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While congenital muscular torticollis (CMT) can occur along with other conditions, such as clavicle fracture or brachial plexus injury, these conditions exist outside the sternocleidomastoid muscle (SCM). We present a rare case with concurrence of CMT and a malignant tumor inside the same SCM, along with serial clinical and radiological findings of the atypical features of CMT. The malignant tumor was in fact a low-grade fibromyxoid sarcoma. To the best of our knowledge, the current case is the first of a concurrent condition of CMT inside the SCM. This case suggests that concurrent conditions could exist either inside or outside the SCM with CMT. Therefore, a thorough evaluation of SCM is required when subjects with CMT display atypical features, such as the increase of mass or poor response to conservative therapy. In that case, appropriate imaging modalities, such as ultrasonogram or magnetic resonance imaging, are useful for differential diagnosis.
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To assess the cross-sectional area (CSA) of the muscles for investigating the occurrence of asymmetry of the paraspinal (multifidus and erector spinae) and psoas muscles and its relation to the chronicity of unilateral lumbar radiculopathy using magnetic resonance imaging (MRI).
This retrospective study was conducted between January 2012 to December 2014. Sixty one patients with unilateral L5 radiculopathy were enrolled: 30 patients had a symptom duration less than 3 months (group A) and 31 patients had a symptom duration of 3 months or more (group B). Axial MRI measured the CSA of the paraspinal and psoas muscles at the middle between the lower margin of the upper vertebra and upper margin of the lower vertebra, and obtained the relative CSA (rCSA) which is the ratio of the CSA of muscles to that of the lower margin of L4 vertebra.
There were no differences in the demographics between the two groups. In group B, rCSA of the erector spinae at the L4–5 level, and that of multifidus at the L4–5 and L5–S1 levels, were significantly smaller on the involved side as compared with the uninvolved side. In contrast, no significant muscle asymmetry was observed in group A. The rCSA of the psoas was not affected in either group.
The atrophy of the multifidus and erector spinae ipsilateral to the lumbar radiculopathy was observed only in patients suffering from unilateral radiculopathy for 3 months or more.
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To investigate the predictive value of enhanced-magnetic resonance imaging (MRI) and fluoroscopic factors regarding the effects of transforaminal epidural steroid injections (TFESIs) in low back pain (LBP) patients with lumbosacral radiating pain.
A total of 51 patients who had LBP with radiating pain were recruited between January 2011 and December 2012. The patient data were classified into the two groups ‘favorable group’ and ‘non-favorable group’ after 2 weeks of follow-up results. The favorable group was defined as those with a 50%, or more, reduction of pain severity according to the visual analogue scale (VAS) for back or leg pain. The clinical and radiological data were collected for univariate and multivariate analyses to determine the predictors of the effectiveness of TFESIs between the two groups.
According to the back or the leg favorable-VAS group, the univariate analysis revealed that the corticosteroid approach for the enhanced nerve root, the proportion of the proximal flow, and the contrast dispersion of epidurography are respectively statistically significant relative to the other factors. Lastly, the multiple logistic regression analysis showed a significant association between the corticosteroid approach and the enhanced nerve root in the favorable VAS group.
Among the variables, MRI showed that the corticosteroid approach for the enhanced target root is the most important prognostic factor in the predicting of the clinical parameters of the favorable TFESIs group.
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Patients with C5 or C6 radiculopathy complain of shoulder area pain or shoulder girdle weakness. Typical idiopathic neuralgic amyotrophy (INA) is also characterized by severe shoulder pain, followed by paresis of shoulder girdle muscles. Recent studies have demonstrated that magnetic resonance neurography (MRN) of the brachial plexus and magnetic resonance imaging (MRI) of the shoulder in patients with INA show high signal intensity (HSI) or thickening of the brachial plexus and changes in intramuscular denervation of the shoulder girdle. We evaluated the value of brachial plexus MRN and shoulder MRI in four patients with typical C5 or C6 radiculopathy. HSI of the brachial plexus was noted in all patients and intramuscular changes were observed in two patients who had symptoms over 4 weeks. Our results suggest that HSI or thickening of the brachial plexus and changes in intramuscular denervation of the shoulder girdle on MRN and MRI may not be specific for INA.
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To evaluate the usefulness of various magnetic resonance imaging (MRI) findings in the prognosis of neurological recovery in paraplegics with thoracolumbar fracture using association analysis with clinical outcomes and electrodiagnostic features.
This retrospective study involved 30 patients treated for paraplegia following thoracolumbar fracture. On axial and sagittal T2-weighted MRI scans, nerve root sedimentation sign, root aggregation sign, and signal intensity changes in the conus medullaris were independently assessed by two raters. A positive sedimentation sign was defined as the absence of nerve root sedimentation. The root aggregation sign was defined as the presence of root aggregation in at least one axial MRI scan. Clinical outcomes including the American Spinal Injury Association impairment scale, ambulatory capacity, and electrodiagnostic features were used for association analysis.
Inter-rater reliability of the nerve root sedimentation sign and the root aggregation sign were κ=0.67 (p=0.001) and κ=0.78 (p<0.001), respectively. A positive sedimentation sign was significantly associated with recovery of ambulatory capacity after a rehabilitation program (χ2=4.854, p=0.028). The presence of the root aggregation sign was associated with reduced compound muscle action potential amplitude of common peroneal and tibial nerves in nerve conduction studies (χ2=5.026, p=0.025).
A positive sedimentation sign was significantly associated with recovery of ambulatory capacity and not indicative of persistent paralysis. The root aggregation sign suggested the existence of significant cauda equina injuries.
To investigate the global functional reorganization of the brain following spinal cord injury with graph theory based approach by creating whole brain functional connectivity networks from resting state-functional magnetic resonance imaging (rs-fMRI), characterizing the reorganization of these networks using graph theoretical metrics and to compare these metrics between patients with spinal cord injury (SCI) and age-matched controls.
Twenty patients with incomplete cervical SCI (14 males, 6 females; age, 55±14.1 years) and 20 healthy subjects (10 males, 10 females; age, 52.9±13.6 years) participated in this study. To analyze the characteristics of the whole brain network constructed with functional connectivity using rs-fMRI, graph theoretical measures were calculated including clustering coefficient, characteristic path length, global efficiency and small-worldness.
Clustering coefficient, global efficiency and small-worldness did not show any difference between controls and SCIs in all density ranges. The normalized characteristic path length to random network was higher in SCI patients than in controls and reached statistical significance at 12%-13% of density (p<0.05, uncorrected).
The graph theoretical approach in brain functional connectivity might be helpful to reveal the information processing after SCI. These findings imply that patients with SCI can build on preserved competent brain control. Further analyses, such as topological rearrangement and hub region identification, will be needed for better understanding of neuroplasticity in patients with SCI.
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To investigate the effectiveness of incentive spirometry on respiratory motion in healthy subjects using cine breathing magnetic resonance imaging (MRI).
Ten non-smoking healthy subjects without any history of respiratory disease were studied. Subjects were asked to perform pulmonary training using incentive spirometry every day for two weeks. To assess the effectiveness of this training, pulmonary function tests and cine breathing MRI were performed before starting pulmonary training and two weeks after its completion.
After training, there were significant improvements in vital capacity (VC) from 3.58±0.8 L to 3.74±0.8 L and in %VC from 107.4±10.8 to 112.1±8.2. Significant changes were observed in the right diaphragm motion, right chest wall motion, and left chest wall motion, which were increased from 55.7±9.6 mm to 63.4±10.2 mm, from 15.6±6.1 mm to 23.4±10.4 mm, and from 16.3±7.6 mm to 22.0±9.8 mm, respectively.
Two weeks of training using incentive spirometry provided improvements in pulmonary function and respiratory motion, which suggested that incentive spirometry may be a useful preoperative modality for improving pulmonary function during the perioperative period.
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To quantify magnetic resonance imaging (MRI) findings of congenital muscular torticollis (CMT) and to demonstrate the usefulness of quantitative MRI findings in the management of CMT.
This was a retrospective study of 160 subjects with CMT who had undergone neck MRI at the age of 48 months or younger at a tertiary medical center. Among the 160 subjects, 54 had undergone surgical release of CMT and 106 subjects had not undergone surgery. For the quantitative analysis, the ratios of area and intensity of the MRI findings were measured and compared between the two groups (ratio of area = the largest cross-sectional area of the SCM with CMT - the cross-sectional area of the contralateral SCM without CMT / the cross-sectional area of the contralateral SCM without CMT; ratio of intensity = the mean gray color intensity of the contralateral SCM without CMT - the lowest mean gray color intensity of the SCM with CMT / the mean gray color intensity of the contralateral SCM without CMT). Receiver operating characteristic (ROC) curve analysis was conducted for the ratios of area and intensity in order to find the optimal cutoff value for determining the need for surgery in CMT cases.
The ratios of area and intensity were significantly higher in the surgical group than in the non-surgical group (p≤0.001), suggesting that the sternocleidomastoid muscle (SCM) was thicker and darker in the surgical group than in the non-surgical group. The optimal cutoff value for the ratio of area was 0.17 and that for the ratio of intensity was 0.05. All subjects with a ratio of intensity less than 0.03 belonged to the non-surgical group, and all subjects with a ratio of intensity greater than 0.16 were categorized in the surgical group.
The quantitative MRI findings, i.e., ratios of area and intensity, may provide a guideline for deciding the need for surgical intervention in CMT patients. Further prospective studies are required to verify these findings.
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Although spinal cord injury without radiographic abnormality (SCIWORA) literally refers to the specific type of spinal cord injury, however, some extents of spinal cord injuries can be detected by magnetic resonance imaging (MRI) in most of cases. We introduce an atypical case of spinal cord injury without radiologic abnormality. A 42-year-old male tetraplegic patient underwent MRI and computed tomography, and no specific lesions were found in any segments of the spinal cord. Moreover, the tetraplegic patient showed normal urodynamic function despite severe paralysis and absent somatosensory evoked potentials from the lower limbs.
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To investigate neuroradiological and neurophysiological characteristics of patients with dyskinetic cerebral palsy (CP), by using magnetic resonance imaging (MRI), voxel-based morphometry (VBM), diffusion tensor tractography (DTT), and motor evoked potential (MEP).
Twenty-three patients with dyskinetic CP (13 males, 10 females; mean age 34 years, range 16-50 years) were participated in this study. Functional evaluation was assessed by the Gross Motor Functional Classification System (GMFCS) and Barry-Albright Dystonia Scale (BADS). Brain imaging was performed on 3.0 Tesla MRI, and volume change of the grey matter was assessed using VBM. The corticospinal tract (CST) and superior longitudinal fasciculus (SLF) were analyzed by DTT. MEPs were recorded in the first dorsal interossei, the biceps brachii and the deltoid muscles.
Mean BADS was 16.4±5.0 in ambulatory group (GMFCS levels I, II, and III; n=11) and 21.3±3.9 in non-ambulatory group (GMFCS levels IV and V; n=12). Twelve patients showed normal MRI findings, and eleven patients showed abnormal MRI findings (grade I, n=5; grade II, n=2; grade III, n=4). About half of patients with dyskinetic CP showed putamen and thalamus lesions on MRI. Mean BADS was 20.3±5.7 in normal MRI group and 17.5±4.0 in abnormal MRI group. VBM showed reduced volume of the hippocampus and parahippocampal gyrus. In DTT, no abnormality was observed in CST, but not in SLF. In MEPs, most patients showed normal central motor conduction time.
These results support that extrapyramidal tract, related with basal ganglia circuitry, may be responsible for the pathophysiology of dyskinetic CP rather than CST abnormality.
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To identify the correlations between the location of multifidus atrophy and the level of lumbar radiculopathy.
Thirty-seven patients who had unilateral L4 or L5 radiculopathy were divided into 2 groups; the L4 radiculopathy (L4 RAD) group and the L5 radiculopathy (L5 RAD) group. Bilateral lumbar multifidus muscles at the mid-spinous process level of L4 vertebra (L4 MSP), the mid-spinous process level of L5 vertebra (L5 MSP), and the mid-sacral crest level of S1 vertebra (S1 MSC) were detected in T1 axial magnetic resonance imaging. The total muscle cross-sectional area of multifidus muscles (TMCSA) and the pure muscle cross-sectional area of multifidus muscles (PMCSA) were measured by a computerized analysis program, and the ratio of PMCSA to TMCSA (PMCSA/TMCSA) was calculated.
There were no significant differences in TMCSA between the involved and the uninvolved sides in both groups. PMCSA was only significantly smaller at the S1 MSC on the involved side as compared with the uninvolved side in the L5 RAD group. The ratio of PMCSA to TMCSA was the lowest at the L5 MSP on the involved side in the L4 RAD group and at the S1 MSC on the involved side in the L5 RAD group.
Our findings suggest that the most severe atrophy of multifidus muscle may occur at the mid-spinous process or mid-sacral crest level of the vertebra which is one level below the segmental number of the involved nerve root in patients with a single-level, unilateral lumbar radiculopathy.
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To clarify the relationship of skin temperature changes to clinical, radiologic, and electrophysiological findings in unilateral lumbosacral radiculopathy and to delineate the possible temperature-change mechanisms involved.
One hundred and one patients who had clinical symptoms and for whom there were physical findings suggestive or indicative of unilateral lumbosacral radiculopathy, along with 27 normal controls, were selected for the study, and the thermal-pattern results of digital infrared thermographic imaging (DITI) performed on the back and lower extremities were analyzed. Local temperatures were assessed by comparing the mean temperature differences (ΔT) in 30 regions of interest (ROIs), and abnormal thermal patterns were divided into seven regions. To aid the diagnosis of radiculopathy, magnetic resonance imaging (MRI) and electrophysiological tests were also carried out.
The incidence of disc herniation on MRI was 86%; 43% of patients showed electrophysiological abnormalities. On DITI, 97% of the patients showed abnormal ΔT in at least one of the 30 ROIs, and 79% showed hypothermia on the involved side. Seventy-eight percent of the patients also showed abnormal thermal patterns in at least one of the seven regions. Patients who had motor weakness or lateral-type disc herniation showed some correlations with abnormal DITI findings. However, neither pain severity nor other physical or electrophysiological findings were related to the DITI findings.
Skin temperature change following lumbosacral radiculopathy was related to some clinical and MRI findings, suggesting muscle atrophy. DITI, despite its limitations, might be useful as a complementary tool in the diagnosis of unilateral lumbosacral radiculopathy.
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To assess the intrarater and interrater reliability of the supraspinatus thickness measured by ultrasonography (US) in normal subjects and to identify the relationship between the supraspinatus thickness measured by US and cross sectional area (CSA) of the supraspinatus muscle by magnetic resonance imaging (MRI) in hemiplegic patients.
We examined 20 shoulders of normal subjects and 10 shoulders of hemiplegic patients. In normal subjects, one examiner measured the supraspinatus thickness twice by US at the scapular notch and another examiner measured the supraspinatus thickness several days later. The intrarater and interrater reliability of supraspinatus thickness measurements were then evaluated. In hemiplegic patients, the supraspinatus thickness at the scapular notch was measured by US in affected side and compared with CSA of the supraspinatus muscle at the scapular notch and the Y-view of MRI.
One examiner's supraspinatus thickness measurement average was 1.72±0.21 cm and 1.74±0.24 cm, and the other examiner's supraspinatus thickness measurement average was 1.74±0.22 cm in normal subjects. Intraclass correlation coefficients of intrarater and interrater examination were 0.91 and 0.88, respectively. For hemiplegic patients, the supraspinatus thickness measured by US was 1.66±0.13 cm and CSA by MRI was 4.83±0.88 cm2 at the Y-view and 5.61±1.19 cm2 at the scapular notch. The Pearson Correlation Coefficient between the supraspinatus thickness at the scapular notch and the CSA at the Y-view was 0.72 and that between the supraspinatus thickness and CSA at the scapular notch was 0.76.
The supraspinatus thickness measurement by US is a reliable method and is positively correlated with the CSA of the supraspinatus muscle in MRI in hemiplegic patients. Therefore, supraspinatus thickness measurement by US can be used in the evaluation of muscle atrophy and to determine therapeutic effects in hemiplegic patients.
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(1) To present the magnetic resonance imaging (MRI) findings of congenital muscular torticollis (CMT) of subjects who underwent surgical release and subjects who showed a good prognosis with stretching exercises and (2) to correlate the MRI findings with the histopathologic findings of CMT for subjects who underwent surgical release in order to examine the hypothesis that the MRI findings of CMT can be used as a determinant to perform surgical release of CMT.
The neck MRI findings of 33 subjects who underwent surgical release for CMT were compared with those of 18 subjects who were successfully managed only with conservative management. The MRI findings were correlated with the histopathologic sections of the CMT mass.
All 33 subjects (100%) who underwent surgical release showed one or more low signal intensities within the involved sternocleidomastoid muscle (SCM) on the T1- and T2-weighted images of neck MRI. The eighteen non-surgical candidates showed only enlargement of the SCM without low signal intensity within the SCM. The histopathologic findings showed interstitial fibrosis and/or the presence of aberrant tendon-like excessive dense connective tissue that was either well-arranged or disorganized.
The histopathologic findings and MRI findings showed good correlation in terms of the amount of fibrosis and aberrant dense connective tissue within the SCM. If multiple or large low signal intensities within the SCM are noted, we think that surgical release should be considered.
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To evaluate the relationship between the cross sectional area (CSA) and isokinetic strength of the back muscles in patients with chronic low back pain.
Data of twenty-eight middle-aged patients with chronic back pain were analyzed retrospectively. CSAs of both paraspinal muscles and the disc at the L4-L5 level were measured in MRI axial images and the relative CSAs (rCSA: CSA ratio of muscle and disc) were calculated. The degree of paraspinal muscle atrophy was rated qualitatively. Isokinetic strengths (peak torque, peak torque per body weight) of back flexor and extensor were measured with the isokinetic testing machine. Multiple regression analysis with backward elimination was used to evaluate relations between isokinetic strength and various factors, such as CSA or rCSA and clinical characteristics in all patients. The same analysis was repeated in the female patients.
In analysis with CSA and clinical characteristics, body mass index (BMI) and CSA were significant influencing factors in the peak torque of the back flexor muscles. CSA was a significant influencing factor in the peak torque of total back muscles. In analysis with rCSA and clinical characteristics, BMI was significant in influencing the peak torque of the back flexors. In female patients, rCSA was a significant influencing factor in the peak torque per body weight of the back flexors, and age and BMI were influencing factors in the peak torque of back flexors and total back muscles.
In middle-aged patients with chronic low back pain, CSA and rCSA were influencing factors in the strength of total back muscles and back flexors. Also, gender and BMI were influencing factors.
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To determine abnormal MRI findings in adults hospitalized with acute severe axial LBP.
Sixty patients with back pain were divided into 3 groups consisting of 1) 23 adults with acute axial severe LBP who could not sit up or stand up for several days, but had not experienced previous back-related diseases or trauma (group A), 2) 19 adults who had been involved in a minor traffic accident, and had mild symptoms but not limited mobility (group B), and 3) 18 adults with LBP with radicular pain (group C)., Various MRI findings were assessed among the above 3 groups and compared as follows: disc herniation (protrusion, extrusion), lumbar disc degeneration (LDD), annular tear, high intensity zone (HIZ), and endplate changes.
The MRI findings of A group were as follows: disc herniation (87%), LDD (100%), annular tear (100%), HIZ (61%), and end plate changes (4.4%). The findings of disc herniation, annular tear, HIZ, and LDD were more prevalent in A group than in B group (p<0.01). HIZ findings were more prevalent in A group than in group B or group C (p<0.05).
Patients with acute severe axial LBP were more likely to have disc herniation, LDD, annular tear, HIZ. Among LBP groups, there was a significant association of HIZ on MRI with acute severe axial LBP.
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To investigate the prognostic value of cross-sectional areas (CSA) of paraspinal (multifidus and erector spinae) and psoas muscles on magnetic resonance imaging (MRI) in chronicity of low back pain.
Thirty-eight subjects who visited our hospital for acute low back pain were enrolled. Review of their medical records and telephone interviews were done. Subjects were divided into two groups; chronic back pain group (CBP) and a group showing improvement within 6 months after onset of pain (IBP). The CSA of paraspinal and psoas muscles were obtained at the level of the lower margin of L3 and L5 vertebrae using MRI.
CSA of erector spinae muscle and the proportion of the area to lumbar muscles (paraspinal and psoas muscles) at L5 level in the CBP group were significantly smaller than that of the IBP group (p<0.05). The mean value of CSA of multifidus muscle at L5 level in the CBP group was smaller than that of the IBP group, but was not statistically significant (p>0.05). CSA of psoas muscle at L5 level and all values measured at L3 level were not significantly different between the groups (p>0.05).
CSA of erector spinae muscle at the lower lumbar level and the proportion of the area to the lumbar muscles at the L5 level can be considered to be prognostic factors of chronicity of low back pain.
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Method Twenty-four patients who had cervical disc herniation in magnetic resonance imaging (MRI) were evaluated. The patients were divided into 2 groups; patients with unilateral cervical radiculopathy in electrodiagnosis (RAD) and patients without definite radiculopathy (HIVD). Twenty six controls without disc herniation were also evaluated. Cervical multifidus muscles from C4-5 to C7-T1 levels were detected in T1 axial MRI, and total cross-sectional area (CSA) of multifidus muscle (TMA) and pure muscle CSA (PMA) were measured.
Results The ratios of TMA in involved side to TMA in uninvolved side (ITMA/UTMA) and PMA in involved side to PMA in uninvolved side (IPMA/UPMA) in HIVD and RAD groups was significantly lower than those in control group especially at C7-T1 level (p＜0.05). We divided the levels of cervical spine into three parts according to lesions found in MRI or electrodiagnosis; above lesion level, at lesion level and below lesion level. Abnormal cases of IPMA/UPMA were not different among levels in HIVD group, but RAD group showed that most of abnormal cases were below lesion (60%).
Conclusion Asymmetric multifidus atrophy was seen in patients with cervical disc herniation and radiculopathy. The ratio of pure muscle CSA between involved and uninvolved sides might be a useful parameter to differentiate patients with unilateral cervical radiculopathy from patients without radiculopathy.
Method: MRI images were reviewed from thirty two patients who were diagnosed electrodiagnostically as unilateral S1 radiculopathy. Areas of herniated disc and spinal canal were measured and the ratio of disc herniation was calculated from the axial images stored and analyzed by PACS. The radiologic measurements were compared with the results of electrodiagnostic studies. Results: The presence of abnormal spontaneous activities in needle EMG and no response in H reflex were associated with larger disc herniation (p＜0.05). There was no other single electrodiagnostic study that showed correlation with any of radiologic measurements. With increasing number of abnormal electrodiagnostic tests, area of disc herniation grew larger (p＜0.05). Area of spinal canal and the ratio of disc herniation did not show difference between normal and abnormal groups in most of electrodiagnostic studies. Conclusion: There were limited correlations between electrodiagnostic results and severity of disc herniation. The size of disc herniation, regardless of the size of spinal canal, was associated with abnormal results of electrodiagnostic tests. (J Korean Acad Rehab Med 2008; 32: 194-199)
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