Of all our human resources, the most precious is the desire to improve!
The following case presentations are available for your review.Dr. Powers and his staff hopes that these cases are interestingand would appreciate your feedback and cases of your own. Whetheryou agree or disagree, your feedback may be helpful and usefulin improving the quality of image interpretation by all who browsethis site.
Many times, interesting cases are seen by the individual orgroup practitioners but not available to the general medical/legalcommunity due to the long delays necessary in preparing thesefor case presentations at conferences or for publication or dueto the fact that the physicians involved in the interpretationof these interesting studies are not oriented towards academicpresentation. Large volumes of imaging studies are interpretedby Dr. Powers, and many findings that are seen are not necessarilyreported or acted upon by many physicians. Also there can be significantdifferences in opinions in relationship to specific findings ormethods of treatment. For instance, the European community maythink differently on the etiologies of back pain compared to theAmerican community, i.e. "extensors are in and abs are out".Yet, the American community may not for long periods of time modifytheir techniques to review data that may be relevant to an alternativeviewpoint. As Dr. Powers attends various conferences and hearsviewpoints, he tries to show findings that are relevant to otherapproaches that may be present on the scan but that are seldomlooked at by other radiologists or that are new to him and maybe of interest to you.
CASE I:
HORSE'S BLINDERS/TUNNEL VISION - Too LimitedAn Approach To The Understanding Of Low Back Anatomy And UnderlyingLow Back Pain.
We all know that there are many parts to the anatomy of thelower back beside just the bony anatomy and the discs. True, itis important to see the visual relationships within the neuroforamina,central canal and observe the intact status of the vertebral bodies,bony rings and facet joints. But yet, there are other anatomicand physiologic markers that will help us further understand backpain and the physical status of the particular patient being imaged.All it takes is a re-direction of your focus to other parts ofthe surrounding anatomy, which in the past, you have probablyoverlooked, either because they have been cut off the film, thetechnologist has filmed the imaging study in a way that this anatomyis not apparent, or you have personally not consciously lookedfor changes in these parts.
1. OLE TO THE TWIST - SCOLIOSIS, A MARKER FOR IMBALANCE...
There are many etiologies for scoliosis of the spine, howevermany disciplines feel that balance of the body is very importantand that asymmetric shifting of the body, a cause of imbalance,affects many structures including the spine and its facet joints,the sacroiliac joints, hips, knees, ankles, etc. It can also bea marker for an on-going physiologic event such as asymmetricweight bearing or on-going musculoligamentous spasm as a resultof underlying sensory irritation. Thus, the presence or absenceof a scoliosis with or without associated psoas muscle asymmetryis an item that is very important to many of the primary physiciansespecially in the osteopathic and chiropractic communities. Thatis not to say that the MD's do not find it significant or cannotmake use of the information, but I have seldom seen other radiologistsreport scoliosis out on MRI examinations unless there is a specificdiagnosis of such and a need to report it. Yet, Radiologists dofor the most part report this out on plain x-rays. Why shouldn'tthey report it out on MRI interpretation?
2. DID YOU KNOW - EXTENSORS ARE IN AND ABS ARE OUT!!!
At the World Congress of Low Back Pain held in San Diego severalyears back, it was my impression that the Europeans favored theposterior back extensor musculature such as the erector spineand multifidus muscles as a major determinant in the strengthand stability of the lower back and its effect on low back andsacroiliac pain syndromes. Although the rectus abdominis musculaturecould be helpful, it was not as important a muscle group. Thuspre-existing weakening of the posterior back extensors or post-traumaticmuscle injury, denervation or disuse may all be contributing factorsto the effects of trauma on the lower back and/or to the chronicrecurrences of low back pain in some individuals. If one carefullyobserves the posterior back extensor muscles they will find thata small amount of fatty infiltration of the medial aspects ofthe distal medial multifidus muscles occurs in the L5 and S1 regions.However, it is observed that seldom is there a direct definiterelationship between the amount of fatty deposition in the posteriorback and buttocks and that involving the posterior back extensors.Although a slight amount of marbling can be present within theupper multifidus and erector spinae muscles of the posterior back,much more than this limited amount of marbling, is from my perspective,abnormal and is not dependent on the amount of excess body weightthat the patient appears to have. Thus, in some very heavy setindividuals, there is very little fatty infiltration of the posteriorback extensors and very little fatty replacement involving thedistal medial multifidus muscles. Yet, in thin individuals, therecan be at times, significant fatty infiltration of the posteriorback extensor musculature and/or fatty replacement of the distalmedial multifidus muscles. Certainly in post-surgical patients,there is oftentimes a significant amount of fatty replacementof the extensor muscles especially in the area of surgical incisiondue to either disuse or actual damage to neural structures andmuscle tissues caused by the surgical procedure. The fatty marblingor replacement may be a significant physiologic indicator thatthe patient needs a hardening program designed specifically forthese muscle groups. It may be an indicator that the patient wouldnot be as ideal a candidate for back surgery until such muscleswere strengthened or that if there is a failed back surgery orchronic debilitating post-traumatic injury that strengtheningof these muscles world be useful in alleviating some of the clinicalsymptoms.
3. SLOSH, SLOSH - INJURY TO THE POSTERIOR BACK FAT...
Most technologists have been trained to film the posteriorback on the sagittal images such that the fat is cut off the images.When it is filmed, the window and leveling is aimed at the thecalsac and nerve canals and not at the posterior back fat which isoften overly bright and white and impossible to interpret further.
Yet, in individuals of moderate to heavy build, be it due toacute or continuous trauma, there exist apparent shearing tearsof the deep fat plane with resultant serous fluid weeping resultingin the accumulation of small to large amounts of fluid. Of course,hematoma formation with resultant seroma formation, abscesses,or post-operative fluid tracking, etc., can cause these findings,yet it appears that the most common cause is specifically a shearingof the deep fat plane near the septum dividing the superficialand deep fat planes, with fluid accumulation present. Althoughsome of these accumulations are very limited with only small punctatescattered amounts, others are quite massive, perhaps the volumeof your hand and wrist. Look at your own hand and wrist and seethe volume of fluid involved and think about how this could causephysical sensations when moving the back about or the potentialfor irritation or clinical symptoms. To my knowledge, no longterm studies nor follow-up reports nor exploratory drainage ofthese particular collections are available to date, however, itis an area of anatomy that is often overlooked and may be a significantetiology for clinical symptoms or at least a marker for significantinjury or soft tissue damage.
CASE II:
ISD: A NEW BUZZWORD, OLD CONCEPTS.
The interpretation of MRI images of the knee has gone throughphases. Initially, there was a grading system for the knee witha 0-III scale, the Grade III was a true tear. [There were otherswho also described a Grade IV meniscal lesion which would alsobe of a true tear type.] Grade I and II findings were consideredrounded or linear abnormalities that did not extend to the articularsuperior or undersurfaces of the meniscus. These have been calledall kinds of abnormalities including mucinous/myxoid deterioration,linear intrasubstance tearing, maceration, etc. The fact is, thatoftentimes, these have been ignored but yet in some circumstances,they have been quite significant. Obviously in association witha meniscal cyst, a horizontal, linear intrasubstance tear is present.There are cases of intrasubstance tearing that can look identicalto a Grade II type of abnormality. Maceration also occurs whichat arthroscopy apparently can appear as multiple small microtears.This is often visualized vis-a-vis a diffuse non-specific GradeI type of finding that extends to an articular surface. It commonlyis more massive than in the more run of the mill Grade I findingsof punctate to triangular high signal. Etiologies can be variedfrom continuous trauma's affect on the integrity and compositionof the meniscus to age-related falling apart of the meniscus toeven acute trauma. Because the findings are non-specific, I havebeen utilizing the term internal structural damage which trulyreflects the findings present, i.e. that the high signal is internal,that it is structural in nature and that it represents damageto the meniscus regardless of etiology. Because internal structuraldamage is an elongated word group, ISD for a shortened abbreviationseems to be good descriptor for the findings. Thus, I recommendthat the image interpreter identifies and describes the morphologysuch as punctate, triangular or linear and indicates whether ornot the findings extend to the articular or non-articular surfaces.At times, maceration can be suggested. At times, linear intrasubstancetearing is definitive such as with a meniscal cyst with fluidtracking into the center of the meniscus through the horizontallinear tear, but in most cases with Grade I and II abnormalities,the findings are non-specific and non-definitive. Thus, this findingsets apart the morphologic changes from more definitive MRI appearancesof tears, the Grade III abnormalities. Thus it is my recommendationthat one describe the meniscus the best they can but categorizesthem into three basic groups.
1. Internal structural damage = ISD (Grade I and II).
2. MRI appearance of tearing = Grade III
3. Post-surgical deformities with or without the MRI appearanceof tearing.
Grading of the meniscus is based upon the following scaleof Grade 0 through Grade III:
Grade 0 is a normal meniscus.
Grade 1 represents a meniscus with rounded/globular or triangularhigh signal intensity within the meniscal mass, not classicallybreaking an articular surface. This is presumed secondary to mucinous/myxoiddeterioration within the fibrocartilage meniscal substance. Exception:Very marked non-descript high signal changes, especially if extendingto an articular surface, may not be visibly seen to form a discretelinear break to an articular surface on the MRI images and yet,at the time of arthroscopy, have been reported to be associatedwith marked maceration/microtearing, cavitation, or that can beeasily punctured into with probing.
Grade II represents a meniscus with linear high signal intensitywithin the meniscal mass that often extends to the ventral ordorsal non-articular periphery, depending on whether it is inthe anterior or posterior horn, but not superiorly or inferiorlyto break an articular surface. This category is most commonlysecondary to mucinous/myxoid deterioration, however, a linearintrasubstance/cleavage tear which does not break the articularsurface of the meniscus or occasionally a horizontal frank meniscaltear usually identified as such by being associated with a meniscalcyst , can give a similar appearance.
A Grade III meniscal abnormality is an obvious, gross tear,usually curvilinear in appearance, but occasionally vertical,with at least one of the superior or inferior articular marginsof the meniscus disrupted. Also included in this category is verticallongitudinal tearing with a bucket handle fragment, fragmentation,truncation or deformity of meniscus including injury to the anteriorand posterior horn meniscal root attachments, maceration and/ora meniscocapsular separation. Exceptions: Occasionally, linearor curvilinear artifact, intrasubstance mucinous/myxoid deteriorationor intrasubstance/cleavage tearing extending to, but not breakingthe articular surface to be visible at arthroscopy, can mimicthis appearance.
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