disturbed her sleep. However, X-ray and MRI did not reveal any fractures or muscle injuries, and brain MRI did not reveal any abnormalities. During neurological consultation, she was in a posture of flexion at the elbow and adduction at the shoulder. Manual muscle testing suggested weakness of the flexor pollicis longus, pronator quadratus, flexor carpi radialis (FCR), and pronator teres (PT), while the flexor digitorum profundus was intact. Medical history and neurological examination suggested neuralgic amyotrophy, particularly anterior interosseous nerve syndrome (AINS) with PT/FCR involvement. Innervation patterns on muscle MRI were compatible with the clinical findings. Conservative treatment with pain medication and oral corticosteroids relieved the pain to minimum discomfort, whereas weakness remained for approximately 3 months. For surgical exploration, lesions above the elbow and fascicles of the median nerve before branching to the PT/FCR were indicated on neurological examinations; thus, we performed high-resolution imaging to detect possible pathognomonic fascicular constrictions. While fascicular constrictions were not evident on ultrasonography, MR neurography indicated fascicular constriction proximal to the elbow joint line, of which the medial topographical regions of the median nerve were abnormally enlarged and showed marked hyperintensity on short-tau inversion recovery. In patients with AINS, when spontaneous regeneration cannot be expected, timely surgical exploration should be considered for a good outcome. In our case, MR neurography was a useful modality for assessing fascicular constrictions when the imaging protocols were appropriately optimized based on clinical assessment.

COVID-19 Vaccine Related Cervical Radiculitis and Parsonage-Turner Syndrome: Case Report and Review of the Literature

Parsonage-Turner Syndrome, or neuralgic amyotrophy, is an acute-onset upper limb and shoulder girdle palsy that can occur in a post-viral, post-surgical or idiopathic setting. There have also been some reported cases of the syndrome occurring following vaccinations. The pathophysiology of neuralgic amyotrophy is not completely understood and many of the commonly used diagnostic imaging modalities we use to try and diagnose this syndrome are inaccurate and misleading. We present the case of a 40-year-old gentleman who presented with acute onset burning pain and fasciculations in his right upper extremity following vaccination with the second dose of the Pfizer-BioNTech COVID-19 vaccine. His symptoms progressed to weakness in isolated muscle groups with electromyographic evidence of decreased nerve conduction. MRI of the cervical spine demonstrated multilevel central and foraminal stenosis, suggesting a diagnosis of cervical radiculopathy. The patient underwent a C4-5/C5-6 and C6-7 laminoforaminotomy and tolerated the procedure well. Post-operatively, the patient has experienced gradual symptom improvement with residual right triceps and pectoralis muscle weakness as well as paresthesias of the right elbow and forearm. Parsonage-Turner Syndrome is a brachial plexus palsy that can affect one or multiple branches of the brachial plexus. It causes acute-onset pain and weakness, and the diagnosis can be difficult to make with the commonly used diagnostic imaging methods. We reviewed other case reports about neuralgic amyotrophy following vaccinations as well as the current literature on more accurate diagnostic imaging modalities that may help our diagnosis and understanding of the pathophysiology of this condition.

High-resolution MR neurography follow-up of SARS-CoV-2 vaccination-associated neuralgic amyotrophy

Little is known about the value of high-resolution follow-up imaging in patients with neuralgic amyotrophy (NA) and the question of the best treatment algorithm remains unclear. Three patients (one female, two male) with the clinical presentation of SARS-CoV-2-vaccination-associated NA underwent initial magnetic resonance neurography (MRN) imaging and follow-up examinations. All patients showed a marked clinical improvement, independent of treatment, including an almost full recovery of motor function over the course of 8-12 months which was accurately mirrored by imaging findings on MRN. MRN imaging is a valuable tool for monitoring the further clinical course of patients suffering from vaccination-associated NA.

Neuralgic amyotrophy: sensitivity and specificity of magnetic resonance neurography in diagnosis: A retrospective study

BACKGROUND

Neuralgic amyotrophy (NA) is a clinically acute or subacute disease. To study the characteristics of brachial plexus magnetic resonance neurography (MRN) in patients with NA, and to explore the clinical application value of MRN combined with electromyography (EMG) in the diagnosis of NA.

METHODS

Brachial plexus MRN images of 32 patients with NA were retrospectively analyzed, and their characteristics were investigated. The accuracy, sensitivity and specificity of MRN, EMG, and the combination of the 2 methods for NA diagnosis were compared.

RESULTS

Among the 32 patients with NA, 28 (87.5%) cases of unilateral brachial plexus involvement, 18 (56.3%) cases of multiple nerve roots involvement. In 10 cases, C5 nerve roots were involved alone, and in 9 cases, C5 to C6 nerve roots were involved together. The T2 signal intensity of the affected nerve increased, and 19 cases showed thickened and smooth nerve root edges. Twelve cases showed uneven thickening and segmental stenosis of the involved nerve roots. The diagnostic accuracy, sensitivity, and specificity of MRN for NA were higher than those of EMG. Combining MRN and EMG could improve the sensitivity and specificity of diagnosis.

CONCLUSION

The main feature of MRN in patients with NA was that it was unilateral brachial plexus asymmetric involvement. The diagnostic effect of MRN was better than that of EMG. The combined diagnosis of MRN and EMG can help clinicians diagnose NA accurately.

Hereditary Neuralgic Amyotrophy with a Lesion Distal to the Brachial Plexus on Magnetic Resonance Imaging

A 35-year-old woman first experienced left upper limb weakness at 17 years old, after which it repeatedly recurred and then remitted. She was diagnosed with carpal tunnel syndrome with median nerve hyperintensity by magnetic resonance imaging (MRI). Surgical treatment was ineffective. We suspected hereditary neuralgic amyotrophy because of enlargement distal to the brachial plexus on MRI and administered steroid therapy, after which the weakness improved. Genetic testing revealed a point mutation in SEPT9. Because lesions outside the brachial plexus can be seen in hereditary neuralgic amyotrophy, the diagnosis should be based on typical characteristics and the family history.

Parsonage-Turner Syndrome Following COVID-19 Vaccination: MR Neurography

Vaccination is one of the several known triggers of Parsonage-Turner syndrome (PTS). This case series describes two individuals with clinical presentations of PTS whose symptoms began 13 hours and 18 days following receipt of the Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273 COVID-19 vaccine, respectively. The diagnosis of PTS was confirmed by using both electrodiagnostic testing and 3.0-T MR neurography. Although research is needed to understand the association between PTS and COVID-19 vaccination, MR neurography may be used to help confirm suspected cases of PTS as COVID-19 vaccines continue to be distributed worldwide.

Magnetic Resonance Neurography in a Patient with Distal Neuralgic Amyotrophy

The pathophysiology of neuralgic amyotrophy (NA) remains to be elucidated. However, high-resolution magnetic resonance imaging and ultrasound sonography have provided new insights into the mechanism underlying the development of NA and its diagnosis. We report a case of idiopathic distal NA with hyperintensity and thickening in the inferior trunk extending to the posterior and medial fasciculus of the left brachial plexus, which was detected by magnetic resonance neurography (MRN) with diffusion-weighted whole-body imaging with background body signal suppression (DWIBS). The abnormal signal intensity diminished after the improvement of symptoms following corticosteroid treatment. MRN with DWI can help diagnose distal NA and evaluate the post-therapeutic response.

Parsonage-turner syndrome associated with SARS-CoV2 (COVID-19) infection

Parsonage-Turner Syndrome (PTS), also known as idiopathic brachial plexopathy or neuralgic amyotrophy, is an uncommon condition characterized by acute onset of shoulder pain, most commonly unilateral, which may progress to neurologic deficits such as weakness and paresthesias (Feinberg and Radecki, 2010 [1]). Although the etiology and pathophysiology of PTS remains unclear, the syndrome has been reported in the postoperative, postinfectious, and post-vaccination settings, with recent viral illness reported as the most common associated risk factor (Beghi et al., 1985 [2]). Various viral, bacterial, and fungal infections have been reported to precede PTS, however, currently there are no reported cases of PTS in the setting of recent infection with SARS-CoV2 (COVID-19). We present a case of a 17 year old female patient with no significant past medical or surgical history who presented with several weeks of severe joint pain in the setting of a recent viral illness (SARS-CoV2, COVID-19). MRI of the left shoulder showed uniform increased T2 signal of the supraspinatus, infraspinatus, teres minor, teres major, and trapezius muscles, consistent with PTS. Bone marrow biopsy results excluded malignancy and hypereosinophilic syndrome as other possible etiologies. Additional rheumatologic work-up was also negative, suggesting the etiology of PTS in this patient to be related to recent infection with SARS-CoV2 (COVID-19). Radiologists should be aware of this possible etiology of shoulder pain as the number of cases of SARS-CoV2 (COVID-19) continues to rise worldwide.

Development of Parsonage-Turner Syndrome After Heat Stroke in Firefighters: A Report of 2 Cases

CASE

Two firefighters developed Parsonage-Turner syndrome (PTS) shortly after sustaining episodes of heat stroke. Patient 1 was a 40-year-old man who presented with shoulder pain and supraspinatus and infraspinatus weakness. Patient 2 was a 35-year-old man who presented with shoulder pain and absent external rotation strength. Both had electrodiagnostic testing and magnetic resonance imaging findings consistent with PTS. Both demonstrated partial but incomplete recovery at 1- and 2.5-year follow-ups, respectively.

CONCLUSIONS

PTS should remain on the differential diagnosis for any patient presenting with sudden onset shoulder pain and neurological deficits after an episode of heat-related illness.

A CARE-compliant article: a case report of idiopathic brachial neuritis treated with ultrasound-guided electroacupuncture

RATIONALE

Electroacupuncture is commonly used for treating nerve injury. However, studies published in recent years have not described an appropriate method for accurately identifying the location and depth of injured nerves beneath the acupoints.

PATIENT CONCERNS

A 26-year-old male patient had left shoulder pain and weakness after tetanus, diphtheria, and pertussis vaccination and was diagnosed with idiopathic brachial neuritis 24 months before this study. The patient had undergone prednisone and ibuprofen treatment in another hospital, but the therapeutic effect was poor and limited.

DIAGNOSES

The nerve conduction studies showed decreased amplitude over the left supraspinatus and deltoid muscles. Electromyography showed increased giant waves and polyphasic waves with reduced recruitments in the left deltoid muscle and increased giant waves with reduced recruitment in the left supraspinatus muscle. The condition was diagnosed with idiopathic brachial neuritis.

INTERVENTIONS

Ultrasound was used to identify the location and depth of axillary and suprascapular nerves, and direct electroacupuncture was conducted at the quadrangular space and suprascapular notch to stimulate the nerves. Other needles were placed according to deltoid and supraspinatus muscles origins and insertions. The procedure was conducted once a week, and rehabilitation activities were conducted daily.

OUTCOMES

The patient experienced significant improvements of left shoulder pain and muscle weakness after ultrasound-guided electroacupuncture treatment. The total shoulder pain and disability index score declined from 49.23% to 11.54%. The scores of both pain and disability domains improved and maintained stable declining after the intervention. The disability of the arm, shoulder; and hand scores declined from 60 to 23.3. According to amplitude data from nerve conduction studies, the injured axillary nerve showed remarkable improvement in the third month. Muscle strength improved to the normal state. The patient was generally satisfied with the ultrasound-guided electroacupuncture treatment.

LESSON

Ultrasound-guided electroacupuncture was based on anatomical correlations between nerves and muscles and on electrical stimulation theories. The results suggest that this intervention might be an alternative therapy for idiopathic brachial neuritis. Furthermore, in this study, it had minimal adverse effects. This therapy is demonstrated to be effective in future controlled studies.

Visceral disseminated varicella zoster virus infection with brachial plexus neuritis detected by fluorodeoxyglucose positron emission tomography and computed tomography

Varicella zoster virus (VZV) infection sometimes result in visceral disseminated VZV infection (VD-VZV), which is a fulminant disease featured by abdominal pain and the absence of skin lesions, particularly occurs in the immunosuppressive patients. Brachial plexus neuritis (BPN) is another rare type of VZV infection usually appears without blisters. Few diagnostic images of both VD-VZV and BPN-VZV have been reported. A 25-year-old woman receiving allogeneic hematopoietic stem cell transplantation (HSCT) for acute myeloid leukemia. Unexplained severe pain in the left upper extremity followed by severe stomachache, liver dysfunction and unconsciousness appeared on day 344 post-HSCT. Computed tomography (CT) showed left brachial plexus hypertrophy and edematous changes to the hepatoduodenal ligament, fluorodeoxyglucose positron emission tomography (FDG-PET) showed increased uptake in both lesions. Intravenous acyclovir therapy was started and successfully resolved all symptoms. Several days later, blisters appeared all over the body and positive VZV DNA from blood using polymerase chain reaction test was obtained. FDG-PET and CT may offer supportive findings for detecting or diagnosing blister-less VZV infectious diseases.

Chronic Brachial Plexus Neuritis That Developed into Typical Neuralgic Amyotrophy and Positively Responded to Immunotherapy

Based on the hypothesis that autoimmunity plays a role in the pathogenesis of neuralgic amyotrophy (NA), immunotherapy is sometimes administered. Early intervention is recommended for a good prognosis. We herein report the case of a 55-year-old man who presented with neuralgia, weakness, and muscle atrophy in his right shoulder girdle and upper arm, which progressed for ten months following a marine sports accident. The patient was diagnosed with NA. His neurological deficits gradually improved after several courses of immunotherapy, suggesting that in addition to being effective for treating early-stage disease, immunotherapy may be effective for treating chronic cases.

Winging of the scapula diagnosed as Parsonage-Turner syndrome: a case report

A 24-year-old active duty female Soldier complained of right shoulder burning, stinging, electrical shock-like pain with radiation to the right hand after completing a ruck march. She also complained of swelling and feelings of her cold right hand. Examination showed a deficit in the deltoid, upper trapezius, supraspinatus, and also right winging of the scapula. She also exhibited weakness to right arm, weak right hand grip, and decreased sensation over the dorsal right hand. The right hand was also noticed to be colder to touch than the left one. She had tenderness to palpation over right paracervical muscles from C3 to C7. A previous magnetic resonance arthrogram of the right shoulder revealed no findings. The cervical magnetic resonance imagery showed mild disc protrusion at C5-C6 without spinal cord impingement. Based on the history and the physical findings, the patient was diagnosed with Parsonage-Turner syndrome.

[Cervicobrachial neuralgia: frequent and sometimes very painful]

Cervicobrachial neuralgia. Cervicobrachial neuralgia is a common reason of rheumatologist consultation. It can be defined as cervicalgia associated with radicular pain of the upper limb, caused by a nerve compression. The most frequent cause is a soft disc herniation. Gravity signs have to be researched by a methodic physical exam: neurological deficit, medullar compression. Imagery is recommended: X-rays, tomodensitometry and/or MRI of cervical spine. The treatment is a combination of medicinal and non medicinal therapies, and in some cases, a surgical intervention is required.

Cervicobrachialgia and pancoast tumor: value of standard anteroposterior cervical radiographs in early diagnosis

Ten patients diagnosed with Pancoast tumor were studied retrospectively. The definitive diagnosis was made between 2 and 24 months after the onset of pain. Pain localization was hard to pinpoint; some patients reported pain in four different sites (neck, shoulder, arm, and scapula). Five patients had previously been diagnosed with degenerative, inflammatory, or infectious diseases of the cervical spine or shoulder. In the remaining five patients, the diagnosis was made during the first clinical visit. In three patients, an orthopedic surgeon made the diagnosis by viewing a standard anteroposterior (AP) cervical radiograph. The radiographic evidence arousing suspicion of a Pancoast tumor was the lack of pulmonary air at the top of the affected lung. Furthermore, a parallel study was conducted on 100 consecutive patients seeking treatment for neck pain. By examining the AP radiographs of their cervical spines, the third rib and the top of both lungs were observed in all cases. This study stresses the value of standard AP cervical radiographs in the diagnosis of Pancoast tumor.

[Imaging of the painful cervical spine]

Neck pain can occur in several circumstances: traumatic, spontaneous, associated or not with motion, with or without head or upper limb irradiations. Each case requires appropriate clinical examination and radiographs. CT and MRI can be used to obtain additional information. Myelography and arteriography are exceptionally used. Cervical discography and facet joint arthrography are used therapeutically. After a brief anatomical review, normal and pathological patterns will be reviewed using radiographs. Each circumstance is studied: traumatic, degenerative, inflammatory and tumoral. It is emphasized that discogenic cervico-brachial neuralgia usually has a favorable spontaneous outcome. A special chapter is dedicated to calcifying and ossifying diseases of the cervical spine. Cervico-occipital neuralgia is also discussed.

Dementia, amyotrophy, and periodic complexes on the electroencephalogram: a diagnostic challenge

BACKGROUND

The clinical diagnosis of neurodegenerative diseases is a challenge to the neurologist. In many cases the diagnosis becomes neuropathological only after the autopsy. Several consensus criteria have been defined for the clinical diagnosis of different neurodegenerative diseases, among them the various types of dementia as well as prion-induced diseases. When compared with neuropathological findings, these criteria have proved to be reasonably accurate for regular practice, research, and epidemiological studies. The problem arises when a combination of complementary and clinical data are obtained that do not easily match these diagnostic criteria.

CASE DESCRIPTION

We describe a patient with dementia and periodic complexes on an electroencephalogram, suggesting a diagnosis of sporadic Creutzfeldt-Jakob disease.

RESULTS

When the condition progressed, signs and symptoms of a motoneuron disease appeared. Thus, 2 different diagnoses were proposed: (1) an amyotrophic variant of a prion-induced disease; or (2) an ELA dementia syndrome with periodic complexes on the electroencephalogram, a finding that previously has not been described.

[Surgical outcome of single segment ventral fusion with plate osteosynthesis in therapy refractory chronic cervico-brachialgia]

INTRODUCTION

In anterior cervical stabilization, collapses of the grafted bone with resulting localized kyphosis and graft dislocation has been reported. It was the aim of this clinical trial to evaluate the benefit of additional plating while taking specific implant-related complications into account.

METHODS

The results of single level anterior cervical spinal fusion were evaluated. In 44 patients suffering from chronic cervical radicular pain with degenerative changes, arthrodesis with iliac-crest bone and plate fixation was performed. Apart from clinical parameters, the pre- and postoperative segmental kyphosis and cervical lordosis were evaluated.

RESULTS

The total cervical alignment increased from 15.4 degrees to 18.5 degrees while the alignment of the fused segment increased from 2.6 degrees to 7.7 degrees. Postoperative decrease of correction did not occur. Bony fusion was confirmed in 95% after 12 months and 100% aller 36 months. Our results show that patients had more relief from radicular pain (80%) than from unspecific neck pain (66%).

DISCUSSION

In single level anterior cervical fusion, additional plating successfully prevents dislocation of the bone graft and postoperative kyphosis. The clinical results and pseudarthrosis rate do not differ from studies without plating. Long. term follow-up studies are necessary to show the benefit of the reduced postoperative kyphosis.

Anatomical basics, variations, and degenerative changes of the shoulder joint and shoulder girdle

This paper summarizes the anatomical basics of the shoulder, their variations, and precise definitions, including differential diagnoses. It also describes the characteristic degenerative changes caused by aging. A typical variation (7-15%) is the os acromiale, which forms the triangular epiphysis of the scapular spine. This abnormality must be differentiated from a fracture of the acromion or a pseudarthrosis. Because ossification of the acromion is complete after age 25, the os acromiale should be diagnosed only after this age. The shape of the acromion is a further important feature. In a recent anatomical study, the following frequencies of the Bigliani-types of the acromial shape were anatomically determined - type 1 (flat), 10.2% and type 2 (curved), 89.8%. Type 3 (hooked) was not observed, which indicates that this type is probably a misinterpretation of the so-called acromial spur. Minor dehiscences and perforations in the infraspinate or supraspinate fossa should not be confused with malignant osteolyses. The scapula has three ligaments of its own, (1) the coracoacromial ligament and its osseous fixations form an osteofibrous arch above the shoulder joint, which plays a part in impingement syndrome; (2) the superior transverse scapular ligament or its ossified correlate arches the scapular incisure and can cause a typical compression syndrome of the suprascapular nerve; (3) the inferior transverse scapular ligament is of no great clinical importance. Two intraarticular structures (glenoid labrum and tendon of the long bicipital head) must be mentioned. The glenoid labrum consists of dense connective tissue and surrounds the margin of the glenoid cavity. Two areas exhibit specialized conditions, cranial at the supraglenoid tubercle an intimate relationship exists to the tendon of the long bicipital head and in about 55% of cases, the labrum is stretched over the glenoid rim at the ventral side. At the area of the biceps-tendon-labrum complex, so-called SLAP-lesions may occur and at the glenoid rim, where the labrum is often not fixed to the bony margin, avulsions of the labrum may occur. This well-established anatomical condition must not be mistaken for a manifest Bankart-lesion. The glenohumeral ligaments, which are located in the ventral articular capsule, have a stabilizing function for the ventral part of the glenoid labrum. The glenohumeral ligaments lift the articular lip where it crosses the glenoid notch. This 'labrum-lift effect' supports the stabilizing features of the articular lip and the glenohumeral ligaments. The rotator cuff is composed of the tendons of the teres minor, infraspinatus, supraspinatus, and subscapularis muscles. This cuff has a poorly vascularized area, due to mechanical conditions, about 1.5 cm from the major tubercle, which causes degenerative changes and eventually may lead to ruptures. Results of the impingement-syndrome and the osteoarthrotic changes of the shoulder and acromioclavicular joint are also presented and discussed. Finally, the coracoclavicular joint, which probably represents no congenital entity but appears due to a changed, lowered position of the shoulder girdle, is discussed. The paper also presents instructive figures of anatomical preparations that can be used to make more precise radiological and differential diagnoses. All preparations were done by the author and are part of a series of more than 300 preparations of the shoulder joint and girdle.

[Surgical therapy in radicular symptoms of the degenerative cervical spine]

Radicular pain is a common feature in day-to-day clinical practice. Only a small percentage of patients with persistent pain and/ or neurological deficit need surgical decompression. Exact anatomical localization of the decompressive agent and the correlation of clinical symptoms and radiological findings are mandatory. In most cases, surgery is performed by an anterior approach; by which the causative agent is removed. In cases with narrowing of the neural foramen total resection of the uncus is indicated. Additional fusion supports the physiological cervical lordosis.

Radiofrequency lesion adjacent to the dorsal root ganglion for cervicobrachial pain: a prospective double blind randomized study

Each of 20 consecutive patients with a history of at least 1 year of intractable chronic cervicobrachial pain was randomly assigned to one of two treatment groups. The pretreatment investigation included at least three diagnostic segmental nerve blocks in each patient. Each patient in Group 1 received a 67 degrees C radiofrequency lesion adjacent to the dorsal root ganglion. The patients in Group II were treated in an identical manner as those in Group I, except that no actual radiofrequency lesion was made. Neither the therapist nor the patients were aware of the treatment group assignment. All patients were questioned about their pain experience 1 week before and 8 weeks after the procedure. The following tests were used in evaluating patient response: Visual Analogue Scale (VAS); McGill Pain Questionnaire, Dutch Language Version (MPQ-DLV); and Multidimensional Pain Inventory, Dutch Language Version (MPI-DLV). These tests showed that 8 weeks after the procedure, there was a significant number of "successful" patients in Group I compared to Group II (P = 0.0027); there was a significant reduction in VAS score (P < 0.01) and also in parameters measured with MPQ-DLV and MPI-DLV in Group I. This study indicates that a 67 degrees C radiofrequency lesion adjacent to the dorsal root ganglion can result in a significant alleviation of pain in chronic cervicobrachial pain.

[The x-ray radiological semeiotics of the pain syndrome in a traumatic lesion of the brachial plexus]

X-ray radionuclide studies revealed a variety of morphological changes at the cervicothoracic levels of the spinal cord and its meninges. Despite a preganglionary injury to the brachial plexus, there was a clear-cut correlation between the level and nature of an injury on the one hand, and the severity of the pain syndrome, on the other. A more significant progression was observed in abruption of the inferior roots than in that of superior ones. The X-ray radionuclide correlations allow one to assess the nature of abnormal changes not only at the preganglionary, but postganglionary levels.

Case report: rapidly progressive neuropathic arthropathy in syringohydromyelia--radiographic and magnetic resonance imaging findings

A rapidly progressive neuropathic shoulder joint in a patient with syringohydromyelia is presented. He developed marked destruction of the shoulder joint over 5 weeks. The MRI findings in the pre- and post-resorptive phases of the arthropathy are presented for the first time. Low signal intensity areas are observed in the medullary cavity of the bone on both T1- and T2-weighted spin-echo images even before the actual resorptive process starts. Additional major findings are the joint effusion and synovial thickening.

Pitfalls in computed tomography of the cervical and lumbar spine

In 10 patients, evaluated by computed tomography studies of the spine, radiological findings alone may have led to misinterpretation of the clinical condition. Five patients demonstrated CT findings of cervical disc herniation or protrusion, while clinical examination resulted in the diagnosis of neuralgic amyotrophy. In contrast, 3 patients with clinical signs of compression of lumbar nerve roots had negative findings in CT studies of the lumbar discs. Additional slices at the level of the vertebral body, however, demonstrated free sequestration of disc substance. Two patients with signs of compression of cervical roots had normal CT findings, but extensive disc herniation was present at surgery.

The radiologist and common cervicobrachial neuralgia

The neuroradiological methods used for the diagnosis of common cervicobrachial neuralgia are not the same in all medical centres and hospitals, one of the main reasons for this lack of unanimity being differences in organization and availability of equipment. However, the modern diagnostic approach should include magnetic resonance as first examination. MRI is the most informative and the least hazardous of all exploratory methods, and it detects or excludes a much greater number of causes than any other radiological technique. False-negative results, as well as late, incomplete or wrong diagnosis are therefore reduced to the minimum. False-positive results can be avoided by a good knowledge of the physiological incidence of uncodiscarthrosis with age.

Automated percutaneous nucleotomy in the treatment of cervicobrachial neuralgia due to disc herniation

Forty-five patients suffering from cervicobrachial neuralgia resistant to medical treatment were treated by automated percutaneous nucleotomy according to the technique used by Onik et al. in the lumbar segment of the spine. Good results were obtained with this technique in 85% of the patients. This figure is similar to that reported for nucleorthesis without the risk of calcification mentioned in the literature.

Plain radiography in the evaluation of cervicobrachial neuralgia

Standard radiography is indispensable to the initial evaluation of cervicobrachial neuralgia. Its main purpose is not to detect a nucleus pulposus herniation or a spondylarthrosis responsible for the neuralgia, but to exclude a possible malignancy. In some cases standard radiography points out to a less frequent cause, such as constitutional stenosis of intervertebral foramina not necessarily associated with a narrow vertebral canal.

CT, myelography and CT-myelography in the evaluation of common cervicobrachial neuralgia

The CT technique used to explore intervertebral discs and foramina is described, as are the CT signs of nucleus pulposus (NP) herniation and cervical degenerative lesions. CT with intravenous contrast injection is the most efficient and easiest method to diagnose a radicular compression of discal or degenerative origin. The advent of high-resolution contrast CT will probably make obsolete the use of contrast media. CT measures the width of the vertebral canal, but it does not evaluate the repercussions on the spinal cord of compression caused by NP herniation or osteophytosis: only CT-myelography or, better, MRI can make this evaluation. Conventional CT scans are sometimes inadequate when exploration is hampered by superimposition of the shoulders (C6-C7 and more often C7-T1), when the scanner is of poor quality or when it is misused. Myelography and CT-myelography can then be utilized to resolve the problem posed by C7 or C8 cervicobrachial neuralgia (CBN). CT makes it possible to exclude most of the causes of non-discal CBN in the extradural spaces (e.g. bone tumour, neurinoma, vertebral vascular malformation, paravertebral expansive process, apical lung tumour). The search for an intradural cause (extra- or intramedullary tumour) rests on myelography, CT-myelography and MRI.

[Comparison of MRI and scanning coupled with myelography in the diagnosis of cervicobrachial neuralgia]

A prospective study was undertaken to compare the accuracy of surface coil magnetic resonance imaging (MRI) and computed tomography with myelography (CTM) in the determination of cervical radiculopathy with or without myelopathy. Twenty five patients underwent both imaging studies. The separately imaging diagnosis and the surgical findings were the basis of this study. The based-MRI and based-CTM predictions were not significant. MRI predicted two disc herniations that CTM did not predict. CTM predicted a combination of disk herniation and stenosis and one more lateral stenosis that MRI did not predict. Among the fourteen patients who underwent surgery, one underwent surgery only on based-MRI prediction, it was a disc herniation; one patient was operated on only on based-CTM prediction, it was a stenosis. In these operated patients, the predictive value of the both imaging modalities was not significant. In this report the diagnostic assessment of MRI and CTM was overall the same. The major advantages of MRI were its ability to display all the cervical spine, to study the disk pathology and to delineate a signal alteration within cord substance but the disadvantage was the difficulty to characterize the osteophytes made of cortical bone which did not give signal.

[Diagnosis of instability of the upper cervical spine by functional computed tomography]

The evaluation by means of functional x-rays, of rotatory instability of the upper cervical spine as a result traumatic or inflammatory destruction of the ligamentous apparatus, is unsatisfactory. Functional CT of the upper cervical spine allows measurement of the segmental rotatory movements. 9 healthy adults and 30 patients were examined after neck injury via functional CT's. A rotation between occiput and atlas greater than 9 degrees, between atlas and axis over 50 degrees, the left-right difference at the level C0/C1 greater than 6 degrees and at the level C1/C2 over 10.5 degrees point to a suspicion of hypermobility or instability.

[X-ray computed tomographic exploration of cervico-brachial neuralgia. Value of the intravenous injection of contrast media]

Cervicobrachial neuralgias can now be easily evaluated by computerized tomography of the cervical spine due to recent technical progress (improved resolution, ultra-thin cuts, precise localization by computed radiography), and especially the use of intravenous contrast material, thus avoiding intrathecal metrizamide. The authors describe normal findings obtained by this method as well as disk herniations and disco-uncarthrosis. On the basis of this initial study of 35 patients (7 disk herniations and 16 disco-uncarthrosis), this method could be employed following routine studies as the first preoperative examination for cervicobrachial neuralgia. Thus, the indications for cervical myelography would decrease, limiting the use of a more invasive procedure and patient discomfort.

Cervicobrachialgia with congenital vertebral anomalies and diastematomyelia

A case of diastematomyelia in an adult female patient is reported. The relationship of the cervicobrachialgia, which was the presenting sign, to the diastematomyelia and the congenital vertebral anomalies is discussed.

[Computed x-ray tomographic evaluation of cervico-brachial neuralgia with intravenous injection of contrast media]

Investigation of the cervical epidural space by a CT scan is facilitated by its filling following intravenous injection of a contrast medium. The spinal ganglia and nerve root sheaths are visualized as negative images in the intervertebral foramen. A herniated disc is seen as a focal protrusion of the anterior epidural space presenting a clearer center (60 to 80 HU) than at the periphery (100 to 120 HU). Disco- osteophytic protrusion is seen as an arthritic hypertrophy of the uncus and a more widespread overlapping of the disc, often with a posterior body osteophytosis. The spinal cord and subarachnoid space are also visualized more clearly than when injections are not given. This technique is proposed as the initial examination after standard films, for preoperative investigation of a resistant cervicobrachial neuralgia .

[An indirect sign of cervical disc hernia: angulation of the alignment of the spinal apophyses in the frontal plane (author's transl)]

An indirect sign of cervical disc hernia is described, consisting of angulation of the alignment of the spinal apophyses of the cervical vertebrae above the site of the hernia in relation to the alignment of those of the vertebrae situated below the lesion.

[Roentgenological diagnosis of the functioning of the cervical spine (author's transl)]

Basing on literature and 230 own functional examinations of the cervical spine, the author reports on a roentgenological method which satisfies practical requirements. In patients with degenerative and post-traumatic changes, the extent and localisation of the disorders of function and structure of the vertebrae can be determined by this method, enabling discovery of functional disorders in a large number of patients with clinical cervical spine syndrome. X-ray functional testing is shown to be a necessary complement to conventional x-ray diagnosis and clinical examination.