The radiological reporting of lumbar Scheuermann's disease: an unnecessary source of confusion amongst clinicians and patients

Patients with mechanical lower back pain not uncommonly present to clinicians with anxiety following a diagnosis of "Scheuermann's disease" based on a report of a plain radiograph of the lumbar spine. In most instances, the radiographs show features of lumbar Scheuermann's, rather than the classical adolescent thoracic kyphosis described by Scheuermann in 1920. The purpose of this study was (i) to investigate how often the diagnosis of Scheuermann's disease was made at a District General Hospital in radiological reports sent to local general practitioners (GPs); (ii) to determine the type of "Scheuermann's disease" being described; and (iii) to assess what GPs understood by the term "Scheuermann's disease" in the context of a specific clinical presentation. 50 reports were identified in a computerized search for diagnoses of "Scheuermann's disease". Review of the radiographs revealed that 80% showed features of lumbar Scheuermann's disease and 20% classical Scheuermann's. A questionnaire was issued to local GPs that described a case history of an adult patient with typical mechanical lower back pain for whom a radiological report, describing degenerative changes in the lumbar spine, concluded that some of the features "were consistent with Scheuermann's disease". 86% of GPs stated that they would inform their patients that they had "Scheuermann's disease" (using that exact term), but only 51% understood the meaning of the diagnosis in the context of the case history. We recommend that the term "Scheuermann's disease" be avoided in radiological reports to GPs and other non-specialist clinicians except when reporting on classical adolescent thoracic kyphosis.     

Assessment of agreement between general practitioners and radiologists as to whether a radiation exposure is justified

The objective of this study was to assess agreement between General Practitioners (GPs) and Consultant Radiologists as to whether a radiation exposure is justified and whether a request conforms to the Royal College of Radiologists (RCR) guidelines. Three GPs and three Consultant Radiologists were asked to review 100 requests for plain film imaging from GPs and to state whether the request justified a radiation exposure and whether the request conformed to RCR guidelines. It was discovered that there is greater agreement between radiologists than between GPs; this is a consistent pattern. The best agreement was between two Consultant Radiologists using the RCR guidelines. The poorest was between GPs using the request form details. It is suggested that the guidelines should be symptom-based to improve efficacy.     

The use of radiological guidelines to achieve a sustained reduction in the number of radiographic examinations of the cervical spine, lumbar spine and knees performed for GPs

AIM: To determine if the use of request guidelines can achieve a sustained reduction in the number of radiographic examinations of the cervical spine, lumbar spine and knee joints performed for general practitioners (GPs). METHODS: GPs referring to three community hospitals and a district general hospital were circulated with referral guidelines for radiography of the cervical spine, lumbar spine and knee, and all requests for these three examinations were checked. Requests that did not fit the guidelines were returned to the GP with an explanatory letter and a further copy of the guidelines. Where applicable, a large-joint replacement algorithm was also enclosed. If the GP maintained the opinion that the examination was indicated, she or he had the option of supplying further justifying information in writing or speaking to a consultant radiologist. RESULTS: Overall the number of radiographic examinations fell by 68% in the first year, achieving a 79% reduction in the second year. For knees, lumbar spine and cervical spine radiographs the total reductions were 77%, 78% and 86%, respectively. CONCLUSION: The use of referral guidelines, reinforced by request checking and clinical management algorithms, can produce a dramatic and sustained reduction in the number of radiographs of the cervical spine, lumbar spine and knees performed for GPs.     

Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee

BACKGROUND: Specific guidelines for operative versus nonoperative management of anterior cruciate ligament injuries do not yet exist. HYPOTHESIS: Surgical risk factors can be used to indicate whether reconstruction or conservative management is best for an individual patient. STUDY DESIGN: Prospective nonrandomized controlled clinical trial; Level of evidence, 2. METHODS: Patients were classified as high, moderate, or low risk using preinjury sports participation and knee laxity measurements. Early anterior cruciate ligament reconstruction (within 3 months of injury) was recommended to high-risk patients and conservative care to low-risk patients. It was recommended that moderate-risk patients have either early reconstruction or conservative care, according to the day of presentation. Assessment of subjective outcomes, activity, physical measurements, and radiographs was performed at mean follow-up of 6.6 years. RESULTS: Early phase conservative management resulted in more late phase meniscus surgery than did early phase reconstruction at all risk levels (high risk, 25% vs 6.5%; moderate risk, 37% vs 7.7%, P = .01; low risk, 16% vs 0%). Early- and late-reconstruction patients' Tegner scores increased from presurgery to follow-up (P < .001) but did not return to preinjury levels. Early-reconstruction patients had higher rates of degenerative change on radiographs than did nonreconstruction patients (P < .05). CONCLUSIONS: Early phase reconstruction reduced late phase knee laxity, risk of symptomatic instability, and the risk of late meniscus tear and surgery. Moderate- and high-risk patients had similar rates of late phase injury and surgery. Reconstruction did not prevent the appearance of late degenerative changes on radiographs. Relationship between bone contusion on initial magnetic resonance images and the finding of degenerative changes on follow-up radiographs were not detected. The treatment algorithm used in this study was effective in predicting risk of late phase knee surgery.     

An investigation of lumbar spine magnetic resonance referrals in two Irish university teaching centres: Radiology clinical judgement versus iRefer guideline compliance

IntroductionWith the annual increase in medical imaging demand, the appropriateness of the lumbar spine magnetic resonance imaging LSMRI referrals is worldwide gaining attention. This study aims to determine the appropriateness of LSMRI referrals and compare radiology clinical decisions to iRefer compliance based solely on referral text content.MethodsReferral text was extracted from 1021 LSMRI referrals. Two review panels were recruited: three expert radiologists and three MRI radiographers. Radiologists classified cases as indicated or not indicated for scanning based on their clinical judgement. The radiographers classified based solely on iRefer guidelines. Majority voting for each case was applied to both review panels and reviewer agreement was tested using Kappa analysis. Logistic regression models were developed to identify medical disciplines associated with high rates of indicated referrals.Results21.7% and 11.9% of the cases were found not indicated for MRI for radiologists and radiographers, respectively. Radiology review identified 18% of the GPs referrals as not indicated and 17% in the radiographers’ review. Panel agreement was fair: Kappa values of 0.23 and0.26 for the radiologists and radiographers respectively. Neurosurgery was associated with the highest rate of indicated referrals across both review panels: oncology referrals raised the highest number of open comments.ConclusionThe study identified a lower number of not indicated referrals compared to previous research. Findings indicate the importance of both guidelines compliance and clinical judgement to optimise practice.Implications for practiceFindings in this study found that even when strict instructions were given to the MR radiographers to vet referrals using the iRefer guidelines, ambiguity within the guidelines resulted in variations in decision-making. This suggests that detailed protocols are required to support radiographers in the vetting process to ensure a standardised approach.     

Effects of mailed dissemination of the Royal College of Radiologists' guidelines on general practitioner referrals for radiography: a time series analysis

AIM: To evaluate the effect of postal dissemination of the third edition of the Royal College of Radiologists' (RCR) guidelines on general practitioner referrals for radiography. MATERIALS AND METHODS: An interrupted time series using monthly data for 34 months before and 14 months after dissemination of the guidelines was employed. Data were abstracted for the period April 1994 to March 1998 from the computerized administrative systems of open access radiological services provided by two teaching hospitals in one region of Scotland. The time series results are contrasted with those obtained by using a simple before and after design. RESULTS: A total of 117 747 imaging requests from general practice were received in the two departments. There were no significant effects of disseminating the guidelines on the total number of requests, or on requests for individual examinations. If a simple before and after study had been used, then we would have erroneously concluded that significant changes had occurred in referral practice for 11 of the 18 procedures concerned. CONCLUSION: Mailing of copies of the RCR guidelines had a small effect on general practitioners' use of X-ray investigations of uncertain clinical significance. Additional dissemination and implementation strategies appear necessary to promote the use of guidelines.     

Reducing unnecessary skull radiographs in children: a multidisciplinary audit

AIM: To review guidelines on the indications for skull radiographs with a view to improving compliance and reducing unnecessary irradiation of children. METHODS: Three audits on the indications, compliance and effect on practice of differing sets of guidelines for skull radiographs following paediatric head trauma were performed. After each audit, alterations in clinical practice with modifications of the guidelines were implemented. The effect of these changes on radiological practice and patient care were recorded. Audits were performed for 3 months (February-April) in 1999, 2001 and 2003. RESULTS: The number of children with head injuries presenting was unchanged. The number of skull radiographs performed fell from 146 in 1999 to 95 in 2001 and 50 in 2003. Compliance with hospital guidelines increased from 85% in 1999 to 100% in 2003. No neurosurgical problems were missed. CONCLUSION: The implementation of guidelines that are acceptable to all specialties will improve compliance and reduce unnecessary radiographs being performed. The involvement of the radiography staff will help maintain compliance. The training of junior staff and maintaining good communication with involved departments will improve patient care.     

Assessment of radiological referral practice and effect of computer-based guidelines on radiological requests in two emergency departments

AIM: To assess medical emergency radiology referral practice compared with a set of French guidelines and to measure the efficiency of computer-based guidelines on unnecessary medical imaging. MATERIALS AND METHODS: All radiological requests were computerized in the medical emergency departments of two French teaching hospitals. During control periods, radiological requests were recorded but no action was taken. During intervention periods, reminder displays on screen indicated the appropriate recommendations. Three control and three intervention periods of 1 month each were conducted. The percentage of requests that did not conform to the guidelines and variation related to periods of control and intervention were measured. RESULTS: The proportion of requests that did not conform to the guidelines was 33.2% when the guidelines were inactive and decreased to 26.9% when the recommendations were active (P < 0.0001). The three imaging examinations (chest radiographs, abdominal plain radiographs and CT of the brain) accounted for more than 80% of all requests; more than 50% of abdominal plain radiographs requests did not conform with recommendations while this percentage was respectively 24.9% and 15.8% for chest radiographs and computed tomography (CT) of the brain. Seven situations accounted for 70% of non-conforming radiological referrals; in these situations, junior practitioners' knowledge was inadequate. CONCLUSION: While the computer provided advice that was tailored to the needs of individual patients, concurrent with care, the effect of our intervention was weak. However, our study identified the few situations that were responsible for the majority of unnecessary radiological requests; we expect that this result could help clinicians and radiologists to develop more specific actions for these situations.     

Osteitis deformans of the hip joint.

It is estimated that 66% of patients with Paget's disease have involvement of the pelvis and 46% of the proximal femur. Therefore, it is not unexpected that hip pain is one of the major presenting complaints. Analysis of the radiographs of 25 hips with one or more articular sufaces involved by Paget's disease demonstrated narrowing in 24. Unlike the findings in primary degenerative joint disease, the majority of cases had a radiographic pattern characterized by uniform narrowing of the articular cartilage and minimal hypertrophic changes. Pathologic correlation was obtained from specimens of four patients who underwent total hip replacements. The pathogenesis of arthritic changes associated with osteitis deformans is not established. The evidence presented suggest that cartilagenous narrowing results from a disturbance in endochondral bone formation related to the hyperemia of Paget's disease. Secondary deformities of bone produce further derangement of joint mechanics. The secondary degenerative changes which ensue differ mechanically, and therefore radiographically, from primary degenerative joint disease.     

Effect of spinal degenerative changes on volumetric bone mineral density of the central skeleton as measured by quantitative computed tomography

Purpose: To evaluate the impact of degenerative changes due to osteoarthritis (OA) at the spine on volumetric bone mineral density (BMD) as measured by volumetric quantitative computed tomography (vQCT).

Material and Methods: Eighty-four elderly women (mean age 73±6 years), comprising 33 with vertebral fractures assessed by radiographs and 51 without vertebral fractures, were studied. Trabecular, cortical, and integral BMD were examined at the spine and hip using a helical CT scanner and were compared to dual X-ray absorptiometry (DXA) measurements at the same sites. OA changes visible on the radiographs were categorized into two grades according to severity. Differences in BMD measures obtained in the two groups of patients defined by OA grade using the described radiologic methods were compared using analysis of variance. Standardized difference (effect sizes) was also compared between radiologic methods.

Results: Spinal trabecular BMD did not differ significantly between OA grade 0 and OA grade 1. Spinal cortical and integral BMD measures showed statistically significant differences, as did the lumbar spine DXA BMD measurement (13%, P = 0.02). The QCT measurements at the hip were also higher in OA 1 subjects. Femoral trabecular BMD was 13-15% higher in OA grade 1 subjects than in OA grade 0 subjects. The cortical BMD measures in the CT_TOT_FEM and CT_TROCH ROI's were also higher in the OA 1 subjects. The integral QCT BMD measures in the hip showed difference between grades OA 1 and 0. The DXA measurements in the neck and trochanter ROI's showed smaller differences (9 and 11%, respectively). There were no statistically significant differences in bone size.

Conclusion: There is no evidence supporting that trabecular BMD measurements by QCT are influenced by OA. Instead, degenerative changes have an effect on both cortical and integral QCT, and on DXA at the lumbar spine and the hip. For subjects with established OA, assessment of BMD by volumetric QCT may be suggested.     

Imaging of hip disorders in athletes

Normal hip joint function is fundamental in running-, jumping-, and kicking-based sporting activities. Hip disorders do not account for a large portion of exercise-related injuries, but they can pose a clinical dilemma since symptoms tend to be non-specific. Conventional radiographs may demonstrate some causes of hip pain, such as stress fractures and degenerative joint disease. Magnetic resonance (MR) imaging of the hip has proven valuable in the diagnosis of radiographically occult osseous abnormalities and periarticular soft tissue disorders such as stress fractures, avulsion injuries, musculotendinous abnormalities, and bursitis. Conventional MR imaging has been less useful in the evaluation of intra-articular lesions including acetabular labral tears, intra-articular loose bodies, and cartilage lesions. The visualization of intra-articular structures and their abnormalities can be improved by the injection of diluted Gadolinium, which distends the capsule and leaks into labral tears. This article will focus on the use of conventional radiography and MR imaging in recreational and professional athletes with painful hip joints, and where possible it will compare MR imaging with other diagnostic modalities such as bone scan and CT.     

General practitioners' use of magnetic resonance imaging: an open randomized trial comparing telephone and written requests and an open randomized controlled trial of different methods of local guideline dissemination

AIM: To determine the impact and cost-effectiveness of telephone versus written access to magnetic resonance imaging (MRI), and of different strategies for disseminating locally produced guidelines, upon requests by general practitioners (GPs) for knee and lumbar spine investigation. MATERIAL AND METHODS: Two sequential pragmatic open cluster-randomized trials were conducted within 39 general practices. The outcome measure in each trial was concordance of request with local guidelines. Trial 1: practices requested MRI by telephone or in writing. Trial 2: all practices received guidelines, plus either: a practice-based seminar, practice-specific audit feedback, both seminar and feedback, or neither. RESULTS: A total of 414 requests were assessed in the two trials. Trial 1: telephone access cost pound4.86 more per request but rates of concordant requests were equivalent (65%/64%: telephone/written). Trial 2: compared to the control group, costs per practice were pound1911 higher in seminar group, pound1543 higher in feedback group and pound3578 higher for those receiving both. Concordance was greater following the intervention (74% vs 65%; P < 0.05), but there was no difference between the four study groups. CONCLUSIONS: Method of access did not affect concordance. Written access was more cost-effective. Seminars and feedback were no more effective in modifying practice than guidelines alone, which was thus the most cost-effective option.     

Musculoskeletal magnetic resonance imaging: importance of radiography

OBJECTIVE: To determine the usefulness of radiography for interpretation of musculoskeletal (MSK) magnetic resonance imaging (MRI) studies. DESIGNS AND PATIENTS: In a 1-year period, 1,030 MSK MRI studies were performed in 1,002 patients in our institution. For each study, the interpreting radiologist completed a questionnaire regarding the availability and utility of radiographs, radiological reports and clinical information for the interpretation of the MRI study. RESULTS: Radiographs were essential, very important or added information in 61-75% of all MSK MRI cases. Radiographs were judged as essential for reading of MRI studies more often for trauma, infection/inflammation and tumors than for degenerative and miscellaneous/normal diagnoses (chi(2)=60.95, df=16, P<0.0001). The clinical information was rated as "essential" or "useful" significantly more often than not (chi(2)=93.07, df=16, P<0.0001). The clinical and MRI diagnoses were the same or partially concordant significantly more often for tumors than for trauma, infection/inflammation and degenerative conditions, while in the miscellaneous/normal group they were different in 64% of cases. When the diagnoses were different, there were more instances in which radiographs were not available. CONCLUSIONS: Radiographs are an important, and sometimes essential, initial complementary study for reading of MSK MRI examinations. It is highly recommended that radiographs are available when MSK MRI studies are interpreted.     

Painful infection at the site of hip prosthesis: CT imaging

PURPOSE: To prospectively determine the accuracy of computed tomography (CT) in the detection of painful infection at the site of hip prosthesis before surgery. MATERIALS AND METHODS: Helical CT examinations of hip prostheses were prospectively performed before surgery after a standard clinical and radiologic examination of 65 patients. CT scans and conventional radiographs were reviewed for periprosthetic bone abnormalities, and CT scans were reviewed for periprosthetic soft-tissue abnormalities (joint distention, fluid-filled bursae, and fluid collection in muscles and perimuscular fat). Patients subsequently underwent revision arthroplasty within 1 month, and infection was diagnosed in 12 (19%) patients. RESULTS: Infection was detected clinically in 25% of patients. Periprosthetic bone abnormalities did not allow differentiation of infection from complications not related to sepsis, except for periostitis, with 100% specificity but only 16% sensitivity. Soft-tissue findings were accurate for detection of infection, with 100% sensitivity and 87% specificity. Fluid collection in muscles and perimuscular fat had a 100% positive predictive value, and absence of joint distention had a 96% negative predictive value. CONCLUSION: CT is accurate in the diagnosis of painful infection at the site of a hip prosthesis on the basis of soft-tissue findings, whereas periprosthetic bone abnormalities are not useful.     

Introduction,audit and review of guidelines for delegated authorization of nuclear medicine investigations in compliance with the Ionising Radiation (Medical Exposure) Regulations 2000

The introduction of the Ionising Radiation (Medical Exposure) Regulations 2000 in Great Britain required every nuclear medicine investigation to be justified by a practitioner holding an appropriate Administration of Radioactive Substances Committee (ARSAC) certificate. The task of authorizing the radiation exposure may be performed by the practitioner (direct authorization) or delegated to an appropriately trained operator working to written guidelines approved by the practitioner (delegated authorization). In this study, we look at the process of implementation, audit and review of a set of Delegated Authorization Guidelines (DAG). The process of drafting the DAG is outlined. Following the introduction of the DAG, an audit of nuclear medicine referrals was performed at two sites for a period of 3 months. Each referral was compared with the DAG to determine whether it matched the criteria set out. If it did not match, it was further categorized as being due to: (1) insufficient referral information; or (2) clinical indication not included in the DAG. All non-matching requests were reviewed by the practitioner. Four hundred and thirty-seven of 632 (69%) referrals fitted the DAG, 12% (n=75) required clarification from the referrer before fitting with the criteria and 19% (n=120) were directly authorized by the practitioner. From those referrals that were directly authorized, some additional indications were identified and the DAG were subsequently revised. In conclusion, a delegated authorization procedure for nuclear medicine investigations can be implemented successfully. Regular audit is essential. This study identified the need to improve the format of the request card and to obtain additional referral information from the referrer.     

General practitioner requests for upper abdominal ultrasound: their effect on clinical outcome

Many radiology departments offer direct access upper abdominal ultrasound (US) scanning to general practitioners (GPs). We aimed to examine the influence of the scan results on the subsequent management and clinical outcome of these patients. A retrospective review was performed on all the patients referred for primary upper abdominal US (n = 82) from a single Birmingham GP practice, of 10,000 patients, between 1991 and 1996. The follow-up period from US was mean 27.9 months, SD 18.2 months. 79 referrals complied with published guidelines. 77 referrals were for suspected gallstone disease. 23 (28%) patients had clinically relevant positive findings. 18 of the positive scans. 16 of whom had gallstones, were subsequently referred to hospital. Of those with gallstones, 15 underwent cholecystectomy, of whom 12 had no further upper abdominal symptoms. Of the 59 negative scans, eight cases (14%) were subsequently referred to hospital. Treatment was changed as a result of review and investigation in only two of these eight cases. The remaining 51 were diagnosed solely on history and clinical examination. 28 of the 51 had self-limiting symptoms which required minor or no treatment. In conclusion, direct access upper abdominal US is considerably reducing the requirement for hospital outpatient referrals from GPs. Positive scans are generally followed by referral to secondary care services with good clinical outcome.     

Asbestos-related pleural disease and asbestosis: a comparison of CT and chest radiography

High-resolution CT (HRCT) has the ability to demonstrate both asbestos-related pleural disease and parenchymal abnormalities consistent with asbestosis. The role of CT in the diagnosis of asbestosis can be defined by comparing it with radiography. We evaluated 60 men who had a history of occupational exposure to asbestos and whose outside chest radiographs were considered abnormal. Chest radiographs (inside films) and HRCT were performed in all patients at our institution and were interpreted independently by experienced radiologists. Outside film results were compiled from the submitted reports. The final conclusion regarding the interpretation of the radiologic examinations was determined by consensus when disagreements existed. Positive predictive values (the likelihood that a positive report is correct) for pleural disease were: outside films 56%, inside films 79%, HRCT 100%. The positive predictive values for parenchymal disease were: outside films 51%, inside films 83%, HRCT 100%. The addition of HRCT to chest radiography is most useful in eliminating false-positive diagnoses of asbestos-related pleural disease caused by subpleural fat and false-positive diagnoses of parenchymal asbestosis in patients with extensive plaques or emphysema obscuring lung detail. The interpretation of chest radiographs in patients exposed to asbestos is often extremely difficult and subjective, and we recommend that positive findings (except calcified plaques) be confirmed with HRCT.     

Heterotopic Ossification of the Hips in a Patient With Guillain Barre Syndrome Demonstrated on SPECT/CT

ABSTRACT: A 55-year-old man developed bilateral hip pain following admission with Guillain Barre syndrome. Hip radiographs showed minor degenerative changes. Tc-methylene diphosphonate bone scintigraphy showed bilateral abnormal activity extending from the acetabula to the trochanteric regions. SPECT/CT localized the abnormal activity to the soft tissues surrounding the hips. Heterotopic ossification is a rare complication of Guillain Barre syndrome.     

Radiographic examination of the lumbosacral spine: an 'age-stratified' study

Of a total of 99 922 radiological requests, 3.3% were for examinations of the lumbosacral spine. An 'age-stratified' study of 657 females aged 15-44 years referred for lumbosacral examination was carried out. 17.3% were referred because of trauma, with a total fracture incidence of 4.1% as compared with 9.5% in the other age-sex groups. Analysis of the other reasons for referral and the radiological diagnoses showed that 80% of all referrals were for more or less non-specific reasons, summarised as lower-back pain; an equal percentage of the radiological diagnoses indicated that there was either no lesion or a lesion which did not influence management.     

The widened teardrop distance: a plain film indicator of hip joint effusion in adults

The teardrop distance is defined as the distance from the lateral margin of the pelvic teardrop to the most medial aspect of the femoral head as seen on anteroposterior pelvic radiographs. The structure responsible for the teardrop is the anteroinferior portion of the acetabular fossa with contributions from the ischium and from the superior pubic ramus. Anteroposterior pelvic radiographs of 10 patients with documented cases of unilateral hip effusion were retrospectively evaluated for teardrop distance widening on the affected side. Proof of the presence of hip effusion was based on the results of percutaneous hip joint aspirations as described in the patient's medical records. A teardrop distance widening of 1 mm or more was always consistent with hip joint fluid. In addition, radiographs from 20 patients with no known hip abnormalities were reviewed as a control population. These showed side-to-side symmetry in 16 cases (80%) and widening of less than 1 mm in the remaining four cases (20%). Thus, hip joint effusion in adults can be accurately diagnosed from plain radiographs in the presence of a teardrop asymmetry of 1 mm or more and in the absence of degenerative joint disease.