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Low back pain
Clinical Radiology (1990) 41, 217-218
Correspondence Letters are published at the discretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors for shortening. Letters in response to a paper may be sent to the author o f the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instruction to Authors at the front o f the Journal.
MYOCARDIAL BRIDGING OF THE CORONARY ARTERIES SIR - Whilst I enjoyed the paper by Charmer et al. (1989) there are two aspects that concern me. I agree that autopsy reports clearly confirm that the left anterior descending coronary artery can run for a variable distance below the epicardial surface. Indeed, our surgical colleagues sometimes report difficulty in finding the vessel because of this. However, it is m y impression that a review of the arteriogram usually shows that there was no compression of the artery at this point. Sometimes there is a long segment of compression and it m a y be these that cause ischaemic episodes due to thrombus within the vessel. On the other hand, the more c o m m o n type of myocardial bridge as seen on angiography is a very short segment of compression. To the best of nay knowledge there is no good correlation between this appearance and the surgical appearances. The vessel seldom shows any inferior deviation at the bridge, and I suspect that the appearances are due to abnormal muscle bands across the vessel on the epicardial surface. I disagree with the authors' opinion that bridging is more c o m m o n at autopsy than during angiography because angiography necessarily raises the intracoronary pressure. T h o u g h I suppose a mild rise in intraluminal pressure m a y be a consequence of selective angiography, any significant rise must surely infer that the catheter is either partially or perhaps even completely wedged in the orifice of the vessel. The consequence of this would be to force contrast through the capillary bed, an event that predisposes very considerably to ventricular fibrillation. It is certainly not desirable for any significant degree of wedging to be achieved by catheter placement and for the authors to suggest that it happens on a regular basis is to some extent a misrepresentation of the technique. J. P A R T R I D G E
PORTAL HYPERTENSION AND SPLENO-RENAL SHUNTING WITHOUT SPLENOMEGALY S m - We were interested to read the case report by Rees and Whyte (1989) as we have recently had a similar patient. A 24-year-old male presented in 1976 with a history of abdominal pain and signs and symptoms o f both superior and inferior venae caval obstruction. At laparotomy, a large retroperitoneal mass and multiple dilated veins were found. Portal vein obstruction was also present with numerous collateral venous channels. Histology revealed the diagnosis of mediastinal and retroperitoneal fibrosis secondary to a sclerosing lymphoma. He responded to chemotherapy but the signs of venae caval obstruction persisted. He relapsed in 1981, responded to chemotherapy and has remained stable since then. At no stage has his spleen been enlarged. A recent dynamic enhanced CT scan for abdominal pain demonstrated the spleno-renal shunt and a normal sized spleen (Fig. la, b). Cavernomatous transformation of the portal vein as well as extensive venous collaterals, including oesophageal varices, were also noted. Portal hypertension and spleno-renal shunting without splenomegaly had not previously been reported. The authors attributed the normal size of the spleen in their patient to the presence of granulomas and fibrosis which prevented enlargement. It is recognised that 33% of patients with l y m p h o m a whose spleens are of normal size have histological involvement of the spleen (Kaplan, 1980). The intense fibrosis seen in this patient m a y have prevented the development of splenomegaly.
Department o f Radiology Mater Misericordiae Hospitals South Brisbane Queensland, Australia 4101
Reference Channer, KS, Bukis, E, Hartnell, G & Russell Rees, J (1989). Myocardial bridging of the coronary arteries. Clinical Radiology, 40, 355-359.
LOW BACK PAIN
Sm- In his Editorial on low back p a i n D r Butt (1989) states that 6800 patients with low back pain out of a total of 7600 will be back at work within 2 m o n t h s having been treated with rest, analgesics, education and general support and should therefore have not been X-rayed. Indeed he says that no useful purpose is served by any type of radiology. However, m his conclusion he states that patients who require surgery need to be diagnosed correctly within one month. How can we correctly diagnose those patients who require surgery in 1 month, if we have to wait for 2 months to see if they respond to conservative measures? R. SELLAR
Reference
(a)
Department o f Clinical Neurosciences Western General Hospital Crewe Road Edinburgh EH4 2XU
Butt, WP (1989). Radiology for back pain. ClinicalRadiology, 40, 6-10. 81~,- Patients who require definitive surgical management for back pain do.best if their surgery is performed within 3 m o n t h s of the onset of their Pare and as 2 m o n t h s will have been taken up by bed rest, analgesia, education and general support there is but 1 m o n t h for diagnosis and treatment. W. p. B U T T
Department o f Radiology St James" Hospital Becketl Street Leeds LS9 7TF
(b) Fig 1.
Correspondence Letters are published at the discretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors for shortening. Letters in response to a paper may be sent to the author o f the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instruction to Authors at the front o f the Journal.
MYOCARDIAL BRIDGING OF THE CORONARY ARTERIES SIR - Whilst I enjoyed the paper by Charmer et al. (1989) there are two aspects that concern me. I agree that autopsy reports clearly confirm that the left anterior descending coronary artery can run for a variable distance below the epicardial surface. Indeed, our surgical colleagues sometimes report difficulty in finding the vessel because of this. However, it is m y impression that a review of the arteriogram usually shows that there was no compression of the artery at this point. Sometimes there is a long segment of compression and it m a y be these that cause ischaemic episodes due to thrombus within the vessel. On the other hand, the more c o m m o n type of myocardial bridge as seen on angiography is a very short segment of compression. To the best of nay knowledge there is no good correlation between this appearance and the surgical appearances. The vessel seldom shows any inferior deviation at the bridge, and I suspect that the appearances are due to abnormal muscle bands across the vessel on the epicardial surface. I disagree with the authors' opinion that bridging is more c o m m o n at autopsy than during angiography because angiography necessarily raises the intracoronary pressure. T h o u g h I suppose a mild rise in intraluminal pressure m a y be a consequence of selective angiography, any significant rise must surely infer that the catheter is either partially or perhaps even completely wedged in the orifice of the vessel. The consequence of this would be to force contrast through the capillary bed, an event that predisposes very considerably to ventricular fibrillation. It is certainly not desirable for any significant degree of wedging to be achieved by catheter placement and for the authors to suggest that it happens on a regular basis is to some extent a misrepresentation of the technique. J. P A R T R I D G E
PORTAL HYPERTENSION AND SPLENO-RENAL SHUNTING WITHOUT SPLENOMEGALY S m - We were interested to read the case report by Rees and Whyte (1989) as we have recently had a similar patient. A 24-year-old male presented in 1976 with a history of abdominal pain and signs and symptoms o f both superior and inferior venae caval obstruction. At laparotomy, a large retroperitoneal mass and multiple dilated veins were found. Portal vein obstruction was also present with numerous collateral venous channels. Histology revealed the diagnosis of mediastinal and retroperitoneal fibrosis secondary to a sclerosing lymphoma. He responded to chemotherapy but the signs of venae caval obstruction persisted. He relapsed in 1981, responded to chemotherapy and has remained stable since then. At no stage has his spleen been enlarged. A recent dynamic enhanced CT scan for abdominal pain demonstrated the spleno-renal shunt and a normal sized spleen (Fig. la, b). Cavernomatous transformation of the portal vein as well as extensive venous collaterals, including oesophageal varices, were also noted. Portal hypertension and spleno-renal shunting without splenomegaly had not previously been reported. The authors attributed the normal size of the spleen in their patient to the presence of granulomas and fibrosis which prevented enlargement. It is recognised that 33% of patients with l y m p h o m a whose spleens are of normal size have histological involvement of the spleen (Kaplan, 1980). The intense fibrosis seen in this patient m a y have prevented the development of splenomegaly.
Department o f Radiology Mater Misericordiae Hospitals South Brisbane Queensland, Australia 4101
Reference Channer, KS, Bukis, E, Hartnell, G & Russell Rees, J (1989). Myocardial bridging of the coronary arteries. Clinical Radiology, 40, 355-359.
LOW BACK PAIN
Sm- In his Editorial on low back p a i n D r Butt (1989) states that 6800 patients with low back pain out of a total of 7600 will be back at work within 2 m o n t h s having been treated with rest, analgesics, education and general support and should therefore have not been X-rayed. Indeed he says that no useful purpose is served by any type of radiology. However, m his conclusion he states that patients who require surgery need to be diagnosed correctly within one month. How can we correctly diagnose those patients who require surgery in 1 month, if we have to wait for 2 months to see if they respond to conservative measures? R. SELLAR
Reference
(a)
Department o f Clinical Neurosciences Western General Hospital Crewe Road Edinburgh EH4 2XU
Butt, WP (1989). Radiology for back pain. ClinicalRadiology, 40, 6-10. 81~,- Patients who require definitive surgical management for back pain do.best if their surgery is performed within 3 m o n t h s of the onset of their Pare and as 2 m o n t h s will have been taken up by bed rest, analgesia, education and general support there is but 1 m o n t h for diagnosis and treatment. W. p. B U T T
Department o f Radiology St James" Hospital Becketl Street Leeds LS9 7TF
(b) Fig 1.