Back pain and the radiologist

The exact role of the radiologist in assessing patients with low back pain remains vague, which is in keeping with this syndrome's uncertain etiology and controversial therapy. Conventional radiographs of the lumbosacral spine have a limited role in most such patients, primarily in excluding neoplasm, infection, or ankylosing spondylitis. This examination can ordinarily be limited to two views; and, for radiation and economic reasons, radiographs should usually be initially deferred in young patients and/or those with acute symptoms. Symptoms will abate in most of these patients, making radiological examination unnecessary. Computed tomography (CT) is the method of choice in the diagnosis of spinal stenosis and possibly herniated nucleus pulposus and facet joint abnormalities as well. Preliminary data showing symptomatic relief of pain following facet joint injection could open an entire new area of interventional radiology. Confirmatory studies are needed in this exciting and potentially important area of investigation.     

Radiological and scintigraphic findings in patients with a clinical history of chronic inflammatory back pain

The prevalence of radiological abnormalities of the sacroiliac joints, the manubriosternal joint, and the lumbar spine were assessed, and quantitative sacroiliac scintigraphy was performed in 151 patients with a history of chronic inflammatory back pain and in 31 controls with non-inflammatory back pain. Sacroiliitis was found in 124 patients (82%), manubriosternal lesions in 84 patients (56%), and lesions of the lumbar spine in 58 patients (38%). In 19 patients (13%), manubriosternal lesions provided the sole radiological abnormality and in five patients (3%) no radiological abnormality could be demonstrated at any of these sites. Quantitative sacroiliac scintigraphy showed increased values in 69 of 137 patients examined (50%), but also in 10 out of 12 control patients with disc degeneration (83%) and is, therefore, nonspecific for inflammatory lesions. Radiological examination of the manubriosternal joint is recommended in patients with inflammatory back pain without radiographic evidence of sacroiliitis.     

主动脉夹层诊断的相关临床特征分析

目的探讨有助于主动脉夹层（ AD）诊断的相关临床特征,提高AD的诊治率。方法回顾性分析2010年3月~2012年10月本院收治的510例因胸背疼痛而行胸腹主动CT血管成像确诊或排除AD患者的病历资料、实验室检查及影像学检查结果,对病情变化中有助诊断AD的可能相关因素进行多因素非条件logistic回归分析。结果确诊AD患者137例,排除AD患者373例,多因素非条件logistic回归分析提示,胸背放射疼痛、高血压、胸腔积液、血D-二聚体升高4个指标进入了AD诊断参数模型（ P〈0.05或P〈0.01）。结论入院胸背放射疼痛、血压高、胸腔积液、血D-二聚体升高是AD诊断的高度密切相关因素。     

Atypical vertebral Paget’s disease

A 40-year-old Mauritanian man consulted for back pain. A computed tomography of the spine showed patchy sclerosis of the fifth and seventh thoracic vertebral bodies with normal neural arch of T5 and sclerosis and hypertrophy of the neural arch of T7, as well as diffuse sclerosis of the T11 vertebral body with a normal neural arch. At MRI, low signal-intensity on T1-weighted images and high signal-intensity on T2-weighted images involved the whole T5 and T7 vertebrae and the vertebral body of T11. Working diagnoses included metastatic disease and lymphoma, and a biopsy of T7 and then T11 was carried out. Both showed pathological findings very suggestive of Paget’s disease. Since CT is usually the more specific radiological examination in vertebral Paget’s disease, we thought it could be useful to report this atypical CT presentation (patchy sclerosis of the vertebral body without diffuse bone texture changes and isolated involvement of the vertebral body) of vertebral Paget’s disease.     

腹膜后纤维化的临床及影像学表现

目的 通过分析腹膜后纤维化的临床及影像学表现，加深对此少见病的认识，提高早期诊断水平。方法 总结我院1990年1月至2004年6月间经病理证实的腹膜后纤维化（RPF）病例14例，详细分析其临床及影像学表现。其中男10例，女4例，平均年龄45.8岁。全部病例均行CT平扫，其中10例同时行增强扫描；8例行MR检查；10例行静脉肾盂造影（IVP）检查；11例行B超检查。结果 （1）临床症状主要以腰背痛、腹痛（10例）及尿路梗阻（3例）为首发症状，常伴以血沉（ESR）、免疫球蛋白G（IgG）、C反应蛋白（CRP）增高及肾功能异常。（2）影像学表现：14例中11例病变位于腹膜后，肿块型10例，弥漫型4例。CT平扫可见腹膜后密度较为均匀或不均匀的软组织肿块，增强扫描显示不同程度强化；MRI在T1WI呈低信号，而在T2WI则信号强度不等。结论 影像学检查是发现和诊断腹膜后纤维化的重要手段，通过病变CT密度及MRI信号的不同表现，并结合临床检查，可以对疾病的分期和疗效提供参考。     

Impact of computed tomography on patient's care in nontraumatic acute abdomen: 90 patients

OBJECTIVES: To determine the contribution of computerized tomography (CT) to the management of nontraumatic acute abdomen, to evaluate interobserver agreement and the contribution of CT to cost control, to look for the predictive factors of CT. PATIENTS: and method. Ninety prospectively included patients, admitted for nontraumatic acute abdomen and examined by a surgeon, received CT examination. Diagnosis and treatment 1) envisioned before and 2) defined after CT, and 3) finally retained were compared, and the interobserver agreement was calculated after the second reading. The predictive value of the clinical and biological criteria as well as the radiological criteria characterizing these patients was sought. RESULTS: CT was contributive in 68.9% of cases, with a reliable diagnosis and treatment strategy, defined after CT examination, for 92.2% and 90%, respectively. Interobserver agreement was 93.3%. CT contributed to reducing costs in 15.5% of patients, for an additional cost estimated at 104-139 euros. The positive predictive factors of the CT contribution were age over 70 years, localized symptoms, fever, and high CRP. CONCLUSION: In agreement with the literature, in our study CT appears to be a choice examination to guide patient care in nontraumatic acute abdomen.     

Acquired degenerative changes of the intervertebral segments at and suprajacent to the lumbosacral junction. A radioanatomic analysis of the nondiscal structures of the spinal column and perispinal soft tissues

A review of the imaging features of normal and degenerative anatomy of the spine on medical imaging studies shows features that have been largely overlooked or poorly understood by the imaging community in recent years. The imaging methods reviewed included computed tomography (CT) with multiplanar reconstructions and magnetic resonance imaging (MRI). A routine part of the MRI examination included fat-suppressed T2 weighted fast-spin- or turbo-spin-echo acquisitions. As compared to the normal features in asymptomatic volunteers, alterations in the observed CT/MRI morphology and MR signal characteristics were sought in symptomatic individuals. Findings in symptomatic subjects which departed from the normal anatomic features of the posterior spinal elements in asymptomatic volunteers included: rupture of the interspinous ligament(s), neoarthrosis of the interspinous space with perispinous cyst formation, posterior spinal facet (zygapophyseal joint) arthrosis, related central spinal canal, lateral recess (subarticular zone) and neural foramen stenosis, posterior element alterations associated with various forms of spondylolisthesis, and perispinal muscle rupture/degeneration. These findings indicate that the posterior elements are major locations of degenerative spinal and perispinal disease that may accompany or even precede degenerative disc disease. Although not as yet proven as a reliable source of patient signs and symptoms in all individuals, because these observations may be seen in patients with radicular, referred and/or local low back pain, they should be considered in the evaluation of the symptomatic patient presenting with a clinical lumbosacral syndrome. Imaging recommendations, in addition to the usual close scrutiny of these posterior spinal elements and perispinal soft tissues on CT and MRI, include the acquisition of high-resolution multiplanar CT reconstructions, and fat-suppressed T2 weighted fast-spin- or turbo-spin-echo sequence MRI in at least one plane in every examination of the lumbar spine.     

Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis

Background

Active spondylolysis is an acquired lesion in the pars interarticularis and is a common cause of low back pain in the young athlete.

Objectives

To evaluate whether the one‐legged hyperextension test can assist in the clinical detection of active spondylolysis and to determine whether magnetic resonance imaging (MRI) is equivalent to the clinical gold standard of bone scintigraphy and computed tomography in the radiological diagnosis of this condition.

Methods

A prospective cohort design was used. Young active subjects with low back pain were recruited. Outcome measures included clinical assessment (one‐legged hyperextension test) and radiological investigations including bone scintigraphy (with single photon emission computed tomography (SPECT)) and MRI. Computed tomography was performed if bone scintigraphy was positive.

Results

Seventy one subjects were recruited. Fifty pars interarticulares in 39 subjects (55%) had evidence of active spondylolysis as defined by bone scintigraphy (with SPECT). Of these, 19 pars interarticulares in 14 subjects showed a fracture on computed tomography. The one‐legged hyperextension test was neither sensitive nor specific for the detection of active spondylolysis. MRI revealed bone stress in 40 of the 50 pars interarticulares in which it was detected by bone scintigraphy (with SPECT), indicating reduced sensitivity in detecting bone stress compared with bone scintigraphy (p  =  0.001). Conversely, MRI revealed 18 of the 19 pars interarticularis fractures detected by computed tomography, indicating concordance between imaging modalities (p  =  0.345). There was a significant difference between MRI and the combination of bone scintigraphy (with SPECT)/computed tomography in the radiological visualisation of active spondylolysis (p  =  0.002).

Conclusions

These results suggest that there is a high rate of active spondylolysis in active athletes with low back pain. The one‐legged hyperextension test is not useful in detecting active spondylolysis and should not be relied on to exclude the diagnosis. MRI is inferior to bone scintigraphy (with SPECT)/computed tomography. Bone scintigraphy (with SPECT) should remain the first‐line investigation of active athletes with low back pain followed by limited computed tomography if bone scintigraphy is positive.     

CT-guided percutaneous radiofrequency denervation of the sacroiliac joint

Defining the origin of low back pain is a challenging task. Among a variety of factors the sacroiliac joint (SIJ) is a possible pain generator, although precise diagnosis is difficult. Joint blocks may reduce pain, but are, in cases, of only temporary effect. This study was conducted to evaluate CT-guided percutaneous radiofrequency denervation of the sacroiliac joint in patients with low back pain. The procedure was performed on 38 patients who only temporarily responded to CT-guided SIJ blocks. The denervation was carried out in the posterior interosseous sacroiliac ligaments and on the dorsal rami of the fifth spinal nerve. All interventions were carried out under CT guidance as out-patient therapies. Three months after the therapy, 13 patients (34.2%) were completely free of pain. Twelve patients (31.6%) reported on a substantial pain reduction, 7 patients (18.4%) had obtained a slight and 3 patients (7.9%) no pain reduction. The data of 3 patients (7.9%) was missing. There were no intra- or postoperative complications. Computed tomography-guided percutaneous radiofrequency denervation of the sacroiliac joint appears safe and effective. The procedure may be a useful therapeutic modality, especially in patients with chronic low back pain, who only temporarily respond to therapeutic blocks.     

Morbus Osler

Osler’s disease, also known as hereditary hemorrhagic telangiectasia (HHT) and Osler-Weber-Rendu syndrome, is an autosomal dominant disorder leading to abnormal blood vessel formation in the skin, mucous membranes and often in organs, such as the lungs, liver and brain (arteriovenous malformations AVM). Various types are known. Patients may present with epistaxis. Teleangiectasia can be identified by visual inspection during physical examination of the skin or oral cavity or by endoscopy. Diagnosis is made after clinical examination and genetic testing based on the Curacao criteria. Modern imaging modalities, such as computed tomography (CT) or magnetic resonance imaging (MRI) have become more important as they can depict the AVMs. Pulmonary AVMs can be depicted in CT imaging even without the use of a contrast agent while other locations including the central nervous system (CNS) usually require administration of contrast agents. Knowledge of possible clinical manifestations in various organs, possible complications and typical radiological presentation is mandatory to enable adequate therapy of these patients. Interventional procedures are becoming increasingly more important in the treatment of HHT patients.     

„Red flags“ in der Diagnostik von Rückenschmerzen

Background

Low back pain is one of the most commonly occurring symptomatic complaints with a lifetime prevalence of 70?%.

Objective

The question of meaningful radiological diagnostics arises in connection with the diagnostics and treatment of low back pain as the common lead symptom.

Material and methods

Special clinical warning signs, so-called red flags, which are indicative of a specific cause of low back pain and of the necessity for possible treatment, are presented with special reference to the national treatment guidelines on low back pain.

Results

The presence of clinical warning signs or red flags and in particular the combination of several red flags increases the probability of a specific cause of low back pain and should be examined using radiological imaging. An uncomplicated low back pain in an otherwise healthy patient does not normally necessitate imaging.     

Double-contrast computed tomographic arthrography of the shoulder joint

Dislocation of the shoulder joint can cause post-traumatic injury to certain anatomical structures, which may lead to recurrent dislocation. The operative visualization of some of these abnormalities may be difficult and their identification preoperatively allows selection of the appropriate surgical approach and avoids the necessity for lengthy surgery. Fifty-one patients with a history of recurrent dislocation, single dislocation or suspected recurrent subluxation as a cause of pain were examined over a 3-year period by double-contrast computed tomographic (CT) arthrography. Thirty-five patients had a demonstrable abnormality and 13 were considered suitable for surgical intervention on radiological criteria. A further 12 patients were advised to have surgery on a combination of clinical and radiological grounds. Eleven of these have so far had surgery, eight of which required an arthrotomy and the CT findings have been confirmed in all these cases. The results of CT arthrography in the patients examined are reported and the technique, normal anatomy and pathological findings are described. The technique is suggested as the imaging method of choice in recurrent dislocation.     

Osteoarthritis of the facet joints and its role in low-back pain: evaluation with conventional tomography.

Thirty-seven patients with chronic low-back pain and an atypical irradiation to one or both legs were examined by conventional tomography of the facet joints. A disc herniation was excluded by computed tomography (CT) in 31 patients. The facet joints were considered normal in 4 patients. Four grades of facet joint disease were used to classify the pathological changes. Correlation of the radiological findings with the facet joint block by injection of a local anesthetic was obtained in 12 patients. It appears that conventional tomography is a very sensitive technique as it is possible to detect even discrete abnormalities of the facet joints. However, as it is time consuming and high in radiation dose, the examinations should be reserved for patients with a normal CT examination of the lumbar spine in whom there still remains a high suspicion of facet joint disease.     

Gout in the spine and sacro-iliac joints: Radiological manifestations

It is well known that deposits of urates in soft tissues occur commonly in gout, particularly in para-articular areas and in articular cartilages of the limbs. Involvement of the spine and sacro-iliac joints by such deposits, however, has been regarded as being relatively unusual and has attracted little attention in the literature. As we were impressed by the frequency of episodes of acute back pain in our patients with gouty arthritis, established definitely on clinical and biochemical grounds, we undertook a radiological investigation of the spine and sacro-iliac joints in a series of 54 subjects. It was suspected that their episodes of pain were clinical manifestations of gout, and 12 of the group had suffered one or more attacks. Of these 12 subjects, eight were found to have radiological abnormalities. In six subjects, evidence of sacro-iliitis was demonstrated, which is comparable to the report of Resnick and Reinke [8], and in two patients vertebral lesions corresponded to those described by Jaffe [5]. Hyperostotic spondylosis was present in no fewer than 29 of the series. Although lacking histological confirmation of the lesions demonstrated radiologically, we believe that our suspicions have been confirmed.     

Atrophy of sacrospinal muscle groups in patients with chronic,diffusely radiating lumbar back pain

Summary After surgery necessitated by lumbar back pain syndromes, radiolucency verified by CT may appear in the sacrospinal muscle group on the operated side. This radiolucency represents muscular atrophy and is in its most severe form a result of the replacement of muscle tissue with adipose tissue. Such muscular atrophy appeared in the present series in 31 out of all 156 patients (19.9%) and in 29 out of 94 patients operated on because of radiating lumbar back pain (30.9%). The radiological appearance, extent, and HU values of this muscular atrophy are presented in detail. Only weak correlations with the multitude of clinical symptoms and signs were found in this retrospective study. The effects of irreversible muscular atrophy on the indications for surgery and physiotherapy are discussed.     

Osteoradionekrose nach Strahlentherapie gynäkologischer Tumoren

AIM: Insufficiency fractures of the pelvis are a well known but rare and frequently misinterpreted radiation sequela. The clinical features and possible risk factors were investigated. PATIENTS AND METHODS: 71 of living 82 patients, who were treated 1986-1994 for gynecologic tumors were clinically examined. 47 patients underwent also bone scan, CT of the pelvis and 13 patients had osteodensitometry. All patients had been treated with adjuvant (n = 29) or curative intent (n = 18) by d.v. fields with 18-MV photons, with 46 Gy in 23 fractions plus brachytherapy (15-39 Gy). Median follow-up was 36 months. RESULTS: Seven patients developed pelvic insufficiency fractures 11 months (median, minimum 2 months) after treatment. All patients complained of moderate to severe pelvic pain, which resolved after 5-28 months without specific therapy in five of seven patients. At first examination all but one bone scan showed extremely increased uptake in the os sacrum and/or iliosacral joints, correlating CT scans demonstrated small fractures and bony destruction. Four of the asymptomatic 40 patients with complete radiologic examinations had medium uptake in bone scan (CT normal). Three of four examined patients with insufficiency fractures and seven of nine patients without insufficiency fractures had osteoporosis. CONCLUSION: In women who present with pelvic pain after radiotherapy for gynecologic tumors bony destruction and fractures may be indicative of a late radiation effect rather than osseous metastasis, even after early onset of symptoms.     

Radioleucoscintigraphy in osteoarthritis. Is there an inflammatory component?

The possible contribution of an inflammatory component in osteoarthritis was investigated. There was no correlation between the percentage uptakes of 99Tcm-hexamethylpropyleneamine oxime (HMPAO)-labelled white blood cells and 99Tcm-methylene diphosphonate (MDP) and between the former and pain scores. A significant correlation was found between the percentage uptake of 99Tcm-MDP and pain scores (0.002 > P > 0.01). In osteoarthritis, 99Tcm-HMPAO-labelled white cell imaging may or may not show a positive localization in the synovial membrane. Positive white cell localization appears to be limited to the area that corresponds to the radiological evidence of the condition and the positive uptake of the skeletal imaging agent.     

Failure of ultrasound to detect extra-pancreatic abscesses in severe acute pancreatitis

The development of intra-abdominal abscesses in patients with severe acute pancreatitis can be associated with a mortality as high as 100%. The clinical findings in these patients may be non specific and therefore imaging is essential. Computed tomography (CT) is the imaging modality of choice. However, a satisfactory ultrasound examination may be regarded as sufficient, particularly when there is limited availability of CT. A case of extra-pancreatic abscess complicating severe acute pancreatitis, in whom sonography was "normal", but CT demonstrated the abscess is presented. The importance of CT in these patients in whom an abscess is suspected and our experience with similar cases is discussed.     

Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study

Background: Groin pain is a diagnostic and therapeutic challenge to sports medicine. The literature provides no consensus on definitions of or diagnostic criteria for groin pain in athletes. To compare the results of research and treatments, the methods used to diagnose and evaluate the degree of groin pain must be clearly defined and reproducible.

Objectives: To describe clinical examination techniques for groin pain in athletes and evaluate the intraobserver and interobserver reliability of these.

Methods: Eighteen athletes, nine with sports related groin pain and nine without groin pain, were examined by two doctors and two physiotherapists. The examiners were trained in the examination techniques before the study. The examiners were blinded to the symptoms and identity of the subjects. The subjects were examined twice by each examiner in random order. The examinations included evaluation of adductor muscle related pain and strength, iliopsoas muscle related pain, strength, and flexibility, abdominal muscle related pain, and strength and pain at the symphysis joint. Kappa statistics and percentage of agreement were used to evaluate the data.

Results: Overall, the κ values and percentage of agreement were in accordance and showed good reliability of the examinations. The κ values for the intraobserver agreement were above 0.60 in 11 of 14 tests, and those for the interobserver agreement of the pain tests were above 0.60 in eight of 10 tests. The only test without acceptable interobserver reliability was the strength test for iliopsoas muscle.

Conclusion: All but one of the tests investigated were reproducible and subject only to limited intraobserver and interobserver variation.

     

一例战斗机飞行员深静脉血栓形成并文献复习

目的探讨深静脉血栓形成与飞行的关系、诊断方法和预防措施。方法结合收治的1例男性高性能战斗机飞行员的临床资料及复习文献,对深静脉血栓形成与飞行的关系及发生机制进行综合分析。结果该飞行员入院前2月无诱因出现右下肢疼痛,当地医院行抗炎药物治疗15d,疼痛减轻。入院前2周出现咳嗽、咯血伴左侧胸痛,无发热。经血管超声、肺部CT等检查,诊断为:深静脉血栓形成;肺栓塞。给予抗凝等治疗后症状缓解。3个月后,一般日常活动无明显不适出院。结论:飞行不合格。结论战斗机的高载荷造成血管壁的轻微损伤,抗荷服对血管的压迫造成的血流淤滞,座舱内缺氧、振动、有毒气体及电磁辐射可能是促进飞行员静脉血栓形成的原因。