Growing evidence suggests an association between lumbar paraspinal muscle degeneration and low back pain (LBP). Currently, time-consuming and laborious manual segmentations of paraspinal muscles are commonly performed on magnetic resonance imaging (MRI) axial scans. Automated image analysis algorithms can mitigate these drawbacks, but they often require individual MRIs to be aligned to a standard “reference” atlas. Such atlases are well established in automated neuroimaging analysis. Our aim was to create atlases of similar nature for automated paraspinal muscle measurements.
Methods
Lumbosacral T2-weighted MRIs were acquired from 117 patients who experienced LBP, stratified by gender and age group (30–39, 40–49, and 50–59 years old). Axial MRI slices of the L4–L5 and L5–S1 levels at mid-disc were obtained and aligned using group-wise linear and nonlinear image registration to produce a set of unbiased population-averaged atlases for lumbar paraspinal muscles.
Results
The resulting atlases represent the averaged morphology and MRI intensity features of the corresponding cohorts. Differences in paraspinal muscle shapes and fat infiltration levels with respect to gender and age can be visually identified from the population-averaged data from both linear and nonlinear registrations.
Conclusion
We constructed a set of population-averaged atlases for developing automated algorithms to help analyze paraspinal muscle morphometry from axial MRI scans. Such an advancement could greatly benefit the fields of paraspinal muscle and LBP research.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
To test for possible thermal injury and tissue damage caused by magnetic-controlled growing rods (MCGRs) during MRI scans.
Methods
Three fresh frozen cadavers were utilized. Four MRI scans were performed: baseline, after spinal hardware implantation, and twice after MCGR implantation. Cross connectors were placed at the proximal end and at the distal end of the construct, making a complete circuit hinged at those two points. Three points were identified as potential sites for significant heating: adjacent to the proximal and distal cross connectors and adjacent to the actuators. Data collected included tissue temperatures at baseline (R1), after screw insertion (R2), and twice after rod insertions (R3 and R4). Tissue samples were taken and stained for signs of heat damage.
Results
There was a slight change in tissue temperature in the regions next to the implants between baseline and after each scan. Average temperatures (°C) increased by 0.94 (0.16–1.63) between R1 and R2, 1.6 (1.23–1.97) between R2 and R3, and 0.39 (0.03–0.83) between R3 and R4. Subsequent histological analysis revealed no signs of heat induced damage.
Conclusion
Recurrent MRI scans of patients with MCGRs may be necessary over the course of treatment. When implanted into human cadaveric tissue, these rods appear to not be a risk to the patient with respect to heating or tissue damage. Further in vivo study is warranted.
Aim of this study is to compare late degenerative MRI changes in a subset of patients operated on with ACDF to a second subset of patients presenting indication to ACDF but never operated on.
Methods
Patients from both subgroups received surgical indication according to the same criteria. Both subgroups underwent a cervical spine MRI in 2004–2005 and 10 years later in 2015. These MRI scans were retrospectively evaluated with a cervical spine ageing scale.
Results
Comparing the two subset of patients both suffering from clinically relevant single-level disease returns no statistically significant difference in the degenerative condition of posterior ligaments, presence of degenerative spondylolisthesis, foraminal stenosis, diameter of the spinal canal, Modic alteration, and intervertebral discs degeneration at 10-year follow-up.
Conclusions
The adjacent segment degeneration represents, in the present cohort, a result of the natural history of cervical spondylosis rather than a consequence of fusion.
Magnetic resonance imaging (MRI) is a sensitive, non-invasive modality to diagnose acetabular labral pathology, and the normal variants of the acetabular labrum have been characterized in adults. However, the prevalence of labral pathology in the asymptomatic pediatric population is unknown.
Methods
All pelvic MRIs performed at a large tertiary-care children’s hospital were reviewed during one calendar year (2014). Only patients aged between 2 and 18 years were included, and scans were excluded for hip pain/pathology or technical inadequacy. A blinded pediatric musculoskeletal radiologist read all eligible scans for the presence or absence of a labral tear.
Results
Three hundred and ninety-four pelvic MRIs were screened, and patients were excluded for hip pain/pathology (85 subjects), or technical inadequacy (190 subjects). One hundred and eight subjects (216 hips) met the inclusion criteria and were technically adequate for analysis. Labral tears were visualized in three of 216 (1.4 %) hips (two of the 110 subjects; 1.9 %).
Conclusions
There is a low rate of asymptomatic labral pathology by MRI in pediatric patients. The clinical history remains the means of differentiating real labral pathology from spurious imaging findings.
Concepts for measuring and improving the quality of patient care in hospitals have become increasingly important in recent years.
Objectives
The peer review procedure which has been developed by the Helios Clinic Group and Initiative for Quality Medicine (IQM) is described.
Materials and methods
In peer review, medical records are reviewed by experienced external physicians. Inadequacies are identified, improvement protocols initiated, and concrete measures for improvement of patient care derived.
Results
The described procedure is able to identify patient risks and errors during the course of treatment with the subsequent goal of avoiding repetition. In a retrospective, observational quality management study, peer review led to a significant decrease in mortality rates for various diseases.
Conclusions
Peer review represents the optimal procedure of medical quality management by systematic review and open discussion with colleagues.
Extraforaminal entrapment of the L5 nerve root is uncommon, and its management can sometimes be very challenging.
Methods
We present the case of a 57-year-old female, complaining of a sciatica in her left leg, for 3 years, with no response to any kind of conservative treatment. MRI and CT scan revealed the presence of a large L5S1 strictly lateral osteophyte compressing the left L5 root in its extraforaminal path.
Results
The patient underwent a left anterior retroperitoneal approach with assistance from a vascular surgeon given the very close relation between the osteophyte and the left common iliac vein, lying just on top of it, osteophyte was removed in one piece with the use of an osteotome after retraction of the vessels. The patient progressively recovered from her left sciatic pain with a satisfactory clinical result at 1 year.
Conclusion
Literature is sparse on the treatment of extraforaminal entrapment of the L5 nerve root; the current case shows a successful treatment strategy with the use of an anterior approach for direct vision of the lesion and good control of the vessels.
Rotational alignment of prosthetic components in total knee arthroplasty (TKA) is important to successful outcomes. Component malrotation is a known cause of revision and understanding normal rotational alignment may help recreate normal joint kinematics. To date, no large MRI study assessing femorotibial rotational alignment in nonarthritic knees has been undertaken.
Questions/Purposes
Is Insall’s tibial axis a reliable rotational landmark against common femoral rotational axes in the nonarthritic patient population?
Methods
We reviewed 544 knee MRI scans performed for suspected soft tissue pathology and identified Insall’s tibial rotational axis as well as the femoral clinical trans-epicondylar axis (TEAc), femoral surgical trans-epicondylar axis (TEAs), posterior condylar articular axis (PCA), and a modified Eckhoff’s cylindrical axis. The perpendiculars of these axes were superimposed on Insall’s tibial axis, and the angular differences were measured.
Results
Insall’s axis was internally rotated to the TEAc by 1.4°, externally rotated to Eckhoff’s cylindrical axis by 1.8°, externally rotated to the TEAs by 2.7°, and externally rotated to the PCA by 3.5°. The mean deviation from 0° (optimal alignment for each femoral axis) was significantly greater for the PCA relative to all other femoral axis.
Conclusion
Insall’s axis is a reliable landmark for rotational positioning of the tibial component and may optimize femorotibial kinematics in fixed-bearing TKA.
Morbidity and Mortality Conferences (M&MCs) have for generations been part of the education of physicians, yet their effectiveness remains questionable. The Ottawa M&M Model (OM3) was developed to provide a structured approach to M&MCs in order to maximize the quality improvement impact of such rounds.
Study design
We conducted a retrospective assessment of the impact of implementing nephrology-specific M&MCs using the OM3.
Setting and participants
All physicians, residents and fellows from the division of nephrology at a large academic medical center were invited to participate.
Quality improvement plan
Structured M&MCs were implemented to identify preventable errors and generate actions to improve quality of care and patient safety.
Outcomes
Number and nature of cases reviewed, number and nature of recommendations generated through identification of preventable health system and/or cognitive factors.
Measurements
Morbidity and/or mortality in each case were identified. A determination of the underlying factors and preventability of these events was made. A qualitative review of resulting recommendations was performed.
Results
Over the course of sixteen 1-h long conferences, 52 cases were presented. For all cases presented, discussion, action items and information dissemination followed the OM3. As a result of the M&MCs, 29 recommendations (emanating from 27 cases) lead to improve care delivery.
Limitations
Limitations of this study include its retrospective nature and single-center design.
Conclusions
The implementation of regularly scheduled M&MCs at an academic nephrology program, using a structured model, identified preventable health-systems issues and cognitive errors. Approximately one-half of the cases reviewed generated actions for health care delivery improvement.
To use radiofrequency ablation (RFA) in the resection of C4 cervical chordoma with a giant paravertebral tumor mass to achieve tumor-free exposed margins and perform a gross total excision.
Methods
A gross total excision using combined posterior and anterior approaches was performed. In the posterior stage, the C4 posterior arch was removed and the C4/C5 nerve roots and vertebral artery were released from the tumor. In the anterior stage, the giant soft mass of tumor from C3 to C6 was treated with RFA to make it shrink and solidify visually to achieve tumor-free exposed margins before resecting the tumor. Finally, a gross total excision was performed followed by the implantation of titanium plate and mesh filled with allograft bone.
Results
A gross total excision was performed with tumor-free exposed margins and radiotherapy. The patient survived more than 5 years without recurrence.
Conclusions
RFA can help achieve tumor-free exposed margins. A gross total excision combined with RFA can improve the local relapse-free survival of patients with cervical chordoma.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
Accurate diagnosis of a wide spectrum of urethral/periurethral pathologies in women remains challenging due to its anatomical location and nonspecific clinical presentations. Magnetic resonance imaging (MRI) has emerged as the modality of choice for diagnosing female urethral and periurethral pathologies due to its multiplanar scanning capability, superior soft tissue differentiation, noninvasive nature, and overall excellent contrast resolution.
Methods
In this narrative review, we describe the use of MRI to visualize the female urethra and periurethral pathologies.
Results
MRI can confidently characterize lesions into cystic or solid, provide a more succinct differential diagnosis, and in some cases provide a specific and accurate diagnosis, enabling surgeons to prepare a roadmap before operative procedure. Moreover, functional MRI can be useful to assess dynamic disorders such as urethral hypermobility.
Conclusions
We provide a comprehensive review of normal MR anatomy of the female urethra, as well as the MR features of practically important urethral and periurethral lesions.
Obstetric fistula, caused by traumatic delivery and patient lack of access to obstetric care, is an important public health concern in developing countries, particularly in Sub-Saharan Africa. This research focuses on the experience of women living with obstetric fistula in Burkina Faso as well as their reintegration into community after surgery.
Methods
This project was funded by the Mères du Monde en Santé (MMS) Foundation and conducted in collaboration with the Boromo Hospital. A qualitative approach based on grounded theory and using the principles of participative action research (PAR) was used with semidirected interviews prior to surgery and follow-up interviews 1–2 years after surgery directly in the women’s village of origin. Thirty-nine participants were recruited between 2012 and 2015.
Results
The results point to circumstances leading to obstetric fistula development: poverty, gender inequality in terms of decision making, healthcare-system deficiencies, and lack of services for referral and treatment of this condition. Our results reinforce the knowledge about the social and psychological repercussions of fistula by exploring the concepts of gossips, shame and self-exclusion as powerful mechanisms of exclusion, but they also show that social support was conserved for several women through their journey with this disease. There was complete social rehabilitation within the community after surgery; however, persistent barriers in term of anxiety regarding obstetric future and economic insecurity were present.
Conclusions
Early recruitment for surgery and prevention are the main objectives when attempting to reduce the impact of obstetric fistula and facilitate patient reintegration. Improvements in local and governmental public health policies are required.
A retrospective case review of patients who underwent 18F sodium fluoride PET/CT imaging of the spine with postoperative pain following vertebral fusion.
Objective
To determine the benefit of 18F sodium fluoride PET/CT imaging in the diagnosis of persistent pain in the postoperative spine.
Summary of background data
The diagnosis of pain generators in the postoperative spine has proven to be a diagnostic challenge. The conventional radiologic evaluation of persistent pain after spine surgery with the use of plain radiographs, MRI, and CT can often fall short of diagnosis in the complex patient. 18F sodium fluoride PET/CT imaging is an alternative tool to accurately identify a patient’s source of pain in the difficult patient.
Methods
This retrospective study looked at 25 adult patients who had undergone 18F sodium fluoride PET/CT imaging. All patients had persistent or recurrent back pain over the course of a 15-month period after having undergone spinal fusion surgery. All patients had inconclusive dedicated MRI. The clinical accuracy of PET/CT in identifying the pain generator and contribution to altering the decision making process was compared to the use of CT scan alone.
Results
Of the 25 patients studied, 17 patients had increased uptake on the 18F sodium fluoride PET/CT fusion images. There was a high-level correlation of radiotracer uptake to the patients’ pain generator. Overall 88% of the studies were considered beneficial with either PET/CT altering the clinical diagnosis and treatment plan of the patient or confirming unnecessary surgery.
Conclusion
18F sodium fluoride PET/CT proves to be a useful tool in the diagnosis of complex spine pathology of the postoperative patients. In varied cases, a high correlation of metabolic activity to the source of the patient’s pain was observed.
Surgical site infection is a catastrophic complication after spinal surgery, which seriously affects the progress of rehabilitation and clinical outcome. Currently the clinical reports on spinal surgical site infections are mostly confined to the surgical segment itself and there are few reports on adjacent segment infections after spinal surgery.
Study design
Case report.
Objective
To report a clinical case with adjacent level infection after spinal fusion.
Methods
We report the case of a 68-year-old woman who underwent posterior lumbar 4?5 laminectomy, posterolateral fusion and internal fixation. The patient showed signs of surgical site infection, such as surgical site pain, high fever and increase of the inflammatory index 1 week after the operation. Magnetic resonance imaging (MRI) confirmed the diagnosis of adjacent intervertebral disc infection. The patient received early combined, high-dose anti-infection treatment instead of debridement.
Results
After the conservative treatment, the infection was controlled and the patient subsequently enjoyed a normal daily life.
Conclusion
Adjacent level infections can occur after spinal surgery. Early diagnosis and anti-infection treatment played an important role in the treatment of this kind of complication.
Despite proven biomechanical superiority and resultant superior clinical outcomes, pedicle instrumentation in cervical spine is not widely practiced due to technical difficulties, steep learning curve, and possible potential catastrophic complications due to screw misplacement. This study was undertaken with the purpose to evaluate the feasibility, accuracy, and complications of cervical pedicle screw instrumentation solely using O-arm-based 3D navigation technology.
Methods
Prospectively maintained data from a single-surgeon case series were retrospectively analyzed. All the patients had undergone cervical pedicle instrumentation under O-arm 3D navigation. Screw placement accuracy was analyzed and compared among different vertebral levels and also between different patient groups.
Results
A total of 241 cervical pedicle screws were inserted in 44 patients. Out of the 241 screws, 197 (81.74%) were inserted at the level of C3–C6 vertebrae with nearly equal distribution among the 4 vertebrae, followed by 32 (13.28%) and 12 (4.98%) screws at C2 and C7 vertebrae, respectively. After the analysis of screw placement as per Gertzbein classification, the overall breach rates were found to be 7.05% (17 screws) with 52.94% (10 screws) Grade I, 47.06% (7 screws) Grade II, and nil Grade III screw breaches.
Conclusion
The use of O-arm-based intra-operative 3D scans for navigation can make cervical pedicle screw placement reliable. High accuracy and better intra-operative control can increase surgeon’s confidence in using cervical pedicle instrumentation on more regular basis.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
Imaging results are frequently considered as hallmarks of disease by spine surgeons to plan their future treatment strategy. Numerous classification systems have been proposed to quantify or grade lumbar magnetic resonance imaging (MRI) scans and thus objectify imaging findings. The clinical impact of the measured parameters remains, however, unclear. To evaluate the pathological significance of imaging findings in patients with multisegmental degenerative findings, clinicians can perform image-guided local infiltrations to target defined areas such as the facet joints.The aim of the present retrospective study was to evaluate the correlation of MRI facet joint degeneration and spinal stenosis measurements with improvement obtained by image-guided intraarticular facet joint infiltration.
Methods
Fifty MRI scans of patients with chronic lumbar back pain were graded radiologically using a wide range of classification and measurement systems. The reported effect of facet joint injections at the site was recorded, and a comparative analysis performed.
Results
When we allocated patients according to their reported pain relief, 27 showed no improvement (0–30%), 16 reported good improvement (31–75%) and 7 reported excellent improvement (>?75%). MRI features assessed in this study did, however, not show any relevant correlation with reported pain after facet joint infiltration: Values for Kendall’s tau ranged from τ?=???0.190 for neuroforaminal stenosis grading as suggested by Lee, to τ?=?0.133 for posterior disc height as proposed by Hasegawa.
Conclusion
Despite the trend in evidence-based medicine to provide medical algorithms, our findings underline the continuing need for individualised spine care that, along with imaging techniques or targeted infiltrations, includes diagnostic dimensions such as good patient history and clinical examination to formulate a diagnosis.
The aims of the study were to introduce a classification scheme for endplate lesions based on T2-weighted magnetic resonance imaging and to detect possible associations between endplate lesions and other variables such as age, sex, disc degeneration and Modic changes in a large population.
Methods
MRI images of 996 low back pain patients were collected. All intervertebral spaces were classified as “normal”, “wavy/irregular”, “notched”, “Schmorl’s node” and “fracture”. The associations between endplate lesions and age, sex, disc degeneration and Modic changes were determined in the considered population.
Results
The most common endplate lesions were “notched” and “Schmorl’s nodes”. The prevalence was higher among the male subjects. In most patients (62.8%), no endplate lesions were detected, with a significant difference between male (57.5%) and female subjects (67.9%) (p?<?0.001). Lesions were found to be associated with intervertebral disc degeneration (relative risk 2.49) and signal alterations (relative risk 3.08). Fleiss kappas of 0.73 and 0.89 were, respectively, assessed for the inter- and intra-observer reliabilities of the new classification system.
Conclusions
Endplate lesions were detected, classified with a novel scheme and analysed in a large population of patients suffering from low back pain based on MRI images. The reliability of the novel classification system was demonstrated.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
The purpose of this study was to examine whether Hounsfield units (HUs), as an alternative bone mineral density measurement to dual-energy X-ray absorptiometry and quantitative computed tomography, which lead to additional radiation exposure for patients, has an effect on the maintenance of reduction in bisegmental Cobb angle (CA) and cage subsidence in patients who receive bisegmental spine stabilization after traumatic thoracolumbar spine fractures.
Methods
A total of 81 patients with a mean follow-up of 12 months were analyzed. CAs and cage subsidence were measured intraoperatively and at follow-up. HU was measured, and patients were subsequently assigned based on HU to three HU subgroups (group 1: HU?<?110 [poor bone quality (BQ)]; group 2: HU 180–110 [diminished BQ]; group 3: HU?>?180 [good BQ]).
Results
Following anterior stabilization, loss of reduction and cage subsidence differed between patients with poor and diminished BQ but not significantly, and both groups showed significantly more loss of reduction and cage subsidence than patients with good BQ.
Conclusion
BQ, estimated with HU, had significant effects on cage subsidence and loss of reduction. We recommend measuring HU before surgery and applying additional treatment strategies, such as polymethylmethacrylate augmentation of endplates or anterior plates, for patients with HU?<?180.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
In resource-limited settings, identification of successful and sustainable task-shifting interventions is important for improving care.
Objective
To determine whether the training of lay people to take vital signs as trauma clerks is an effective and sustainable method to increase availability of vital signs in the initial evaluation of trauma patients.
Design
We conducted a quasi-experimental study of patients presenting with traumatic injury pre- and post-intervention.
Setting
The study was conducted at Kamuzu Central Hospital, a tertiary care referral hospital, in Lilongwe, Malawi.
Participants
All adult (age ≥ 18 years) trauma patients presenting to emergency department over a six-month period from January to June prior to intervention (2011), immediately post-intervention (2012), 1 year post-intervention (2013) and 2 years post-intervention (2014).
Intervention
Lay people were trained to take and record vital signs.
Main outcomes and measures
The number of patients with recorded vital signs pre- and post-intervention and sustainability of the intervention as determined by time-series analysis.
Results
Availability of vital signs on initial evaluation of trauma patients increased significantly post-intervention. The percentage of patients with at least one vital sign recorded increased from 23.5 to 92.1%, and the percentage of patients with all vital signs recorded increased from 4.1 to 91.4%. Availability of Glasgow Coma Scale also increased from 40.3 to 88.6%. Increased documentation of vital signs continued at 1 year and 2 years post-intervention. However, the percentage of documented vital signs did decrease slightly after the US-trained medical student and surgeon who trained the trauma clerks were no longer available in country, except for Glasgow Coma Scale. Patients who died during emergency department evaluation were significantly less likely to have vital signs recorded.
Conclusions and relevance
The training of lay people to collect vital signs and Glasgow Coma Scale is an effective and sustainable method of task shifting in a resource-limited setting.
This study aims to determine whether secondary CT findings can predict posterior ligament complex (PLC) injury in patients with acute thoracic (T) or lumbar (L) spine fractures.
Methods
This is a retrospective study of 105 patients with acute thoracic and lumbar spine fractures on CT, with MRI as the reference standard for PLC injury. Three readers graded CT for facet joint alignment (FJA), widening (FJW), pedicle or lamina fracture (PLF), spinous fracture (SPF), interspinous widening (ISW), vertebral translation (VBT), and posterior endplate fracture (PEF). Univariate and multivariate logistic regression analyses were performed separately for each reader to test for associations between CT and PLC injury, and diagnostic performance of CT was calculated.
Results
Fifty-three of 105 patients had PLC injury by MRI. Statistically significant predictors of PLC injury were VBT, PLF, ISW, and SPF. Using these four CT findings, odds of PLC injury ranged from 3.8 to 5.6 for one positive finding, but increased to 13.6–25.1 for two or more. At least one positive CT finding was found to yield average sensitivity of 82% and specificity 59%, while two or more yielded sensitivity 46% and specificity 88%.
Conclusion
While no individual CT finding is sufficiently accurate to diagnose or exclude PLC injury, greater the number of positive CT findings (VBT, PLF, ISW, and SPF), the higher the odds of PLC injury. The presence of a single abnormal CT finding may warrant confirmatory MRI for PLC injury, while two or more CT findings may have adequate specificity to avoid need for MRI prior to surgical intervention.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
