BACKGROUND AND PURPOSE:The conventional fluoroscopy-guided (CF) selective cervical nerve root block (SCNRB) is being used commonly as a treatment for cervical radicular pain as well as a diagnostic tool. This study aimed to identify any major complications and determine the safety and clinical utility of CF-SCNRB performed in a university hospital and associated outpatient clinics.MATERIALS AND METHODS: Two-hundred fifty-four conventional fluoroscopy-guided selective cervical nerve root blocks were retrospectively identified from 2011 to 2018 using a radiology report search tool. Each procedure was performed by an experienced neuroradiologist performing spinal injections on a full-time basis in clinical practice. A 10-point pain scale was used for pre-and postprocedural pain-level assessment. Successful conventional, fluoroscopy-guided, selective cervical nerve root block was defined as a patient-reported pain scale reduction of at least 50% and/or alleviation of numbness or paresthesia at $2 weeks postinjection. All clinically important immediate and delayed complications were also recorded. RESULTS: Two-hundred fifty-four conventional fluoroscopy-guided selective cervical nerve root blocks were performed via an anterolateral approach with an average fluoroscopy time of 24.3 seconds for all cases. There were no aborted procedures and no major or permanent complications. There were 14 minor complications; 12 of these were periprocedural and resolved by the 2-week follow-up visit. One-hundred eighty-five patients (75.2%) reported pain improvement of .50% from baseline at 15 minutes postinjection. Overall, 172 patients (67.7%) reported .50% pain scale reduction or alleviation from paresthesia at least 2 weeks postinjection.CONCLUSIONS: Conventional fluoroscopy-guided selective cervical nerve root block is an efficacious, efficient, and safe outpatient procedure when performed by a skilled and experienced proceduralist.

510 Background: We have previously reported that up to 48% of the early features of colorectal cancer (subtle wall thickening, pericolonic stranding, and small lymph nodes in the draining nodal station) were not identified on the original CT abdomen and pelvis (CTAP) reports. This resulted in a 36% decrease in five-year survival based on historical data. In this report, we assessed whether dedicated assessment of the colon on routine CT scans could lead to early detection of colorectal cancer. Methods: 210 CTAPs over a three-month period were screened from the emergency room records at a tertiary care hospital. 194 scans met eligibility. Exclusion criteria included: cases known to the evaluating radiologist and age ≤ 19 or > 89 years. No study was excluded for suboptimal image quality. The original report was reviewed for abnormalities involving the colon, mesentery and bowel and was recorded. A blinded evaluation of the eligible case was then performed by a board-certified radiologist with attention specifically to the colon and the mesentery for the suspicious early features of CRC. The concordance and discordance was then tabulated. Discordant findings were re-evaluated to determine if the discordance was true. Results: 72/194 patients were male, median age 44.5 years (range 20 - 89). 55/194 patients (29.1%) included in the study were noted to have suspicious features. 26 had abnormal lymph nodes, 24 had abnormal colonic wall thickening and 16 had pericolonic stranding and/or wall edema. 45/55 studies were truly discordant from the original interpretation. These included one missed colorectal cancer (confirmed), one likely small bowel neuroendocrine tumor (no follow up), and one likely transitional cell carcinoma of the right renal pelvis (no follow up). Conclusions: Dedicated search of the colon and mesentery on CTAP can identify subtle findings, although their true relevance is being evaluated in a larger future study. Our observational data does indicate that there maybe a potential role for a focused evaluation of the colon and mesentery on routine CTAP in an attempt to potentially increase the rate of cancer detection especially in younger low-average risk patients.

Cushing's disease is caused by an excess of cortisol. In a cushingoid state, excess cortisol leads to a cytoplasmic accumulation of cytokeratin filaments. This accumulation of cytokeratin filaments and hyalinization characterizes a Crooke cell tumor which is an interesting variant of corticotroph adenoma (1) This transformation is known as Crooke’s cell transformation. Crooke’s cell tumors are very rare (largest case series of 36) reported by George et al. (2), aggressive, and prone to recurrence after resection which makes identification and distinction from adenomas important for treatment and patient management. A 42-year-old Caucasian male, with a PMH of obesity, HTN, DM2, and refractory hypokalemia presented to the hospital, with symptoms of headache, eye pressure, bilateral pedal edema, and weight gain x 4 weeks. admitted for evaluation with suspicion for Cushing's syndrome. The patient appeared cushingoid with positive parinaud sign (limited upward eye deviation) suggestive of a pituitary mass. CT head revealed a 1.2cm right pituitary macroadenoma with remodeling of sella turcica. Random cortisol 39.6 and ACTH 140. Dexamethasone suppression testing, low and high dose, failed to suppress cortisol production which suggested hypercortisolism from an ectopic source. Inferior petrosal sinus sampling confirmed pituitary Cushing's with lateralization to the right pituitary, as the source of hypercortisolemia. The patient underwent endoscopic endonasal transsphenoidal (EET) resection of pituitary macroadenoma, Postoperatively cortisol levels initially decreased, plateaued and then began rising again with suspicion for a residual tumor in the sella. The patient underwent repeat EET mass resection. Cortisol levels dropped and reached a nadir of 3.0 with ACTH 13 upon discharge. Pathology results revealed Crooke cell adenoma. Discussion : Crooke’s cell tumors are a rare variant of pituitary adenoma and are important to distinguish from other types of adenomas due to their unique cellular behavior. There isn’t a good explanation as to why these tumors cause hyalinization and despite this hyalinization and microfilament deposition, which would be expected to suppress functionality, result in increased production of ACTH. There have been cases reported multiple recurrences in patients requiring repeat surgical removal. Prompt and complete resection may limit the risk for recurrence, and the increase in morbidity and mortality that are inherent to tumor regrowth and continued invasive resection. Additionally, nonsuppressable serum cotrisol with high dexamethasone dose in the presence of pituitary tumor , should raise possibility of Crook cell tumor in addition to paraneoplastic syndromes . conclusion: this case highlights the importance of suspecting Crooke’s tumor in patients with evidence of pituitary adenoma and Cushing’s syndrome.

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