Abstract Introduction Improved outcome measures of muscle reinnervation would facilitate clinical translation of new therapies which hope to enhance human peripheral nerve repair. Valid outcome measures should be receptive to the biological process of muscle reinnervation and correlate with clinical assessments of muscular function. This study investigated the responsiveness of volumetric MRI to the biological process of muscle reinnervation and its relationship with clinical indices of muscular function. Method Twenty-five patients who underwent nerve transfer to reinnervate elbow flexor muscles were followed-up at a median time of 258 days (-86 to 1698 days) post-operatively for a mean of two (one to three) volumetric MRI assessments. Medical Research Council (MRC) grade, peak volitional force (PVF), muscular fatigue, co-contraction and Stanmore Percentage of Normal Elbow Assessment (SPONEA) was also measured at each appointment. The responsiveness of each parameter was compared using Pearson or Spearman correlation as appropriate. Results Elbow flexor muscle volume per unit BMI demonstrated responsiveness to the biological process of muscle reinnervation (R2=0.73, p < 0.001) and correlated with patient reported impairments of reinnervated muscle; co-contraction (R2=0.63, p = 0.02) and muscle fatigue (R2=0.64, p = 0.04). Conclusions Volumetric MRI may is an excellent candidate as an outcome measure of muscle reinnervation.

To identify if morphology of the entering and exiting nerve involved by a nerve sheath tumour in the brachial plexus can help differentiate between benign (B) and malignant (M) peripheral nerve sheath tumours (PNSTs). Retrospective review of 85 patients with histologically confirmed primary PNSTs of the brachial plexus over a 12.5-year period. Clinical data and all available MRI studies were independently evaluated by 2 consultant musculoskeletal radiologists blinded to the final histopathological diagnosis assessing for maximal lesion dimension, visibility and morphology of the entering and exiting nerve, and other well-documented features of PNSTs. The study included 47 males and 38 females with mean age 46.7 years (range, 8–81 years). There were 73 BPNSTs and 12 MPNSTs. The entering nerve was not identified in 5 (7%), was normal in 17 (23%), was tapered in 38 (52%) and showed lobular enlargement in 13 (18%) BPNSTs compared with 0 (0%), 0 (0%), 2 (17%) and 10 (83%) MPNSTs respectively. The exiting nerve was not identified in 5 (7%), was normal in 20 (27%), was tapered in 42 (58%) and showed lobular enlargement in 6 (8%) BPNSTs compared with 4 (33%), 0 (0%), 2 (17%) and 6 (50%) MPNSTs respectively. Increasing tumour size, entering and exiting nerve morphology and suspected MRI diagnosis were statistically significant differentiators between BPNST and MPNST (p < 0.001). IOC for nerve status was poor to fair but improved to good if normal/tapered appearance were considered together with improved specificity of 81–91% for BPNST and sensitivity of 75–83%. Morphology of the adjacent nerve is a useful additional MRI feature for distinguishing BPNST from MPNST of the brachial plexus.

Introduction In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated. Methods All paediatric patients (<= 16 years) treated in our institution during the six-week peak period of the pandemic were included. Prospective data for all paediatric trauma and urgent elective admissions and retrospective data for all sarcoma admissions were collected. Telephone interviews were conducted with all patients and families to assess COVID-19 related morbidity at 14 days post-discharge. Results Overall, 100 children underwent surgery or interventional radiological procedures under GA between 20 March and 8 May 2020. There were 35 trauma cases, 20 urgent elective orthopaedic cases, two spinal emergency cases, 25 admissions for interventional radiology procedures, and 18 tumour cases. 78% of trauma cases were performed within 24 hours of referral. In the 97% who responded at two weeks following discharge, there were no cases of symptomatic COVID-19 in any patient or member of their households. Conclusion Despite the extensive restructuring of services and the widespread concerns over the surgical and anaesthetic management of paediatric patients during this period, we treated 100 asymptomatic patients across different orthopaedic subspecialties without apparent COVID-19 or unexpected respiratory complications in the early postoperative period. The data provides assurance for health care professionals and families and informs the consenting process.

AIM:To evaluate the response measures in continuing an image-guided intervention service in two tertiary-level musculoskeletal oncology centres during the COVID-19 pandemic.MATERIALS AND METHODS:This study was a retrospective review of all patients undergoing image-guided intervention in the computed tomography (CT) and normal ultrasound (US) rooms from 24 March 2020 to 24 May 2020 (during the COVID-19 pandemic peak) at Royal National Orthopaedic Hospital, London, and Royal Orthopaedic Hospital, Birmingham, UK. Measures were put in place to address air pressures, airflow direction, aerosol generation, and the safe utilisation of existing scanning rooms and work lists for interventional procedures.RESULTS:Three hundred and thirty-one patients (164 at Royal National Orthopaedic Hospital and 167 at Royal Orthopaedic Hospital) underwent image-guided procedures at both sites in the CT and US rooms. At the Royal National Orthopaedic Hospital, 40% of all procedures were performed under general anaesthesia. These consisted of 47 CT biopsies, 7 CT radiofrequency ablations (RFAs), and 12 US biopsies. At the Royal Orthopaedic Hospital, 86% of all procedures were performed under local anaesthetic, with no general anaesthetic procedures. These consisted of 61 CT biopsies and 83 US biopsies. All 256 patients having procedures in the CT room had no post-procedural complications or COVID-19-related symptoms and morbidity on follow-up.CONCLUSION:By adopting a pragmatic approach with meticulous planning, a limited, but fully functional image-guided interventional list can be run without any adverse patient outcomes.

Background Chronic recurrent multifocal osteomyelitis (CRMO) is an auto-inflammatory bone disorder affecting children and adolescents, characterised by sterile bone inflammation. There is a clinical spectrum, ranging from presentation with a single, non-recurrent bone lesion to a chronic relapsing course affecting multiple, often symmetrical bone sites. Whole body MR imaging may reveal multiple lesions and therefore is promising for assessing progression of CRMO and effectiveness of treatment. Nevertheless, no tool has been available for quantitative measurement of multiple lesions in whole body MRI scans, and a fast, reproducible scoring system for CRMO patient assessment is warranted. Objectives Methods Whole-body static MRI STIR images from 4 patients were analysed by 2 different readers. The workflow for each reading was: 1) Define reference/baselines in fat, bone and muscle region in both left and right side of the body, respectively. 2) Draw regions of interests (ROIs) around lesions defined as areas of marrow hyper intensity. 3) Compute, Norml parametric maps by comparison with corresponding baseline. NormI have previously shown to be useful in semi-automatic quantification of inflammatory lesions in the spine on STIR or DWI-MRI sequences [1]. 4) Group the selected 2D ROIs across slices into volume of interests (VOIs). 5) Generate and save report - automated generation of lesion ROI parameters, including the sum, maximum and mean of all positive pixel values in the VOIs (SumNormI,MaxNormI and MeanNormI). Inter-reader agreement for SumNormI and MeanNormI was calculated using the intraclass correlation coefficient for each VOI. Results Single or multiple lesions seen in whole body MRI scans of CRMO patients were identified and quantified using NormI parametric maps. As shown in figure, quantification parameters for the lesions identified in right femur and right clavicle have been computed by normalising to the baseline in muscle. Reproducibility assessed by ICC is shown in table. Conclusions The suggested workflow and postprocessing technique provides a relatively fast and reproducible scoring method for both single and multiple lesions in CRMO from wholebody STIR MRI scans. Larger trials to test day-to-day variation and sensitivity to change following treatment response are warranted and currently ongoing. References D. Roettger, et al. A novel MRI-based analysis workflow for spinal lesions in Ankylosing Spondylitis, in Proceeding of 15th Annual European Congress of Rheumatology EULAR, June 11–14, 2014. Disclosure of Interest Y. Chu Employee of: Image Analysis Ltd., D. Roettger Employee of: Image Analysis Ltd., C. Trentin Employee of: Image Analysis Ltd., M. Hinton Employee of: Image Analysis Ltd., O. Kubassova Employee of: Image Analysis Ltd., R. Hargunani: None declared, M. Boesen Consultant for: Image Analysis Limited as Head of Clinical Advisory Board, P. O9Donnell: None declared

The high intensity zone (HIZ) was first described by Aprill and Bogduk on lumbar spine magnetic resonance imaging (MRI) studies in 1992. Correlation with lumbar computed tomography (CT) discography showed that the HIZ represents a deep radial tear of the annulus fibrosus, which may be a cause of chronic low back pain. Initial studies comparing the finding of a HIZ on MRI with discography suggested that it may be a highly specific marker of a painful lumbar disc, but later investigators demonstrated that it is also present in asymptomatic individuals. The purpose of this article is to review the literature regarding the lumbar HIZ 20 years after its initial description.

The spine is a complex structure that comprises multiple joints and soft tissue elements that in concert allow weight bearing and function. There are numerous clinical indications for imaging in the spine; 'back' pain and neurological symptoms are the most common presenting complaints with a wide variety of disorders that could contribute to symptoms. This article will outline important spinal pathologies and illustrate how imaging plays a pivotal role in their assessment and management.

To review the technique of pre-operative PVE in selected patients with primary or secondary hepatobiliary malignancy and a small estimated future liver remnant prior to major hepatic resection at our institution and compare our results with the published literature. Over a 7-year period, 51 consecutive patients (33 male, 18 female) underwent PVE. The majority of patients (36/51) had colorectal metastases; 7/51 had cholangiocarcinoma, 5/51 had hepatocellular carcinoma, 1/51 had gallbladder carcinoma, 1/51 had epithelioid hemangioepithelioma and 1 patient had ovarian sarcoma metastases. The median patient age was 65 years (range 26-82 years). Patient clinical and radiologic records were retrospectively reviewed to assess outcomes. The median ratio between future liver remnant volume to tumor free liver (FLR/TFL) prior to PVE was 0.22 (range 0.075 – 0.30) and after PVE was 0.31 (range 0.12 – 0.48). Three patients (6 %) had PVE-related complications which included total portal vein occlusion, inadvertent partial embolization of both lobes and an hepatic abscess. There were no deaths at 30 days post PVE. Thirty patients (61%) underwent hepatic resection. Of the remaining 20 patients, 13 had progressive disease precluding resection, 5 had insufficient hypertrophy, 1 had intra-operative complications precluding resection and the remaining patient had total portal venous occlusion precluding resection. PVE is a safe procedure with an acceptable complication rate, which allows selected patients with primary or secondary hepatobiliary malignancy to undergo major hepatic resection. Our results compare well with the published literature.

The detection of gastric neoplasia has traditionally been limited to barium examination and direct visualization at endoscopy. The rapid development of techniques such as multidetector computed tomography (MDCT) and endoscopic ultrasound (EUS) has resulted in more accurate diagnosis and staging of gastric neoplasia. In this review we describe the normal anatomy of the stomach with multi-modality illustrations and review the imaging manifestations of gastric neoplasia, including adenocarcinoma, lymphoma, neuroendocrine and gastro-intestinal stromal tumours. We also describe the optimal techniques for up-to-date and accurate gastric imaging, outlining the role of MDCT and EUS.

Haematuria is a classical symptom of urological disease often signifying a primary bladder cancer. Rarely, however, the presence of blood in the urine can be due to secondary spread of tumours into the bladder from distant sites. Notably this has been reported to occur in breast cancer, malignant melanoma and gastric cancers. Haematuria due to spread from a primary oesophageal cancer to the bladder has never been reported. We present a case of haematuria confirmed histologically to be due to metastases from a primary oesophageal tumour. Oesophageal cancer is capable of spread to all three neighbouring compartments (abdomen, chest and neck) and therefore has the potential to spread to unusual sites. Clinicians should always carefully regard haematuria in a patient previously treated for cancer and retain a high index of suspicion for distant metastases as being the cause.