SUMMARY: SIFs are a common, though often unsuspected, cause of low back pain in the elderly. Although numerous radiographic modalities can be used to diagnose SIFs, bone scintigraphy and MR imaging are the most sensitive. Conservative management involves various combinations of bed rest, rehabilitation, and analgesics. More recently, sacroplasty has emerged as an alternative therapy for the treatment of SIFs, with prospective studies and case reports suggesting that it is a safe and effective therapy. This article reviews the imaging appearance of SIFs and discusses treatment options with a focus on sacroplasty.ABBREVIATIONS: FEA ϭ finite-element analysis; MDP ϭ methylene diphosphonate; PMMA ϭ polymethylmethacrylate; SIF ϭ sacral insufficiency fracture; VAS ϭ visual analog pain scale.

SUMMARY:Spinal cord infarction following lumbar transforaminal epidural steroid injection is a rare and devastating complication. We describe the case of a 55-year-old woman who developed spinal cord infarction following right L2-3 transforaminal epidural injection, diagnosed on the basis of clinical and MR imaging findings. Spinal angiography demonstrated occlusion of the right L2 segmental artery with reconstitution of the radicular branch from collaterals. The artery of Adamkeiwicz could not be demonstrated and was presumably occluded by the steroid injection.T ransforaminal epidural steroid injection (TF ESI) is a common procedure in the nonsurgical management of lumbosacral radiculopathy. The incidence of significant complications is low. Spinal cord infarction (SCI) following lumbar TF ESI is one of the rarest yet most devastating complications, with 5 cases reported in the literature.1-3 Inadvertent vascular penetration of a radiculomedullary artery by the procedure needle has been implicated as the likely etiology. Cord ischemia could result from vascular injury with thrombosis or embolism involving the artery of Adamkiewicz or from occlusion secondary to intra-arterial injection of steroid suspension. In this case, we describe the MR imaging and angiographic findings in a case of SCI following lumbar TF ESI. To our knowledge, the angiographic findings have never been reported. Case ReportA 55-year-old woman with an acute-on-chronic disk herniation at L1-2 presented for TF ESI at L2-3 on the right. Initial placement of a 22-gauge spinal needle reportedly showed backbleeding on removal of the stylet, which apparently resolved once the needle was repositioned. Epidural placement of the needle tip was reportedly confirmed following injection of 2 mL of myelographic contrast (Fig 1), followed by therapeutic injection of an additional 1 mL of triamcinolone acetonide (Kenalog) and 0.25% bupivacaine. Within minutes of the injection, the patient developed bilateral lower extremity weakness, which progressed to flaccid paralysis.The patient underwent CT of the thoracolumbar spine within 1.5-hours of the injection, which demonstrated no evidence of epidural hematoma. MR imaging of the spine was performed approximately 4 hours after the injection, including sagittal and axial T1 (TR, 350; TE, 15.7), T2 (TR, 3950; TE, 105), and echo-planar diffusionweighted imaging (bϭ1000). T2-weighted images demonstrated subtly increased signal intensity within the central gray matter of the distal thoracic cord with restricted water diffusion in the same area (Fig 2).Catheter-directed spinal angiography was performed to evaluate potentially treatable causes of spinal cord ischemia, including spasm or dissection. The ostium of the right L2 segmental artery could not be selected and was presumed to be occluded. Injection of the right L3 segmental artery demonstrated collateral vessels coursing toward the right L2-3 foramen, with irregular attenuated reconstitution of the distal L2 segmental branch and radicular artery (Fig 3). Addi...

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Prior studies involving inner city populations detected higher cerebral white matter hyperintensity (WMH) scores in African Americans (AAs), relative to European Americans (EAs). This finding may be attributable to excess cardiovascular disease (CVD) risk factors in AAs and poorer access to healthcare. Despite racial differences in CVD risk factor profiles, AAs have paradoxically lower levels of subclinical CVD. We hypothesized that AAs with diabetes and access to healthcare would have comparable or lower levels of WMH as EAs. Racial differences in the distribution of WMH were analyzed in 46 AAs and 156 EAs with type 2 diabetes (T2D) enrolled in the Diabetes Heart Study (DHS)-MIND, and replicated in a sample of 113 AAs and 61 EAs patients who had clinically-indicated cerebral MRIs. Wilcoxon two-sample tests and linear models were used to compare the distribution of WMH in AAs and EAs and test for association between WMH and race. The unadjusted mean WMH score in AAs from DHS-MIND was 1.9, compared to 2.3 in EAs (p=0.3244). Among those with clinically-indicated MRIs, WMH scores were 2.9 in AAs and 3.9 in EAs (p=0.0503). Adjustment for age and gender showed no statistically significant differences in WMH score between AAs and EAs. These independent datasets reveal comparable WMH scores between AAs and EAs. This result suggests that disparities in access to healthcare and environmental exposures likely underlie the previously reported excess burden of WMH in AAs.

Erdheim-Chester disease (ECD) is a disseminated non-Langerhans' cell histiocytosis with multisystem involvement, including characteristic sclerotic musculoskeletal lesions. We present the case of a 27-year-old woman with a fulminant course and atypical involvement by ECD manifesting as extensive cerebrovascular disease and lytic musculoskeletal lesions. This case represents an unusual and aggressive presentation of ECD owing to the patient's young age, the severity of the cerebrovascular involvement and the lytic osseous lesions.