Imaging of the thoracic and lumbar spine in a high volume level 1 trauma center: are reformatted images of the spine essential for screening in blunt trauma?

Reformatted CTs of the thoracic and lumbar spine (CT T/L) from CTs of the chest, abdomen, and pelvis (CT body) may be performed for screening the thoracolumbar spine in patients sustaining blunt trauma. The purpose of this study was to determine whether there was a difference in the rate of detection of spinal fractures on CTs of the body compared to the reformatted T/L spine. A secondary endpoint was to evaluate whether cases dictated by trainees improved fracture detection rate. We reviewed the records of 250 consecutive blunt trauma patients that received CTs of the chest, abdomen, and pelvis (CT body) with concurrent CT T/L reformats. Each report was reviewed to determine if there was a thoracolumbar fracture and whether a trainee had been involved in interpreting the CT body. If a fracture was identified on either report, then the number, type, and location of each fracture was documented. Sixty-nine fractures, from a total of 38 patients, were identified on either the CT of the body or the CT T/L. Sensitivity for CT body interpretations was 94 % (95 % CI: 86–98 %) compared to a 97 % (95 % CI: 89–100 %) sensitivity for the CT T/L (p > 0.5). Although the sensitivity was 97 % (95 % CI: 88–100 %) when a trainee was involved in interpreting the body CT, there was no statistically significant improvement. The results suggest that with careful scrutiny most spine fractures can be diagnosed on body CT images without the addition of spine reformats. The most commonly missed finding is an isolated non-displaced transverse process fracture, which does not require surgical intervention and does not alter clinical management. The results suggest that thin section reformats do not need to be routinely ordered in screening blunt trauma patients, unless a bony abnormality is identified on the thicker section body CT images.     

Is there need for thoracic spine radiographs following a negative chest CT in trauma patients?

The purpose of this study was to assess the need for conventional radiographs of the thoracic spine for routine clearance of trauma patients in whom chest CT has revealed no spinal trauma. The study was in the form of a retrospective review of trauma patients over the previous five years who underwent conventional radiographs of the thoracic spine following a chest CT that revealed no spinal trauma. Two hundred thirty-five trauma patients were found to have undergone conventional thoracic spine series following a chest CT that showed no spinal trauma. In 234 of the cases, the thoracic spine series was also negative. In one case, the thoracic spine series revealed mild anterior compression of the T7 vertebral body. This injury was stable and required no specific intervention. CT of the chest is an adequate evaluation of the thoracic spine in trauma patients who require routine thoracic spine clearance, making subsequent conventional radiographs of the thoracic spine unnecessary. Electronic Publication     

MDCT of abdominal wall hernias: is there a role for valsalva's maneuver?

OBJECTIVE: Our objective was to evaluate the role of Valsalva's maneuver during MDCT for the diagnosis and characterization of abdominal wall hernias. SUBJECTS AND METHODS: From September 2002 to May 2003, 100 consecutive patients (37 men and 63 women; mean age, 53 years) with suspected anterior abdominal wall hernias underwent 4-, 8-, or 16-MDCT with and without Valsalva's maneuver. Patients received both oral and IV contrast material. On a workstation, three independent reviewers evaluated each scan obtained during rest and during Valsalva's maneuver for the following parameters: anteroposterior (AP) diameter of the abdomen; presence, location, and contents of the hernia; and transverse diameter of the fascial defect. The scans were compared to assess for changes in hernia size and contents and to determine whether the hernia would have been overlooked without Valsalva's maneuver. Fisher's exact test, the McNemar test, and Cohen's kappa coefficient were used to assess for significant differences. RESULTS: The three reviewers identified a mean of 72 abdominal wall hernias (72%). The reviewers agreed (kappa = 0.723) with respect to the presence of a hernia. AP diameters increased an average of 1.33 cm during Valsalva's maneuver (p < 0.001). The transverse diameter of the fascial defect increased an average of 0.66 cm and the AP diameter of the hernia sac increased an average of 0.79 cm during Valsalva's maneuver (p < 0.001). Fifty percent of the hernias became more apparent with Valsalva's maneuver. Ten percent of the hernias could be detected only on the scan obtained during Valsalva's maneuver. Conversely, in no patients was the hernia detected only on the rest scan. CONCLUSION: As opposed to scans obtained at rest, scans obtained during Valsalva's maneuver aid in the detection and characterization of suspected abdominal wall hernias. A single scan obtained during Valsalva's maneuver is sufficient to detect 100% of anterior abdominal wall hernias identified on CT.     

Chest pain evaluation in the emergency department: can MDCT provide a comprehensive evaluation?

OBJECTIVE: The purpose of our study was to determine whether MDCT can provide a comprehensive assessment of cardiac and noncardiac causes of chest pain in stable emergency department patients. SUBJECTS AND METHODS: Patients with chest pain who presented to the emergency department without definitive findings of acute myocardial infarction based on history, physical examination, and ECG were recruited immediately after the initial clinical assessment. For each patient, the emergency department physician was asked whether a CT scan would normally have been ordered on clinical grounds (e.g., to exclude pulmonary embolism). Each consenting patient underwent enhanced ECG-gated 16-MDCT. Ten cardiac phases were reconstructed. The images were evaluated for cardiac (coronary calcium and stenosis, ejection fraction, and wall motion and perfusion) and significant noncardiac (pulmonary embolism, dissection, pneumonia, and so forth) causes of chest pain. Correlation was made between the presence of significant cardiac and noncardiac findings on CT and the final clinical diagnosis based on history, examination, and any subsequent cardiac workup at the 1-month follow-up by a consensus of three physicians. RESULTS: Sixty-nine patients met all criteria for enrollment in the study, of whom 45 (65%) would not otherwise have undergone CT. Fifty-two patients (75%) had no significant CT findings and a final diagnosis of clinically insignificant chest pain. Thirteen patients (19%) had significant CT findings (cardiac, 10; noncardiac, 3) concordant with the final diagnosis. CT failed to suggest a diagnosis in two patients (3%), both of whom proved to have clinically significant coronary artery stenoses. In two patients (3%), CT overdiagnosed a coronary stenosis. Sensitivity and specificity for the establishment of a cardiac cause of chest pain were 83% and 96%, respectively. Overall sensitivity and specificity for all other cardiac and noncardiac causes were 87% and 96%, respectively. CONCLUSION: ECG-gated MDCT appears to be logistically feasible and shows promise as a comprehensive method for evaluating cardiac and noncardiac chest pain in stable emergency department patients. Further hardware and software improvements will be necessary for adoption of this paradigm in clinical practice.     

Can chest and abdominal trauma CT eliminate the need for plain films of the spine? – Experience with 329 multiple trauma patients

Purpose: To compare the accuracy of spine plain films with chest and abdominal trauma CT in detection of spine fractures. Methods: The study prospectively enrolled 329 multiple trauma patients. Of these, 38 patients had both chest CT for trauma and thoracic spine plain films, and 87 patients had both abdominal CT for trauma and lumbar spine plain films. Results: Of the fractures visible at either chest trauma CT or thoracic spine plain film examination, all were diagnosed on CT and 62 % on plain films. Of fractures visible at either abdominal trauma CT or lumbar spine plain films, 94 % were diagnosed on CT and 67 % on plain films. The one false negative CT involved an articular process fracture, which was visible but not mentioned, in a patient with a sacral fracture. Conclusion: Evaluation of the digital scout images and bone windows when a patient has chest and abdominal trauma CT appears to be as accurate as thoracic and lumbar spine plain films in the evaluation of spinal trauma.     

Is unenhanced CT sufficient for evaluation of acute abdominal pain?

Background: To determine whether intravenous contrast improves the ability of radiologists to establish the cause of acute abdominal pain after nondiagnostic or normal unenhanced CT. Methods: Out of 164 consecutive emergency department patients presenting with less than 48 h of nontraumatic, acute abdominal pain, a confident diagnosis for cause of pain was made prospectively in 71/164 (43%) patients on these unenhanced scans by the monitoring radiologist. In the other 93 patients, our study sample, intravenous contrast-enhanced CT was obtained. At a later date, retrospectively, two experienced abdominal CT radiologists independently evaluated unenhanced CT scans alone for potential causes of pain and diagnostic confidence level on a 1–3 scale. At least 2 weeks later, intravenous enhanced and unenhanced scans were read side-by-side for the same assessment. Results: There was no significant difference in diagnostic confidence levels comparing unenhanced CT alone (2.59) vs. intravenous enhanced and unenhanced CT together (2.64). Chi-square analysis found no significant difference in finding a cause for pain when intravenous contrast was added compared to the initial unenhanced scan alone. Conclusions: Intravenous contrast did not significantly improve the ability of CT to establish a cause of abdominal pain after a negative or nondiagnostic unenhanced CT.     

Internal jugular and upper extremity central venous access in interventional radiology: is a postprocedure chest radiograph necessary?

OBJECTIVE: The necessity of obtaining a postprocedure chest radiograph after central venous access using the upper extremity or internal jugular veins and interventional radiologic techniques was evaluated. SUBJECTS AND METHODS: A prospective study of 937 consecutive central venous access procedures in interventional radiology using the internal jugular veins or upper extremities was performed from June 1995 through September 1997. Established interventional radiologic techniques were used to place various ports (n = 34) and tunneled (n = 670) and nontunneled (n = 233) catheters. All catheters were positioned using fluoroscopy and readjusted if necessary before termination of the procedure. Afterward, a chest radiograph was obtained with the patient upright to evaluate catheter position and possible procedural complications. Procedural complications and manipulations or interventions that resulted from the radiographic findings were noted. In addition, nursing time for acquisition of the chest radiograph was recorded. RESULTS: We found seven procedural complications (four air emboli, two pneumothoraces, one innominate vein laceration) significant enough to alter the patient's treatment. These complications were apparent during the examination. Postprocedure chest radiography failed to reveal any unknown complications and revealed only one catheter sufficiently malpositioned to require manipulation. The amount of nursing time to acquire postprocedure chest radiographs ranged from 8 to 40 min (mean, 23 min) per patient. CONCLUSION: When imaging guidance and interventional radiologic techniques are used for upper extremity and internal jugular central venous access, performing postprocedure chest radiography yields little benefit.     

Traumatic injuries of the pelvis and thoracic and lumbar spine: does thin-slice multidetector-row CT increase diagnostic accuracy?

The objective is to evaluate different multidetector-row CT (MDCT) strategies for adequate classification of spinal and pelvic injuries. Seventy intubated patients after multiple trauma underwent conventional radiography (CR) and MDCT. Examinations included the pelvis (P), the lumbar spine (LS) and the thoracic spine (TS). Conventional radiographs, 3-mm (CT5) and 5-mm scans (CT3) and 3-mm and 5-mm scans combined with MPR (CT3R/CT5R) were compared to surgery, autopsy and clinical course. MDCT led to significantly better results than CR (P<0.01). Correlation coefficients were r=1.0 (CT3R), r=0.96 [TS] to r=1.0 [P/LS] (CT5R), r=0.8 [P] to r=1.0 [TS] (CT3), r=0.80 [P] to r=0.86 [TS] (CT5) and r=0.3 [TS] to r=0.69 [P] (CR). Fractures were identified by CT3R in 100% of cases, by CT5R in 95%, by CT3 in 90% [P]–100% [TS], by CT5 in 83.3% [LS]–90% [P] and by CR in 57.1% [TS]–87.2% [P]. Unstable fractures were identified in 100% by CT3R, CT5R and CT3, 85.7% [TS]–100% [P/LS] by CT5 and 57.1% [TS]–80% [P] by CR. Only overlapping thin-slice multiplanar reformation allows for an adequate classification of spinal and pelvic injuries and thus is highly emphasized in patients after severe blunt trauma.     

Assessment of chest pain in the emergency room: What is the role of multidetector CT?

Chest pain is one of the most frequent complaints for patients seen in the emergency department. The current article describes the clinical stratification of patients who present to the emergency department with chest pain and discusses imaging options and analysis for these patients. It reviews conventional imaging approaches to assessing chest pain including chest radiography and stress testing. The main discussion focuses on the potential utility use of cross-sectional imaging, particularly multidetector CT, in the evaluation of chest pain in the emergency department.     

The triple rule out CT in acute chest pain: a challenge for emergency radiologists?

Emergency Radiology - To evaluate the feasibility of triple rule out computed tomography (TRO-CT) in an emergency radiology workflow by comparing the diagnostic performance of cardiovascular and...     

Screening for cerebellopontine angle tumors: is a CISS sufficient?

This study attempted to evaluate the reliability of ultra-thin T₂-weighted imaging with a constructive interference in steady state (CISS) sequence as a screening method for tumors in the cerebellopontine angle. A retrospective study of 200 CISS examinations was made by five investigators. The examinations were inspected on plain film supported by clinical information. The interobserver agreement in the detection of lesions was analyzed. Fourteen cases (50% of the contrast-enhancing lesions) were rated pathological by all five readers. One case of subarachnoid lymphoma infiltration was overlooked by all five readers. Overall, six pathological lesions (median = 6, range 1–9) were not identified. The interobserver agreement for all pathological lesions was moderate (=0.53; 95% CI, 0.43–0.62). The mean sensitivity was 77.8% (range 72.0–96.3%), and the mean specificity was 97.6% (range 94.8–100%). The median sensitivity for pathological lesions concerning only patients with acute sensorineural hearing loss (n=148, patients with 20 contrast-enhancing cases) was 86.6% (range 80–100%), and median specificity was 95.2% (range 84.4–96.9%) with a moderate interobserver agreement (=0.55; 95% CI, 0.44–0.66). In our opinion the CISS sequence is a valuable addition to the examination of the cerebellopontine angle but lacks sufficient reliability for the detection of tumors of small size or of tumors adjacent to brain parenchyma or the temporal bone.     

Radiography of cervical spine injury in children: are flexion-extension radiographs useful for acute trauma?

OBJECTIVE: We assessed the role of cervical spine flexion-extension radiographs in the acute evaluation of pediatric trauma patients. MATERIAL AND METHODS: We performed a retrospective review of all pediatric trauma patients who underwent static cervical spine radiography followed by flexion-extension radiography during a 22-month period. We reviewed the mechanism of injury, physical examination findings, and patient age, and tabulated the results of initial and follow-up imaging studies. RESULTS: Two hundred forty seven children (age range, 1.6-18 years; mean age, 11.5 years) with a history of trauma underwent cervical spine radiography followed by flexion-extension radiography. Static cervical spine radiographs revealed normal findings in 224 patients (91%). Flexion-extension radiographs revealed normal findings for all patients with normal findings on cervical spine radiographs. Of 23 children (9%) with abnormal findings on static cervical spine radiographs, seven (30%) had congenital abnormalities visible on flexion-extension radiographs; 10 (43%) had traumatic injuries including fracture, subluxation, or soft-tissue swelling; two (9%) had instability; and six (26%) had questionable abnormalities that were noted on static cervical spine radiographs. In four patients (66%) with abnormal findings on static cervical spine radiographs, flexion-extension radiographs were helpful in ruling out abnormality. CONCLUSION: In children with a history of trauma and normal findings on static cervical spine radiographs, additional flexion-extension radiographs are of questionable use.     

Imaging of cervical spine trauma: are the anteroposterior and odontoid radiographs needed when CT of the entire cervical spine is routine?

Objective: To evaluate the contribution of the anteroposterior (AP) and odontoid radiographs in cervical spine trauma when helical CT of the entire cervical spine is performed in routine screening. Methods: In part 1 of the study, 47 patients with cervical spine fracture (positive) and 92 patients without fracture (negative) were retrospectively assembled into a study population. For each patient, the lateral radiograph and the CT were evaluated for the presence or absence of fracture. The results were compared to the radiology report at the time of injury which was based on the lateral, AP, and odontoid radiographs plus the CT (gold standard). In part 2 of the study, the individual sensitivities of CT and each radiograph were determined by review of the 47 positive patients with the fracture locations known a priori. Results: In all 47 positive patients, the presence of fracture was correctly identified using only the lateral radiograph and the CT. In none of the 92 negative patients was the lateral radiograph plus CT incorrectly interpreted as positive for fracture. The sensitivities for fracture of CT, the lateral radiograph, the AP radiograph, and the odontoid radiograph were 100, 47, 28, and 18 % respectively. Conclusion: The AP and odontoid radiographs did not contribute to the evaluation of suspected cervical spine fracture when the lateral radiograph and helical CT of the entire cervical spine were performed in routine screening.     

Evidence-based radiology (part 1): Is there sufficient research to support the use of therapeutic injections for the spine and sacroiliac joints?

Introduction

This review article addresses the best evidence currently available for therapeutic injection therapy for conditions targeting the spine and sacroiliac joints. The article is presented by spinal region. Controversies and areas of interest for further studies are identified.

Discussion

There is conclusive evidence supporting the effectiveness of the caudal approach for the administration of epidural steroid injections for patients with low back pain from a variety of causes. In general, there is moderate-to-strong evidence supporting the use of transforaminal therapeutic epidural injections for lumbar nerve-root compression and facet injections for joint pain arising from these joints in the cervical, thoracic and lumbar spine, but further subgroup analysis is needed to help predict which specific patients may receive the most benefit from these procedures.

Conclusion

No randomized controlled trials, meta-analyses or systematic reviews addressing the effectiveness of therapeutic sacroiliac joint injections have been found. For some injections, corticosteroids may not provide better outcomes compared to local anesthetic injections alone.