Alendronate in the treatment of avascular necrosis of the hip SIR, Avascular necrosis (AVN) of the bone results from decreased blood supply to the bone, resulting in bone death. The most common site is the head of the femur. AVN is characterized by persistent, often nagging and disabling pain associated with significant reduction in joint movement and mobility. The condition tends to run a progressively downhill course. Medical and surgical management generally aims to improve the blood supply by vasodilators and antiplatelet drugs or by physically drilling holes and bone grafting to restore the blood supply to the avascular area. Eighty-five per cent of patients with symptomatic AVN progress to endstage disease over a 2-yr period [1]. So far, there is no universally accepted treatment that relieves pain and halts its progression. In this communication we report our early experience with the use of alendronate, a bisphosphonate, in AVN of the hip. All cases of proven AVN seen by us between February and October 2000 were assessed. All grades of AVN were considered eligible. Patients were excluded if they had one or more of the following: inability to be followed up regularly, symptoms of oesophagitis or gastritis, age below 18 yr, lactation, and abnormal renal, liver or bone profile. Besides routine physical examination, parameters specifically studied were range of motion, standing and walking time in minutes, pain on visual analogue scale of 0-10 (0, no pain; 10, maximum possible pain) and disability on a scale of 0-10 (0, no disability; 10, totally handicapped). Baseline investigations included complete blood count, liver, renal and bone profiles, Serum 25 (hydroxy) vit D 3 and magnetic resonance imaging (MRI) of both hips. MRI was staged according to the classification of Mitchell et al. [2]. If both hips were affected, for MRI staging the stage of the maximally affected hip was used for analysis. All patients received alendronate 10 mguday plus a calcium supplement of 1 guday. Oral vitamin D 3 was administered to patients

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Spinal dysraphism is a common congenital anomaly with many associated variants. One of the rarest associated findings is a full grown or rudimentary third limb, collectively called Tripagus. We present two cases of spinal dysraphism with rudimentary third limb arising from the ilium.

We report a case of a 35-year-old multigravida with a chief complaint of 8 days of mild pain in the lower abdomen with history of vaginal hysterectomy 2 years prior. Ultrasonography and MRI showed a gestational sac-like structure with a fetal pole in the pelvis. Urine pregnancy test was positive with increased beta-HCG levels. Diagnosis of ectopic pregnancy was made. Surgical exploration and subsequent histopathology confirmed the sonographic findings.

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References 1. Voltz R. Paraneoplastic neurological syndromes: an update on diagnosis, pathogenesis, and therapy. Lancet Neurol 2002; 1:294-305. 2. Baloh RW, DeRossett SE, Cloughesy TF, Kuncl RW, Miller NR, Merrill J, et al. Novel brainstem syndrome associated with prostate carcinoma. Neurology 1993; 43:2591-6. 3. Berger JR, Bensalem M, Dalmau J. A brainstem paraneoplastic syndrome associated with prostate cancer. J Neurol Neurosurg Psychiatry 2009; 80:934-5. 4. Schüller M, Jenne D, Voltz R. The human PNMA family: Novel neuronal proteins implicated in paraneoplastic neurological disease. J Neuroimmunol 2005; 169:172-6. 5. Dalmau J, Graus F, Villarejo A, Posner JB, Blumenthal D, Thiessen B. Clinical analysis of anti-Ma2-associated encephalitis. Brain 2004; 127:1831-44. 6. Gultekin SH, Rosenfeld MR, Voltz R, Eichen J, Posner JB, Dalmau J. Paraneoplastic limbic encephalitis: Neurological symptoms, immunological findings and tumour association in 50 patients. Brain 2000; 123:1481-94. 7. Sutton I, Winer J, Rowlands D, Dalmau J. Limbic encephalitis and antibodies to Ma2: A paraneoplastic presentation of breast cancer.

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Amyotrophic Lateral Sclerosis (ALS) is a rare, devastating motor neuron disease characterized by the degeneration of upper and lower motor neurons causing muscular weakness, paralysis, and eventual death. MRI plays a supportive role in the diagnosis; its primary role is to exclude other clinical mimics. Some of the imaging features associated with ALS include hypointense signal along the motor cortices on susceptibility or T2*-weighted imaging and hyperintensity along the corticospinal tracts (CST) within the cerebral hemispheres, brainstem, and spinal cord on the T2 weighted imaging. In this report, we discuss the value of T1 hyperintensity along the CST, especially in the spinal cord.