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Atique S, Mekkodathil A, Siddiqui T, Mathradikkal S, Ahmed K, Al-Ani M, Kanbar A, Alaieb A, Hakim S, Younis B, Ajaj A, Guerrero A, Masood M, Khoschnau S, Hammo AA, Abdurraheim N, Abdelrahman H, Peralta R, Nabir S, Al-Hilli S, El-Menyar A, Al-Thani H. Diagnostic Clinical Tool in Trauma Patients to Rule out Thoracolumbar Fracture. J Emerg Trauma Shock 2024; 17:159-165. [PMID: 39552826 PMCID: PMC11563237 DOI: 10.4103/jets.jets_145_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/07/2024] [Accepted: 03/18/2024] [Indexed: 11/19/2024] Open
Abstract
Introduction The primary objective of this study was to assess the effectiveness of the clinical decision tool (CDT) in trauma patients, providing a comparable ability to rule out thoracolumbar (TL) fractures as traditional imaging methods. The goal is to facilitate early clearance of the TL spine without an immediate requirement for radiological tests, thereby minimizing unnecessary utilization of TL-spine imaging. Methods A prospective, observational study was conducted on trauma patients with suspected TL injury. To achieve early TL clearance, the CDT assessed criteria such as absence of pain, tenderness, and pain-free axial movement and flexion. The study enrolled alert trauma patients with thoracic and/or lumbar spine injuries, defined by the Glasgow Coma Scale of 15. The study excluded patients not aligning with CDT criteria, such as those who received intravenous opioid analgesia within 4 h and those unable to stand due to suspected pelvic or lower limb injuries. Results Following the completion of the CDT steps, there were 31 true negative cases, signifying the absence of TL fractures according to both CDT and imaging studies. The sensitivity of the CDT was 99.38% (95% confidence interval [CI]: 96.59%-99.98%), specificity 9.1% (95% CI: 6.30%-12.73%), negative predictive value (NPV) 96.87% (95% CI: 81.02%-99.56%), positive predictive value (PPV) 34.19% (95% CI: 33.38%-35.00%), negative likelihood ratio (LHR) 0.07 (95% CI: 0.01-0.49), and positive LHR 1.09 (95% CI: 1.06-1.13). The sensitivity, specificity, NPV, PPV, negative LHR, and positive LHR varied with each step in the CDT. Notably, the overall sensitivity was high; however, the stepwise sensitivity decreased, albeit with an improvement in specificity with each further step in the tool. The overall sensitivity in the study cohort (n = 500) was high; however, the stepwise sensitivity decreased, albeit with an improvement in the specificity. Conclusions The CDT to rule out TL fracture is a feasible bedside stepwise tool in fully awake trauma patients after a thorough clinical neurological examination on arrival. The tool could help Level II or III trauma centers avoid secondary triage to the higher center.
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Affiliation(s)
- Sajid Atique
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ahammed Mekkodathil
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Tariq Siddiqui
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Saji Mathradikkal
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Ahmed
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mushreq Al-Ani
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ahad Kanbar
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Abubaker Alaieb
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Suhail Hakim
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Ajaj
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Aldwin Guerrero
- Department of Emergency, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Maarij Masood
- Department of Emergency, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Sherwan Khoschnau
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Abdel Aziz Hammo
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Nuri Abdurraheim
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
- Department of Surgery, Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic
| | - Syed Nabir
- Department of Radiology, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Shatha Al-Hilli
- Department of Radiology, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
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Peterson A, Behrens J, Salari P, Place H. Isolated thoracic and lumbar transverse process fractures: Do they need spine surgeon evaluation? a high volume level I trauma center experience with cost analysis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 15:100242. [PMID: 37560400 PMCID: PMC10407537 DOI: 10.1016/j.xnsj.2023.100242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/29/2023] [Accepted: 07/01/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Transverse process fractures (TPF) of the thoracic and lumbar spine have become increasingly identified due to CT imaging. Spine service consultation is common for further evaluation and management. There are several studies that demonstrate no difference in clinical outcome with or without spine service intervention. However, no study to our knowledge provides an additional cost analysis. We hypothesize that isolated thoracolumbar TPF are stable injuries. Furthermore, spine service consultation and evaluation results in increased health care costs. METHODS Patients were identified using trauma registry data at Saint Louis University (SLU) from January 2012 to August 2018. Chart and imaging review was performed to determine if additional spine fractures were identified by the spine team which were not included in the initial radiology report. TPF associated with other spinal injuries were defined as one or more thoracic and/or lumbar TPF in addition to any other acute fracture or dislocation in the cervical, thoracic, or lumbar spine. A separate cost analysis with institution-specific charges was also performed. RESULTS Six hundred eighty-two patients with TPF from January 2012 to August 2018 were identified. Two hundred twenty-eight patients met the criteria to be included in this study. Additional spinal pathology that was not included in the initial radiology report was identified in 5 (2.19%) patients, none of which required surgical intervention. Cost analysis demonstrated additional costs associated with spine service intervention totaled $1,725,360.28. Average cost per patient in our cohort summed to $2,529.85. CONCLUSIONS These data support that isolated TPF of the thoracic and lumbar spine are stable injuries that likely do not require spine service intervention and in fact may represent unnecessary financial burden. Foregoing unnecessary consultation can alleviate time constraints within spine service practices and reduce health care costs by eliminating costly extraneous interventions from the patient's care.
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Affiliation(s)
- Asa Peterson
- Department of Orthopedic Surgery, Center for Specialized Medicine, St. Louis University Hospital, 1225 S Grand Blvd, St. Louis, MO 63104, United States
| | - Jonathan Behrens
- Department of Orthopedic Surgery, Center for Specialized Medicine, St. Louis University Hospital, 1225 S Grand Blvd, St. Louis, MO 63104, United States
| | | | - Howard Place
- Department of Orthopedic Surgery, Center for Specialized Medicine, St. Louis University Hospital, 1225 S Grand Blvd, St. Louis, MO 63104, United States
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Tonkaz G, Sengul D, Bekci T, Sengul I, Cakir IM, Onder RO, Tonkaz DE, Eryuruk U, Aksoy I, Veiga ECDA, Aslan S. A needful, unique, and in-place evaluation of the injuries in earthquake victims with computed tomography, in catastrophic disasters! The 2023 Turkey-Syria earthquakes: part II. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20230550. [PMID: 37585998 PMCID: PMC10427186 DOI: 10.1590/1806-9282.20230550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 05/14/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE This study aimed to determine the computed tomography findings associated with very recent catastrophic 2023 Turkey-Syria earthquake-related injuries and their anatomotopographic distribution in the adult population. METHODS The incorporated computed tomography scans of 768 adult cases who had been admitted to the hospital and had undergone computed tomography imaging after these tragic disasters had been examined on the Teleradiology Reporting System of the Turkish Ministry of Health. To this end, the injuries were classified into six categories: head, thoracic, spinal, pelvic, extremity, and abdominal injury, with three age groups (18-34, 35-64, and ³65 years) and four different imaging intervals (<24, 24-48, 49-72, and >72 h). RESULTS This study incorporated 316 (41.1%) cases on the first day, 57 (7.5%) on the second day, 219 (28.5%) on the third day, and 176 (22.9%) on the fourth day after the earthquake or later. Of the 768 cases, 109 (14.2%) had a head injury, 100 (13.0%) had a thoracic injury, 99 (12.9%) had a spinal injury, 51 (6.6%) had a pelvic injury, 41 (5.4%) had an extremity injury, and 11 (1.4%) had an abdominal injury. CONCLUSION In these regrettable earthquake disasters, we determined a high ratio of head injuries, which was closely followed by thoracic and spinal injuries, in our preliminary outcomes for the pediatric population, Part I. The frequency of abdominal injuries was low among individuals who experienced the earthquake. Last but not least, we have noticed a higher likelihood of spinal injury in individuals older than 65 years in the studied population.
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Affiliation(s)
- Gokhan Tonkaz
- Giresun University, Faculty of Medicine, Department of Radiology – Giresun, Turkey
| | - Demet Sengul
- Giresun University, Faculty of Medicine, Department of Pathology – Giresun, Turkey
| | - Tumay Bekci
- Giresun University, Faculty of Medicine, Department of Radiology – Giresun, Turkey
| | - Ilker Sengul
- Giresun University, Faculty of Medicine, Division of Endocrine Surgery – Giresun, Turkey
- Giresun University, Faculty of Medicine, Department of General Surgery – Giresun, Turkey
| | - Ismet Mirac Cakir
- Giresun University, Faculty of Medicine, Department of Radiology – Giresun, Turkey
| | - Ramazan Orkun Onder
- Giresun University, Faculty of Medicine, Department of Radiology – Giresun, Turkey
| | | | - Uluhan Eryuruk
- Giresun University, Faculty of Medicine, Department of Radiology – Giresun, Turkey
| | - Iskender Aksoy
- Giresun University, Faculty of Medicine, Department of Emergency Medicine – Giresun, Turkey
| | - Eduardo Carvalho de Arruda Veiga
- Universidade de São Paulo, Faculty of Medicine of Ribeirão Preto, Department of Gynecology and Obstetrics – São Paulo (SP), Brazil
| | - Serdar Aslan
- Giresun University, Faculty of Medicine, Department of Radiology – Giresun, Turkey
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Hussain O, Kaushal M, Agarwal N, Kurpad S, Shabani S. The Role of Magnetic Resonance Imaging and Computed Tomography in Spinal Cord Injury. Life (Basel) 2023; 13:1680. [PMID: 37629537 PMCID: PMC10455833 DOI: 10.3390/life13081680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 08/27/2023] Open
Abstract
Traumatic injuries of the spine are associated with long-term morbidity and mortality. Timely diagnosis and appropriate management of mechanical instability and spinal cord injury are important to prevent further neurologic deterioration. Spine surgeons require an understanding of the essential imaging techniques concerning the diagnosis, management, and prognosis of spinal cord injury. We present a review in the role of computed tomography (CT) including advancements in multidetector CT (MDCT), dual energy CT (DECT), and photon counting CT, and how it relates to spinal trauma. We also review magnetic resonance imaging (MRI) and some of the developed MRI based classifications for prognosticating the severity and outcome of spinal cord injury, such as diffusion weighted imaging (DWI), diffusion tractography (DTI), functional MRI (fMRI), and perfusion MRI.
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Affiliation(s)
- Omar Hussain
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (O.H.); (M.K.); (S.K.)
| | - Mayank Kaushal
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (O.H.); (M.K.); (S.K.)
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - Shekar Kurpad
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (O.H.); (M.K.); (S.K.)
| | - Saman Shabani
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (O.H.); (M.K.); (S.K.)
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Teuber H, Halvachizadeh S, Muthirakalayil M, Yin L, Eisenkrein H, Hildebrand F, Kobbe P, Sprengel K, Mica L, Alkadhi H, Pape HC, Pfeifer R. Can radiologic parameters used to detect cervical spinal instability be used in patients with ankylosing spondylitis? Eur J Med Res 2023; 28:97. [PMID: 36841781 PMCID: PMC9960164 DOI: 10.1186/s40001-023-01052-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/07/2023] [Indexed: 02/27/2023] Open
Abstract
INTRODUCTION Cervical spinal instability can be difficult to detect in the shock room setting even with the utilization of computed tomography (CT) scans. This may be especially true in patients with cervical degenerative disease, such as ankylosing spondylitis (AS). The purpose of this study was to investigate the influence AS has on various radiologic parameters used to detect traumatic and degenerative instability of the cervical spine, to assess if CT imaging in the shock room is diagnostically appropriate in this patient population. METHODS A matched, case-control retrospective analysis of patients with AS and controls without AS admitted at two level-1 trauma centers was performed. All patients were admitted via shock room and received a polytrauma CT. Twenty-four CT parameters of atlanto-occipital dislocation/instability, traumatic and degenerative spondylolisthesis, basilar invagination, and prevertebral soft tissue swelling were assessed. Since the study was assessing normal values, study patients were included if they had no injury to the cervical spine. Study patients were matched by age and sex. RESULTS A total of 78 patients were included (AS group, n = 39; control group, n = 39). The evaluated cervical radiologic parameters were largely within normal limits and showed no significant clinical or morphologic differences between the two groups. CONCLUSION In this analysis, CT measurements pertaining to various cervical pathologies were not different between patients with and without AS. Parameters to assess for atlanto-occipital dislocation/instability, spondylolisthesis, or basilar invagination in the trauma setting may reliably be used in patients with AS.
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Affiliation(s)
- Henrik Teuber
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Melvin Muthirakalayil
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luxu Yin
- Department of Orthopedics Trauma Surgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Harry Eisenkrein
- Department of Orthopedics Trauma Surgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopedics Trauma Surgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Philipp Kobbe
- Department of Orthopedics Trauma Surgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Kai Sprengel
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ladislav Mica
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hatem Alkadhi
- Department of Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Artificial Intelligence Accurately Detects Traumatic Thoracolumbar Fractures on Sagittal Radiographs. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58080998. [PMID: 35893113 PMCID: PMC9330443 DOI: 10.3390/medicina58080998] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 11/18/2022]
Abstract
Background and Objectives: Commonly being the first step in trauma routine imaging, up to 67% fractures are missed on plain radiographs of the thoracolumbar (TL) spine. The aim of this study was to develop a deep learning model that detects traumatic fractures on sagittal radiographs of the TL spine. Identifying vertebral fractures in simple radiographic projections would have a significant clinical and financial impact, especially for low- and middle-income countries where computed tomography (CT) and magnetic resonance imaging (MRI) are not readily available and could help select patients that need second level imaging, thus improving the cost-effectiveness. Materials and Methods: Imaging studies (radiographs, CT, and/or MRI) of 151 patients were used. An expert group of three spinal surgeons reviewed all available images to confirm presence and type of fractures. In total, 630 single vertebra images were extracted from the sagittal radiographs of the 151 patients—302 exhibiting a vertebral body fracture, and 328 exhibiting no fracture. Following augmentation, these single vertebra images were used to train, validate, and comparatively test two deep learning convolutional neural network models, namely ResNet18 and VGG16. A heatmap analysis was then conducted to better understand the predictions of each model. Results: ResNet18 demonstrated a better performance, achieving higher sensitivity (91%), specificity (89%), and accuracy (88%) compared to VGG16 (90%, 83%, 86%). In 81% of the cases, the “warm zone” in the heatmaps correlated with the findings, suggestive of fracture within the vertebral body seen in the imaging studies. Vertebras T12 to L2 were the most frequently involved, accounting for 48% of the fractures. A4, A3, and A1 were the most frequent fracture types according to the AO Spine Classification. Conclusions: ResNet18 could accurately identify the traumatic vertebral fractures on the TL sagittal radiographs. In most cases, the model based its prediction on the same areas that human expert classifiers used to determine the presence of a fracture.
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Three-dimensional conditional generative adversarial network-based virtual thin-slice technique for the morphological evaluation of the spine. Sci Rep 2022; 12:12176. [PMID: 35842451 PMCID: PMC9288435 DOI: 10.1038/s41598-022-16637-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 07/13/2022] [Indexed: 11/08/2022] Open
Abstract
Virtual thin-slice (VTS) technique is a generative adversarial network-based algorithm that can generate virtual 1-mm-thick CT images from images of 3–10-mm thickness. We evaluated the performance of VTS technique for assessment of the spine. VTS was applied to 4-mm-thick CT images of 73 patients, and the visibility of intervertebral spaces was evaluated on the 4-mm-thick and VTS images. The heights of vertebrae measured on sagittal images reconstructed from the 4-mm-thick images and VTS images were compared with those measured on images reconstructed from 1-mm-thick images. Diagnostic performance for the detection of compression fractures was also compared. The intervertebral spaces were significantly more visible on the VTS images than on the 4-mm-thick images (P < 0.001). The absolute value of the measured difference in mean vertebral height between the VTS and 1-mm-thick images was smaller than that between the 4-mm-thick and 1-mm-thick images (P < 0.01–0.54). The diagnostic performance of the VTS images for detecting compression fracture was significantly lower than that of the 4-mm-thick images for one reader (P = 0.02). VTS technique enabled the identification of each vertebral body, and enabled accurate measurement of vertebral height. However, this technique is not suitable for diagnosing compression fractures.
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Imaging of Thoracolumbar Spine Traumas. Eur J Radiol 2022; 154:110343. [DOI: 10.1016/j.ejrad.2022.110343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/15/2022]
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Abstract
In the evaluation of spinal trauma, diagnostic imaging is of paramount importance. Computed tomography (CT), flexion/extension radiographs, and MRI are complementary modalities. CT is typically obtained in the initial setting of spinal trauma and provides detailed information about osseous structures. MRI provides detailed information about structural injury to the spinal cord. Diffusion tensor imaging provides microstructural information about the integrity of the axons and myelin sheaths, but its clinical use is limited. Novel imaging techniques may be better suited for the acute clinical setting and are under development for potential future clinical use.
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Arena JD, Kvint S, Ghenbot Y, Howard S, Ramayya AG, Sinha S, Petrov D, Chen HI, Schuster JM. Thoracolumbar Transverse Process Fractures Are More Frequently Associated with Nonspinal Injury than Clinically Significant Spine Fracture. World Neurosurg 2020; 146:e1236-e1241. [PMID: 33271381 DOI: 10.1016/j.wneu.2020.11.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/23/2020] [Accepted: 11/23/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We studied the risk of associated spinal and nonspinal injuries (NSIs) in the setting of observed thoracolumbar transverse process fracture (TPF) and examined the clinical management of TPF. METHODS Patients treated at a Level I trauma center over a 5-year period were screened for thoracolumbar TPF. Prevalence of associated spinal fractures and NSIs as well as relationship to level of TPF was explored. Clinical management and follow-up outcomes were reviewed. RESULTS A total of 252 patients with thoracolumbar TPFs were identified. NSIs were commonly observed (70.6%, n = 178); however, associated spinal fractures were more rarely seen (24.6%, n = 62, P < 0.0001). No patients had neurological deficits attributable to TPFs, and only 3 patients with isolated TPFs were treated with orthosis. Among patients with outpatient follow-up (70.6%, n = 178), none developed delayed-onset neurological deficits or spinal instability. Thoracic TPFs (odds ratio = 3.56, 95% confidence interval = 1.20-10.56) and L1 TPFs (odds ratio = 2.48, 95% confidence interval = 1.41-4.36) were predictive of associated thoracic NSIs. L5 TPF was associated with pelvic fractures (odds ratio = 6.30, 95% confidence interval = 3.26-12.17). There was no difference in rate of NSIs between isolated TPF (70.0%) and TPF with associated clinically relevant spinal fracture (72.6%, P = 0.70). CONCLUSIONS NSIs are nearly 3 times more common in patients with thoracolumbar TPFs than associated clinically relevant spinal fractures. Spine service consultation for TPF may be unnecessary unless fracture is associated with a clinically relevant spinal injury, which represents a minority of cases. However, detection of TPF should raise suspicion for high likelihood of associated NSIs.
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Affiliation(s)
- John D Arena
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Svetlana Kvint
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yohannes Ghenbot
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susanna Howard
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin G Ramayya
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saurabh Sinha
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dmitriy Petrov
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - H Isaac Chen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Schuster
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Murata K, Endo K, Aihara T, Suzuki H, Sawaji Y, Matsuoka Y, Nishimura H, Takamatsu T, Konishi T, Maekawa A, Yamauchi H, Kanazawa K, Endo H, Tsuji H, Inoue S, Fukushima N, Kikuchi H, Sato H, Yamamoto K. Artificial intelligence for the detection of vertebral fractures on plain spinal radiography. Sci Rep 2020; 10:20031. [PMID: 33208824 PMCID: PMC7674499 DOI: 10.1038/s41598-020-76866-w] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/29/2020] [Indexed: 12/26/2022] Open
Abstract
Vertebral fractures (VFs) cause serious problems, such as substantial functional loss and a high mortality rate, and a delayed diagnosis may further worsen the prognosis. Plain thoracolumbar radiography (PTLR) is an essential method for the evaluation of VFs. Therefore, minimizing the diagnostic errors of VFs on PTLR is crucial. Image identification based on a deep convolutional neural network (DCNN) has been recognized to be potentially effective as a diagnostic strategy; however, the accuracy for detecting VFs has not been fully investigated. A DCNN was trained with PTLR images of 300 patients (150 patients with and 150 without VFs). The accuracy, sensitivity, and specificity of diagnosis of the model were calculated and compared with those of orthopedic residents, orthopedic surgeons, and spine surgeons. The DCNN achieved accuracy, sensitivity, and specificity rates of 86.0% [95% confidence interval (CI) 82.0-90.0%], 84.7% (95% CI 78.8-90.5%), and 87.3% (95% CI 81.9-92.7%), respectively. Both the accuracy and sensitivity of the model were suggested to be noninferior to those of orthopedic surgeons. The DCNN can assist clinicians in the early identification of VFs and in managing patients, to prevent further invasive interventions and a decreased quality of life.
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Affiliation(s)
- Kazuma Murata
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Kenji Endo
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takato Aihara
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hidekazu Suzuki
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Yasunobu Sawaji
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Yuji Matsuoka
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hirosuke Nishimura
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Taichiro Takamatsu
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takamitsu Konishi
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Asato Maekawa
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hideya Yamauchi
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kei Kanazawa
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hiroo Endo
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hanako Tsuji
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Shigeru Inoue
- Department of Preventive Medicine and Public Health, Tokyo Medical University, Tokyo, Japan
| | - Noritoshi Fukushima
- Department of Preventive Medicine and Public Health, Tokyo Medical University, Tokyo, Japan
| | - Hiroyuki Kikuchi
- Department of Preventive Medicine and Public Health, Tokyo Medical University, Tokyo, Japan
| | - Hiroki Sato
- Department of Preventive Medicine and Public Health, Tokyo Medical University, Tokyo, Japan
| | - Kengo Yamamoto
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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12
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Hamard A, Greffier J, Bastide S, Larbi A, Addala T, Sadate A, Beregi JP, Frandon J. Ultra-low-dose CT versus radiographs for minor spine and pelvis trauma: a Bayesian analysis of accuracy. Eur Radiol 2020; 31:2621-2633. [PMID: 33034747 DOI: 10.1007/s00330-020-07304-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 08/08/2020] [Accepted: 09/16/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To compare diagnosis performance and effective dose of ultra-low-dose CT (ULD CT) versus radiographs in suspected spinal or pelvic ring or hip fracture for minor trauma. METHODS ULD CT, in addition to radiography, was prospectively performed in consecutive patients admitted to the emergency department for minor traumas, during working hours over 2 months. Presence of a recent fracture was assessed by two blind radiologists independently. Sensitivities and specificities were estimated using the best valuable comparator (BVC) as a reference and using a latent class model in Bayesian inference (BLCM). Dosimetric indicators were recorded and effective doses (E) were calculated using conversion coefficient. RESULTS Eighty areas were analyzed in 69 patients, including 22 dorsal spine, 28 lumbar spine, and 30 pelvic ring/hip. Thirty-six fractures (45%) were observed. Applying the BVC method, depending on location, ULD CT sensitivity was 80 to 100% for reader 1 and 85 to 100% for reader 2, whereas radiographic sensitivity was 60 to 85% for reader 1 and 50 to 92% for reader 2. With BLCM approach for reader 2, ULD CT sensitivity for all locations/dorsal spine/lumbar spine and pelvic ring-hip was 87.1/75.9/84.2/76.9% respectively. Corresponding radiograph sensitivity was 73.8, 54.8, 80.4, and 68.7%. Effective doses of ULD CT were similar to radiographs for dorsal and hip locations whereas for lumbar spine, ULD CT effective dose was 1.83 ± 0.59 mSv compared with 0.96 ± 0.59 mSv (p < 0.001). CONCLUSION Sensitivity for fracture detection was higher for ULD CT compared with radiographs with an effective dose comparable to radiographs. KEY POINTS • Ultra-low-dose spine and pelvis CT demonstrates better fracture detection when compared with radiographs. • The effective dose of ultra-low-dose spine and pelvis CT scan and radiographs is comparable. • Replacement of radiographs by ULD CT in daily practice for trauma patients is an option to consider and should be evaluated by a randomized trial.
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Affiliation(s)
- Aymeric Hamard
- Medical Imaging Group, CHU Nimes, Univ Montpellier, Montpellier, France.
| | - Joel Greffier
- Medical Imaging Group, CHU Nimes, Univ Montpellier, Montpellier, France
| | - Sophie Bastide
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nimes, Univ Montpellier, Montpellier, France
| | - Ahmed Larbi
- Medical Imaging Group, CHU Nimes, Univ Montpellier, Montpellier, France
| | - Takieddine Addala
- Medical Imaging Group, CHU Nimes, Univ Montpellier, Montpellier, France
| | - Alexandre Sadate
- Medical Imaging Group, CHU Nimes, Univ Montpellier, Montpellier, France
| | - Jean-Paul Beregi
- Medical Imaging Group, CHU Nimes, Univ Montpellier, Montpellier, France
| | - Julien Frandon
- Medical Imaging Group, CHU Nimes, Univ Montpellier, Montpellier, France
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13
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Weinrich JM, Warncke M, Wiese N, Regier M, Tahir E, Heinemann A, Sehner S, Püschel K, Adam G, Laqmani A. Feasibility of extremely reduced-dose CT of the thoracic spine in human cadavers. Acta Radiol 2020; 61:1034-1041. [PMID: 31840526 DOI: 10.1177/0284185119891417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND According to the as low as reasonably achievable (ALARA) principle, radiation exposure in computed tomography (CT) should be minimized while maintaining adequate image quality. Dedicated CT protocols combined with iterative reconstruction (IR) can reduce radiation dose and/or improve image quality. PURPOSE To investigate the feasibility of extremely reduced-dose (RD) CT of the thoracic spine in human cadavers using a standard-dose (SD) and three different RDCT protocols reconstructed with filtered back projection (FBP) and IR. MATERIAL AND METHODS The thoracic spines of 11 cadavers were examined using different RDCT protocols with decreasing reference tube currents (RDCT-1: 50 mAs; RDCT-2: 30 mAs; RDCT-3: 10 mAs) at 140 kV. A clinical SDCT (70 mAs, 140 kV) served as reference. Raw data were reconstructed using FBP and two increasing levels of IR (IRL4 and IRL6). Images were evaluated for image quality, diagnostic acceptability, and visibility of anatomical structures according to a 5-point-scale. RESULTS Regardless of the reconstruction technique, image quality was rated as diagnostically acceptable for all cadavers in SDCT and RDCT-1. Image quality of reconstructions with FBP were generally rated lower. Application of IR improved image quality ratings in SDCT and RDCT. RDCT-2 with IR was the most reduced-dose CT protocol which enabled diagnostically acceptable image quality in all cadavers. Compared to SDCT, RDCT protocols resulted in significantly reduced effective radiation doses (SDCT: 4.1 ± 1.5 mSv; RDCT-1: 2.9 ± 1.1 mSv; 2:1.7 ± 0.6 mSv; 3:0.6 ± 0.1 mSv; P = 0.001). CONCLUSION Diagnostically acceptable RDCT of the thoracic spine with 1.7 mSv is feasible using IR.
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Affiliation(s)
- Julius Matthias Weinrich
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Warncke
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Nis Wiese
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Regier
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Enver Tahir
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Heinemann
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Sehner
- Department of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Püschel
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Azien Laqmani
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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14
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Abstract
BACKGROUND The lumbar spine forms the lowermost part of the mobile spinal column. Due to anatomical properties, the lumbar spine is highly flexible in the sagittal directions, thus, rendering it susceptible to both flexion and extension forces with the thoracolumbar junction being the most vulnerable part of it. To date, the modern thoracolumbar spine fracture classification is given by the AOSpine classification system based on the well-known Magerl classification of vertebral fracture morphology but now includes both neurological criteria and clinical modifiers, such as ankylosing spondylitis. DIAGNOSTICS Whereas plain radiography remains a mainstay in the diagnostic evaluation of low-energy trauma patients, computed tomography (CT) exhibits its unsurpassed power in polytrauma and plays a decisive role in all equivocal cases where the osseous situation is unclear. However, magnetic resonance imaging (MRI) is increasingly gaining importance for assessing both discoligamentous integrity and intraspinal condition. Both CT and MRI have direct input in classifying fractures according to the AOSpine classification. RESULTS Regarding fracture morphology, three main types (A-C) based on the stability are distinguished. C‑type spinal injuries are all considered unstable, irrespective of type and severity of vertebral malalignment. Injuries to the anterior and posterior ligamentous complex are also considered to interfere with stability (B-type injuries). CONCLUSIONS Special fracture patterns of the injured ankylosed and osteoporotic spine as well as of the pediatric lumbar spine are discussed. A survey is also given about several differential diagnoses (malignant fractures, anomalies, normal variants).
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Affiliation(s)
- Thomas Grieser
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
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15
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Radiological protocol in spinal trauma: literature review and Spinal Cord Society position statement. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:1197-1211. [PMID: 31440893 DOI: 10.1007/s00586-019-06112-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 06/29/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The Spinal Cord Society constituted a panel tasked with reviewing the literature on the radiological evaluation of spinal trauma with or without spinal cord injury and recommend a protocol. This position statement provides recommendations for the use of each modality, i.e., radiographs (X-rays), computed tomography (CT), magnetic resonance imaging (MRI), as well as vascular imaging, and makes suggestions on identifying or clearing spinal injury in trauma patients. METHODS PubMed was searched for the corresponding keywords from January 1, 1980, to August 1, 2017. A MEDLINE search was subsequently undertaken after applying MeSH filters. Appropriate cross-references were retrieved. Out of the 545 articles retrieved, 105 relevant papers that address the present topic were studied and the extracted content was circulated for further discussions. A draft position statement was compiled and circulated among the panel members via e-mail. The draft was modified by incorporating relevant suggestions to reach a consensus. RESULTS AND CONCLUSION For imaging cervical and thoracolumbar spine trauma patients, CT without contrast is generally considered to be the initial line of imaging and radiographs are required if CT is unavailable or unaffordable. CT screening in polytrauma cases is best done with a multidetector CT by utilizing the reformatted images obtained when scanning the chest, abdomen, and pelvis (CT-CAP). MRI is indicated in cases with neurological involvement and advanced cervical degenerative changes and to determine the extent of soft tissue injury, i.e., disco-ligamentous injuries as well as epidural space compromise. MRI is also usually performed when X-rays and CT are unable to correlate with patient symptomatology. These slides can be retrieved under Electronic Supplementary Material.
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16
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Lee GY, Hwang JY, Kim NR, Kang Y, Choi M, Kim J, Ha EJ, Baek JH. Primary Imaging Test for Suspected Traumatic Thoracolumbar Spine Injury: 2017 Guidelines by the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency. Korean J Radiol 2019; 20:909-915. [PMID: 31132816 PMCID: PMC6536791 DOI: 10.3348/kjr.2018.0792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/12/2018] [Indexed: 12/25/2022] Open
Abstract
The Korean Society of Radiology and the National Evidence-based Healthcare Collaborating Agency developed a primary imaging test for suspected traumatic thoracolumbar spine injury. This guideline was developed using an adaptation process involving collaboration between the development committee and the working group. The development committee, consisting of research methodology experts, established the overall plan and provided support on research methodology. The working group, composed of radiologists with expertise in musculoskeletal imaging, wrote the recommendation. The guidelines recommend that thoracolumbar spine computed tomography without intravenous contrast enhancement be the first-line imaging modality for diagnosing traumatic thoracolumbar spine injury in adults.
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Affiliation(s)
- Guen Young Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Ji Young Hwang
- Department of Radiology, Ewha Womans University Seoul Hospital, Seoul, Korea.
| | - Na Ra Kim
- Department of Radiology, Gunkuk University Hostpial, Seoul, Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Jimin Kim
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Eun Ju Ha
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea
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17
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Mitra B, El-Menyar A, Mercier E, Liew S, Varma D, Fitzgerald MC, Al-Hilli S, Peralta R, Al-Thani H, Cameron PA. Clinical clearance of the thoracic and lumbar spine: a pilot study. ANZ J Surg 2019; 89:718-722. [PMID: 31083786 DOI: 10.1111/ans.15253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/21/2019] [Accepted: 03/27/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients who are awake with normal mental and neurologic status, it has been suggested that the thoracolumbar (TL) spine may be cleared by clinical examination, irrespective of the mechanism of injury. The aim of this pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the TL spine during assessment of patients in the emergency department after trauma. METHODS A prospective interventional study was conducted at two major trauma centres. The intervention of a clinical decision tool for assessment of the TL spine was applied prospectively to all patients with subsequent imaging results acting as the comparator. The primary outcome variable was fracture of the thoracic or lumbar vertebra(e). The clinical decision tool was assessed using sensitivity and specificity for detecting a TL fracture and reported with 95% confidence intervals (CIs). RESULTS There were 188 cases included for analysis that all underwent imaging of the thoracic and/or lumbar vertebrae. There were 34 (18%) patients diagnosed with fractures of the thoracic and/or lumbar vertebrae. In this pilot study, sensitivity of the clinical decision tool was 100% (95% CI 87.3-100%) and specificity was 37.0% (95% CI 29.5-45.2%) for the detection of a thoracic or lumbar vertebral fracture. CONCLUSIONS Feasibility of clinical clearance of the TL spine in two major trauma centres was demonstrated in a clinical study setting. Evaluation of this clinical decision tool in patients following blunt trauma, particularly in reducing imaging rates, is indicated using a larger prospective study.
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Affiliation(s)
- Biswadev Mitra
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Ayman El-Menyar
- Department of Surgery, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar.,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Eric Mercier
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices, Université Laval, Québec, Canada.,Département de Médecine Familiale et Médecine d'Urgence, Faculté de Médecine, Université Laval, Québec, Canada.,Centre de Recherche Sur Les Soins Et Les Services De Première Ligne De l'Université Laval, Québec, Canada
| | - Susan Liew
- Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Dinesh Varma
- Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark C Fitzgerald
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Shatha Al-Hilli
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar.,Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Peter A Cameron
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
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18
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Juliano AF, Policeni B, Agarwal V, Burns J, Bykowski J, Harvey HB, Hoang JK, Hunt CH, Kennedy TA, Moonis G, Pannell JS, Parsons MS, Powers WJ, Rosenow JM, Schroeder JW, Slavin K, Whitehead MT, Corey AS. ACR Appropriateness Criteria ® Ataxia. J Am Coll Radiol 2019; 16:S44-S56. [PMID: 31054758 DOI: 10.1016/j.jacr.2019.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 01/14/2023]
Abstract
Ataxia can result from an abnormality in the cerebellum, spinal cord, peripheral nerves, and/or vestibular system. Pathology involving the brain, such as infarct or hydrocephalus, can also present with ataxia as part of the symptom constitution, or result in symptoms that mimic ataxia. Clinical evaluation by history and careful neurological examination is important to help with lesion localization, and helps determine where imaging should be focused. In the setting of trauma with the area of suspicion in the brain, a head CT without intravenous contrast is the preferred initial imaging choice. If vascular injury is suspected, CTA of the neck can be helpful. When the area of suspicion is in the spine, CT or MRI of the spine can be considered to assess for bony or soft-tissue injury, respectively. In the setting of ataxia unrelated to recent trauma, MRI is the preferred imaging modality, tailored to assess the brain or spine depending on the area of suspected pathology. The use of intravenous contrast is generally helpful. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Amy F Juliano
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts.
| | - Bruno Policeni
- Panel Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Vikas Agarwal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | - Jenny K Hoang
- Duke University Medical Center, Durham, North Carolina
| | | | | | - Gul Moonis
- Columbia University Medical Center, New York, New York
| | - Jeffrey S Pannell
- University of California San Diego Medical Center, San Diego, California
| | | | - William J Powers
- University of North Carolina School of Medicine, Chapel Hill, North Carolina; American Academy of Neurology
| | - Joshua M Rosenow
- Northwestern University Feinberg School of Medicine, Chicago, Illinois; neurosurgical consultant
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19
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He L, Yi C, Hak DJ, Hou Z. Functional outcome of surgically treated U-shaped sacral fractures: experience from 41 cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1146-1155. [PMID: 30680636 DOI: 10.1007/s00586-019-05900-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/07/2018] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To delineate the changes in functional outcomes of surgically treated U-shaped sacral fractures. METHODS Forty-one patients with U-shaped sacral fractures were followed for a mean of 4.1 years after surgery. Impairment of lower extremities was assessed via a modified Gibbons score. Urinary function was assessed with a structured interview and residual urine volume. Sexual and bowel functions, as well as patient-reported health, were evaluated using a structured interview, and pain was evaluated with the visual analog scale. Comparisons of data at different time points were conducted with a mixed model, and Z-scores of the SF-36 questionnaire were calculated. RESULTS Forty patients reported pain at 1 year and demonstrated no change at 2 years (p = 0.24). Thirty-six of 39 eligible patients had neurological deficits involving the lower extremities at baseline and demonstrated improvement at 1 year (p = 0.0002) but not between years 1 and 2 (p = 0.47). Twenty-three of 38 eligible patients had impaired bladder function, and 13 of 35 eligible patients had impaired bowel function at 3 months. Urinary function was worse at 2 years than at 1 year (p = 0.02). Sexual dysfunction was common, and patient-reported health was significantly worse than that of the normal population. CONCLUSIONS Neurological function in the lower extremities of patients with U-shaped sacral fractures improved after surgery; however, bowel and sexual functions did not change, and urinary function deteriorated over time. The majority of impairments appear to be permanent if still present at 1 year after surgery. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Li He
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jie Fang Avenue 1095, Wuhan, China
| | - Chengla Yi
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jie Fang Avenue 1095, Wuhan, China.
| | - David J Hak
- Department of Orthopedics, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, The Third Hospital of HeBei Medical University, Zi Qiang Avenue 139, Shijiazhuang, China
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20
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Differentiation of Acute/Subacute versus Old Vertebral Fractures in Multislice Detector Computed Tomography: Is Magnetic Resonance Imaging Always Needed? World Neurosurg 2019; 122:e676-e683. [DOI: 10.1016/j.wneu.2018.10.121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/19/2018] [Indexed: 11/18/2022]
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21
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Eriksson T, Berg P, Olerud C, Shalabi A, Hänni M. Low-dose CT of postoperative pelvic fractures: a comparison with radiography. Acta Radiol 2019; 60:85-91. [PMID: 29665704 DOI: 10.1177/0284185118770919] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Computed tomography (CT) is superior to conventional radiography (CR) for assessing internal fixation of pelvic fractures, but with a higher radiation exposure. Low-dose CT (LDCT) could possibly have a sufficient diagnostic accuracy but with a lower radiation dose. PURPOSE To compare postoperative diagnostic accuracy of LDCT and CR after open reduction and internal fixation of pelvic fracture. MATERIAL AND METHODS Twenty-one patients were examined with LDCT and CR 0-9 days after surgery. The examinations were reviewed by two musculoskeletal radiologists. Hardware, degree of fracture reduction, image quality, and reviewing time were assessed, and effective radiation dose was calculated. Inter-reader agreement was calculated. RESULTS LDCT was significantly better than CR in determining whether hardware positioning was assessable ( P < 0.001). Acetabular congruence was assessable in all fractured patients with LDCT. In 12 of the 32 assessments with CR of patients with an acetabular fracture, joint congruence was not assessable due to overlapping hardware ( P = 0.001). Image quality was significantly higher for LDCT. Median time to review was 240 s for LDCT compared to 180 s for CR. Effective dose was 0.79 mSv for LDCT compared to 0.32 mSv for CR ( P < 0.001). CONCLUSION LDCT is more reliable than CR in assessing hardware position and fracture reduction. Joint congruency is sometimes not possible to assess with CR, due to overlapping hardware. The image quality is higher, but also the effective dose, with LDCT than with CR.
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Affiliation(s)
- Thomas Eriksson
- Department of Radiology, Uppsala University Hospital, Uppsala, Sweden
| | - Per Berg
- Department of Orthopaedic Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Claes Olerud
- Department of Orthopaedic Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Adel Shalabi
- Department of Radiology, Uppsala University Hospital, Uppsala, Sweden
| | - Mari Hänni
- Department of Radiology, Uppsala University Hospital, Uppsala, Sweden
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22
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Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging. J Emerg Med 2018; 56:153-165. [PMID: 30598296 DOI: 10.1016/j.jemermed.2018.10.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 10/16/2018] [Accepted: 10/25/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging. OBJECTIVE Our aim was to quantify the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients. METHODS A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov was performed. Excluded studies lacked data to construct 2 × 2 tables, were duplicates, were not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios. RESULTS In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1-152.2; I2 = 94%; p < 0.001) and negative likelihood ratio (-LR) = 0.43 (95% CI 0.32-0.59; I2 = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1-467.9; I2 = 87%; p < 0.001) and -LR = 0.04 (95% CI 0.02-0.08; I2 = 23%; p = 0.26). CONCLUSIONS CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures.
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Hardy C, Hazelton JP, Gefen R. Added Value of Dedicated Spine CT to Detect Fracture in Patients with CT Chest, Abdomen, and Pelvis in the Trauma Setting. Curr Probl Diagn Radiol 2018; 48:554-557. [PMID: 30209025 DOI: 10.1067/j.cpradiol.2018.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/31/2018] [Accepted: 08/06/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE Fractures of the thoracolumbar spine account for up to 90% of spinal fractures, and are associated with significant disability. The advantage of acquiring dedicated spine CT imaging in addition to visceral CT studies of the chest, abdomen and pelvis for detection of spinal fractures has not been definitively established. This retrospective study seeks to determine the contribution of dedicated spine CT in the acute clinical setting. METHODS Patients who were diagnosed with fractures of the thoracic or lumbar spine at our institution between January 1, 2010 and June 30, 2014 were identified. Additional inclusion criteria included having a CT of the chest and/or abdomen and pelvis followed by a dedicated thoracic or lumbar spine CT within 30 days. Reports were reviewed for accuracy of fracture detection, and missed fractures were retrospectively analyzed on images for detectability. RESULTS A total of 102 patients met our inclusion criteria for a total of 312 fractures. Of the 312 fractures, 31 (10%) were missed on the initial visceral CT in 18 of the 102 patients. In all but two cases, at least one fracture was identified on the visceral spine CT. There were no cases in which the newly identified fractures changed patient management. CONCLUSION All fractures requiring surgical intervention were identified on the visceral CT. A dedicated spine CT does detect additional spine fractures but does not clearly alter patient management.
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Affiliation(s)
- Caitlin Hardy
- Department of Radiology, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ
| | - Joshua P Hazelton
- Department of Surgery, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ
| | - Ron Gefen
- Department of Radiology, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ.
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Weinrich JM, Well L, Regier M, Behzadi C, Sehner S, Adam G, Laqmani A. MDCT in suspected lumbar spine fracture: comparison of standard and reduced dose settings using iterative reconstruction. Clin Radiol 2018; 73:675.e9-675.e15. [PMID: 29576224 DOI: 10.1016/j.crad.2018.02.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/16/2018] [Indexed: 01/16/2023]
Abstract
AIM To compare standard (SD-) and reduced-dose computed tomography (RD-CT) in combination with iterative reconstruction (IR) in emergency patients with suspected lumbar spine fracture. MATERIAL AND METHODS Forty emergency patients with suspected lumbar spinal disorder who underwent RD-CT and 40 body mass index-matched patients undergoing SD-CT were enrolled in this retrospective study. Raw data for RD-CT were reconstructed using two increasing IR levels (IRL) 4 and 6, while SD-CT was reconstructed with IRL3. Two radiologists assessed image quality, image noise, and reader confidence in interpreting findings of spinal fractures in a blinded manner. RESULTS Effective radiation dose was reduced by 50% using RD-CT. Overall subjective image quality (SIQ) was high for both protocols and slightly superior in the RD-CT protocol for both IRL compared to SD-CT. The detection rate of spinal disorders was high for both protocols with a high interobserver agreement. CONCLUSION RD-CT with higher levels of IR results in substantial dose reduction of 50% in lumbar spine CT while maintaining an excellent subjective image quality resulting in a high diagnostic confidence.
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Affiliation(s)
- J M Weinrich
- Department for Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - L Well
- Department for Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Regier
- Department for Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - C Behzadi
- Department for Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Sehner
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - G Adam
- Department for Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Laqmani
- Department for Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Philipp LR, Boulter J, Deibert C, Ahmad FU. Isolated Transverse Process Spinal Fractures Increase the Likelihood of Incurring Visceral and Pelvic Injuries: A Retrospective Review at a Level-1 Trauma Center. World Neurosurg 2018; 110:e168-e176. [DOI: 10.1016/j.wneu.2017.10.116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/22/2017] [Indexed: 10/18/2022]
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Singh R, Taylor DM, D'Souza D, Gorelik A, Page P, Phal P. Mechanism of Injury and Clinical Variables in Thoracic Spine Fracture: A Case Control Study. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791101800102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To determine the mechanisms of injury and clinical findings significantly associated with traumatic thoracic spine (T-spine) fractures. Methods This was a case-control study in a tertiary adult trauma centre. Cases were patients admitted with traumatic T-spine fractures between January 1999 and August 2007, inclusive. Each case had two controls matched for gender, age and injury severity. Data were collected from patient medical records and the trauma service database. Factors potentially associated with T-spine fracture were derived from the literature, expert consensus and univariate analysis. Multivariate logistic regression was employed to determine factors significantly associated with T-spine fracture. Results Two hundred and sixty one cases and 512 controls were enrolled. Univariate analysis showed the mechanisms of fall from a height ≥2 meters (m) and motorbike accident ≥60 kilometers per hour were significantly associated with T-spine fracture (p<0.001). The clinical findings of thoracic back pain, tenderness, intoxication, step deformity and abnormal neurological symptoms were also significantly associated with T-spine fracture (p<0.05). Multivariate analysis indicated that falls from a height of ≥2 m and thoracic back pain were significantly and positively associated with T-spine fracture (p<0.001). However, intoxication was negatively associated with T-spine fracture. Conclusions Patients with T-spine injury are significantly more likely to have fallen from a height ≥2 m or to have had thoracic back pain but less likely to be intoxicated. These findings should be validated prospectively prior to development of clinical guidelines for the identification of patients who may benefit from CT screening of the thoracic spine.
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Affiliation(s)
- R Singh
- University of Melbourne, Faculty of Medicine, Parkville, Melbourne, Victoria, Australia 3010
| | | | - D D'Souza
- Toronto General Hospital, Toronto, Canada
| | - A Gorelik
- Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia 3050
| | - P Page
- Box Hill, Box Hill Radiology, Victoria, Australia 3128
| | - P Phal
- Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia 3050
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Can CT imaging of the chest, abdomen, and pelvis identify all vertebral injuries of the thoracolumbar spine without dedicated reformatting? Am J Surg 2017; 216:52-55. [PMID: 29246407 DOI: 10.1016/j.amjsurg.2017.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 12/01/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The main objective of this study was to compare detection rates of clinically significant thoracolumbar spine (TLS) fracture between computed tomography (CT) imaging of the chest, abdomen, and spine (CT CAP) and CT for the thoracolumbar spine (CT TL). METHODS We retrospectively identified patients at our institution with a TLS fracture over a two-year period that had both CT CAP and reformatted CT TL imaging. The sensitivity of CT CAP to identify fracture was calculated for each fracture type. RESULTS A total of 516 TLS fractures were identified in 125 patients using reformatted CT TL spine imaging. Overall, 69 of 512 fractures (13%) were missed on CT CAP that were identified on CT TL. Of those, there were no clinically significant missed fractures. CONCLUSIONS CT CAP could potentially be used as a screening tool for clinically significant TLS injuries.
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Nagasawa DT, Bui TT, Lagman C, Lee SJ, Chung LK, Niu T, Tucker A, Gaonkar B, Yang I, Macyszyn L. Isolated Transverse Process Fractures: A Systematic Analysis. World Neurosurg 2017; 100:336-341. [DOI: 10.1016/j.wneu.2017.01.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/06/2017] [Accepted: 01/09/2017] [Indexed: 01/15/2023]
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Tins BJ. Imaging investigations in Spine Trauma: The value of commonly used imaging modalities and emerging imaging modalities. J Clin Orthop Trauma 2017; 8:107-115. [PMID: 28720986 PMCID: PMC5498756 DOI: 10.1016/j.jcot.2017.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/03/2017] [Indexed: 10/19/2022] Open
Abstract
Traumatic spine injuries can be devastating for patients affected and for health care professionals if preventable neurological deterioration occurs. This review discusses the imaging options for the diagnosis of spinal trauma. It lays out when imaging is appropriate and when it is not. It discusses strength and weakness of available imaging modalities. Advanced techniques for spinal injury imaging will be explored. The review concludes with a review of imaging protocols adjusted to clinical circumstances.
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Lombardo G, Petrone P, Prabhakaran K, Marini CP. Isolated transverse process fractures: insignificant injury or marker of complex injury pattern? Eur J Trauma Emerg Surg 2016; 43:657-661. [PMID: 27913838 DOI: 10.1007/s00068-016-0745-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 11/28/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This study investigates the incidence of isolated transverse process fractures (ITPFx) amongst vertebral fractures in trauma patients, and specific-associated injury patterns present in patients with ITPFx. MATERIALS AND METHODS A retrospective, 4-year review of our Level 1 Trauma Center registry was performed. Patients with blunt spinal column fractures were identified. Data collected included patient demographics, Injury Severity Score (ISS), type of imaging obtained, and concomitant injuries, including rib and pelvic fractures, liver, spleen, and kidney injury (SOI). RESULTS Of the 10,186 patients admitted during the study period, 881 (8.6%) suffered blunt thoraco-abdominal trauma resulting in vertebral fractures; 214/881 (24%) had ITPFx. All patients (10,186) underwent dedicated spinal multi-detector CT (MDCT) imaging; 26/214 (12.1%) patients had MRI. In all 26 patients, the MRI confirmed the CT findings. 202/214 (94.4%) had associated injuries: rib and pelvic fractures, 45.5 and 20.2%, respectively, and splenic, liver and kidney injury with an incidence of 13.8, 10.9, and 9.4%, respectively. A higher incidence of rib fractures was associated with ITPFx at the T1-4 levels, whereas ITPFx at the level of L5 were associated with pelvic fractures and SOI. Multiple logistic regression analysis identified T1-4 and L5 fractures as predictors of rib fractures and pelvic fractures independent of ISS, with OR: 2.55 (95% CI: 1.12-5.82) and 6.81 (95% CI: 3.14-14.78), respectively. CONCLUSIONS Based on the results of this study, we conclude that: (1) the use of MDCT imaging has increased the rate of identification of ITPFx; (2) dedicated spinal MDCT reconstruction and MRI may not be necessary to diagnose isolated thoracic and lumbar ITPFx; and (3) ITPFx of the thoracic spine and lower lumbar spine are markers of associated rib fractures and pelvic ring fractures, respectively, as well as of solid organ injuries.
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Affiliation(s)
- G Lombardo
- Division of Trauma Surgery, Surgical Critical Care and Acute Care Surgery, Westchester Medical Center University Hospital, 100 Woods Road, Taylor Pavilion, Suite E-145, Valhalla, NY, 10595, USA.
| | - P Petrone
- Department of Surgery New York Medical College, Valhalla, NY, USA
| | - K Prabhakaran
- Division of Trauma Surgery, Surgical Critical Care and Acute Care Surgery, Westchester Medical Center University Hospital, 100 Woods Road, Taylor Pavilion, Suite E-145, Valhalla, NY, 10595, USA
| | - C P Marini
- Department of Surgery New York Medical College, Valhalla, NY, USA
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Riddell J, Inaba K, Jhun P, Herbert M. A Clinical Decision Rule for Thoracolumbar Spine Imaging in Blunt Trauma? Ann Emerg Med 2016; 68:781-783. [DOI: 10.1016/j.annemergmed.2016.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Deramo P, Agrawal V, Amos J, Patel N, Jefferson H. Does MRI of the Thoracolumbar Spine Change Management in Blunt Trauma Patients with Stable Thoracolumbar Spinal Injuries Without Neurologic Deficits? World J Surg 2016; 41:970-974. [PMID: 27878353 DOI: 10.1007/s00268-016-3841-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In blunt trauma patients with computed tomography (CT) findings of stable thoracolumbar (TL) spinal injury without neurologic deficits, magnetic resonance imaging (MRI) studies are commonly obtained, though the impact on overall management remains unclear. The indication for MRI in patients with TL injury without neurologic deficits continues to remain unclear. Here, we evaluate the role of MRI on clinical management of patients presenting with this diagnosis. METHODS After IRB approval, all registry patients from December 2005 to December 2015 with all blunt TL injuries without defects were extracted. General demographics, injury parameters, hospital and ICU length of stay (ILOS/HLOS), CT/MRI findings, and intervention were collected. Impact of variant ISS in the four groups was corrected by dividing HLOS and ILOS by ISS. The Student's t test was conducted for statistical analysis. RESULTS Of 613 patients, 236 met the inclusion criteria with average age of 52 ± 23 y, ISS (7 ± 4), HLOS (5 ± 3 days), and ILOS (1 ± 2 days). One hundred and thirty-three patients underwent MRI, and 103 patients underwent CT only. Patients who underwent MRI were no more likely to attain intervention (p < 0.06) but had longer length of stay relative to ISS (p < 0.006). CONCLUSIONS MRI did not affect rate of intervention though increased HLOS accounting for ISS. CT findings of stability were concordant with MRI findings. Our results suggest that MRI may not affect intervention decisions in blunt trauma patients with CT findings of stable thoracolumbar spinal injury without neurological deficits.
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Affiliation(s)
- Paul Deramo
- Department of Graduate Medical Education, Methodist Dallas Medical Center, Dallas, TX, 75208, USA
| | - Vaidehi Agrawal
- Clinical Research Institute, Methodist Health System, Pavilion III, Suite 168, 1411 N. Beckley Avenue, Dallas, 75203, TX, USA.
| | - Joseph Amos
- Associates in Surgical Acute Care, Methodist Dallas Medical Center, Dallas, 75208, TX, USA
| | - Nimesh Patel
- Methodist Moody Brain and Spine Institute, Methodist Dallas Medical Center, Dallas, 75203, TX, USA
| | - Henry Jefferson
- Associates in Surgical Acute Care, Methodist Dallas Medical Center, Dallas, 75208, TX, USA
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Boulter JH, Lovasik BP, Baum GR, Frerich JM, Allen JW, Grossberg JA, Pradilla G, Ahmad FU. Implications of Isolated Transverse Process Fractures: Is Spine Service Consultation Necessary? World Neurosurg 2016; 95:285-291. [DOI: 10.1016/j.wneu.2016.08.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/06/2016] [Accepted: 08/08/2016] [Indexed: 10/21/2022]
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Haris AM, Vasu C, Kanthila M, Ravichandra G, Acharya KD, Hussain MM. Assessment of MRI as a Modality for Evaluation of Soft Tissue Injuries of the Spine as Compared to Intraoperative Assessment. J Clin Diagn Res 2016; 10:TC01-5. [PMID: 27134961 DOI: 10.7860/jcdr/2016/17427.7377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/08/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Traumatic injuries of the spine and spinal cord are potentially devastating as they may lead to significant neurological damage as the clinical and prognostic spectrum of the effects of spinal injuries is vast. Timely imaging studies can help mitigate these possibly life threatening complications. There is a dearth of studies that directly compare MR imaging findings to surgical findings. AIM Hence, this study was undertaken to assess the sensitivity of MRI in identifying injuries to the soft tissue structures of the spine. MATERIALS AND METHODS MRI scans were performed on 31 cases of acute spinal injuries that presented within 72 hours of the trauma and underwent surgical fixation by either an anterior or posterior approach. The non-osseous structures namely; Anterior Longitudinal Ligament (ALL), Posterior Longitudinal Ligament (PLL), Intervertebral Disc, Ligamentum Flavum, Interspinous Ligament (ISP) and the Spinal Cord were evaluated. They were classified as 'True Positive' if an injury was found to correlate with intraoperative findings and as 'False Negative' when diagnosed falsely as normal. The statistical sensitivity of MRI in diagnosing injuries to the non-osseous structures of the spine were thus calculated. RESULTS Of the 31 patients, in 51.6% of patients the site of injury was to the cervical spine (n=16), thoracic spine was the next highest in occurrence of 39% (n=12) and lumbar spine accounted for the least. In correlating the imaging findings to the intraoperative findings, MRI was highly sensitive in detecting injuries to the Posterior Longitudinal Ligament (94.4%) and the Spinal cord (93%) and fairly high in detecting injuries to the Intervertebral disc. However coming to the ligamentum flavum and interspinous ligaments, the sensitivity of the MRI dropped to 62.5% and 63.6% respectively. CONCLUSION MRI was found to be highly sensitive in detecting injuries to the spinal cord and the posterior longitudinal ligament and moderately sensitive for detection of disc injuries. Though concerning the Anterior Longitudinal Ligament, Ligamentum Flavum and the Interspinous Ligaments MRI performed ineffectively with higher number of false negative interpretations.
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Affiliation(s)
- Arafat Muhammed Haris
- Assistant Professor, Department of Radiology, Yenepoya University , Mangalore, Karnataka, India
| | - Chembumkara Vasu
- Professor, Department of Radiology, Yenepoya University , Mangalore, Karnataka, India
| | - Mahesha Kanthila
- Associate Professor, Department of Orthopaedics, Yenepoya University , Mangalore, Karnataka, India
| | | | | | - Mohamed Musheer Hussain
- Assistant Professor, Department of Orthopaedics, Yenepoya University , Mangalore, Karnataka, India
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Cason B, Rostas J, Simmons J, Frotan MA, Brevard SB, Gonzalez RP. Thoracolumbar spine clearance: Clinical examination for patients with distracting injuries. J Trauma Acute Care Surg 2016; 80:125-30. [PMID: 26491795 DOI: 10.1097/ta.0000000000000884] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to prospectively assess the sensitivity of clinical examination to screen for thoracolumbar spine (TLS) injury in awake and alert blunt trauma patients with distracting injuries. METHODS From December 2012 to June 2014, all blunt trauma patients older than 13 years were prospectively evaluated as per standard TLS examination protocol at a Level 1 trauma center. Awake and alert patients with Glasgow Coma Scale (GCS) score of 14 or greater underwent clinical examination of the TLS. Clinical examination was performed regardless of distracting injuries. Patients with no complaints of pain or tenderness on examination of the TLS were considered clinically cleared of injury. Patients with distracting injuries, including those clinically cleared and those with complaints of TLS pain or tenderness, underwent computed tomographic scan of the entire TLS. Patients with minor distracting injuries were not considered to have a distracting injury. RESULTS A total of 950 blunt trauma patients were entered, 530 (56%) of whom had at least one distracting injury. Two hundred nine patients (40%) with distracting injuries had a positive TLS clinical examination result, of whom 50 (25%) were diagnosed with TLS injury. Three hundred twenty-one patients (60%) with distracting injuries were initially clinically cleared, in whom 17 (5%) TLS injuries were diagnosed. There were no missed injuries that required surgical intervention, with only four injuries receiving TLS orthotic bracing. This yielded an overall clinical clearance sensitivity for injury of 75% and sensitivity for clinically significant injury of 89%. CONCLUSION In awake and alert blunt trauma patients with distracting injuries, clinical examination is a sensitive screening method for significant TLS injury. Radiologic assessment may be unnecessary for safe clearance of the asymptomatic TLS in patients with distracting injuries. These findings suggest significant potential reduction of both health care cost and patient radiation exposure. LEVEL OF EVIDENCE Diagnostic study, level IV; therapeutic/care management study, level IV.
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Affiliation(s)
- Ben Cason
- From the Department of Surgery (B.C., J.R., J.S., S.B.B.), University of South Alabama, Mobile, Alabama; Department of Surgery (M.A.F.), Texas Health Presbyterian, Dallas, Texas; and Division of Trauma, Surgical Critical Care, Burns (R.P.G.), Loyola University Medical Center, Maywood, Illinois
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Abstract
The treatment of a patient with a vertebral fracture requires an accurate diagnosis and categorization of the problem. Treatment decisions must be based on clinical data and information about the lesion itself, which is provided by imaging studies and their interpretation.
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Guarnieri G, Izzo R, Muto M. The role of emergency radiology in spinal trauma. Br J Radiol 2016; 89:20150833. [PMID: 26612468 DOI: 10.1259/bjr.20150833] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Spinal trauma is very frequent injury with different severity and prognosis varying from asymptomatic condition to temporary neurological dysfunction, focal deficit or fatal event. The major causes of spinal trauma are high- and low-energy fall, traffic accident, sport and blunt impact. The radiologist has a role of great responsibility to establish the presence or absence of lesions, to define the characteristics, to assess the prognostic influence and therefore treatment. Imaging has an important role in the management of spinal trauma. The aim of this paper was to describe: incidence and type of vertebral fracture; imaging indication and guidelines for cervical trauma; imaging indication and guidelines for thoracolumbar trauma; multidetector CT indication for trauma spine; MRI indication and protocol for trauma spine.
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Affiliation(s)
| | - Roberto Izzo
- Neuroradiology Unit, Cardarelli Hospital, Naples, Italy
| | - Mario Muto
- Neuroradiology Unit, Cardarelli Hospital, Naples, Italy
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Gamanagatti S, Rathinam D, Rangarajan K, Kumar A, Farooque K, Sharma V. Imaging evaluation of traumatic thoracolumbar spine injuries: Radiological review. World J Radiol 2015; 7:253-265. [PMID: 26435776 PMCID: PMC4585949 DOI: 10.4329/wjr.v7.i9.253] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 05/14/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
Spine fractures account for a large portion of musculoskeletal injuries worldwide. A classification of spine fractures is necessary in order to develop a common language for treatment indications and outcomes. Several classification systems have been developed based on injury anatomy or mechanisms of action, but they have demonstrated poor reliability, have yielded little prognostic information, and have not been widely used. For this reason, the Arbeitsgemeinschaftfür Osteosynthesefragen (AO) committee has classified thorocolumbar spine injuries based on the pathomorphological criteria into3 types (A: Compression; B: Distraction; C: Axial torque and rotational deformity). Each of these types is further divided into 3 groups and 3 subgroups reflecting progressive scale of morphological damage and the degree of instability. Because of its highly detailed sub classifications, the AO system has shown limited interobserver variability. It is similar to its predecessors in that it does not incorporate the patient’s neurologic status.The need for a reliable, reproducible, clinically relevant, prognostic classification system with an optimal balance of ease of use and detail of injury description contributed to the development of a new classification system, the thoracolumbar injury classification and severity score (TLICS). The TLICS defines injury based on three clinical characteristics: injury morphology, integrity of the posterior ligamentous complex, and neurologic status of the patient. The severity score offers prognostic information and is helpful in decision making about surgical vs nonsurgical management.
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40
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Peetz AB, Salim A. Clearance of the Spine. CURRENT TRAUMA REPORTS 2015. [DOI: 10.1007/s40719-015-0019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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France JC. Commentary on: "Traumatic Spondylopelvic Dissociation: A Report of Two Cases of Spondylolisthesis at L5-S1 and Review of Literature". Global Spine J 2015; 5:231-2. [PMID: 26131391 PMCID: PMC4472298 DOI: 10.1055/s-0035-1549440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 02/10/2015] [Indexed: 10/25/2022] Open
Affiliation(s)
- John C. France
- Department of Orthopaedic Surgery, West Virginia University, Morgantown, West Virginia, United States,Address for correspondence John C. France, MD Professor of Orthopaedic SurgeryWest Virginia UniversityMorgantown, WVUnited States
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Scholtz JE, Wichmann JL, Kaup M, Fischer S, Kerl JM, Lehnert T, Vogl TJ, Bauer RW. First performance evaluation of software for automatic segmentation, labeling and reformation of anatomical aligned axial images of the thoracolumbar spine at CT. Eur J Radiol 2015; 84:437-442. [DOI: 10.1016/j.ejrad.2014.11.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 11/28/2014] [Accepted: 11/30/2014] [Indexed: 10/24/2022]
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Abul-Kasim K, Ohlin A. Evaluation of implant loosening following segmental pedicle screw fixation in adolescent idiopathic scoliosis: a 2 year follow-up with low-dose CT. SCOLIOSIS 2014; 9:13. [PMID: 25177357 PMCID: PMC4149778 DOI: 10.1186/1748-7161-9-13] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 08/20/2014] [Indexed: 11/15/2022]
Abstract
Background The long term radiological status of screw fixation following scoliosis surgery with all pedicle screw construct is not previously studied. Aim To evaluate the incidence of loosening (implant failure) evaluated with low-dose CT two years following scoliosis surgery. Study design Retrospective study. Methods 81 consecutive patients with adolescent idiopathic scoliosis (AIS), aged 18 ± 3 years at 2 years follow-up (83% were female), subjected for scoliosis corrective surgery with all pedicle screw construct (total of 1666 screws) has been examined with plain radiography and with low dose CT 6 weeks and 2 years postoperatively. Results In 26 out of 81 (32%) patients there were signs of loosening of one or more screws, a maximum 3 screws. 47 out of 1666 (2.8%) screws showed evidence of loosening. Preoperative Cobb angle was 56° among patients with loosening compared with 53° among patients with no evidence of loosening (P = 0.288). In males there were signs of loosening in 8 out of 14 (57%) and in females 18 out of 67 (27%), (P = 0.027). Among cases with loosening, 14% had suboptimal screw placement at the first postoperative CT compared with 11% among patients with no evidence of loosening (P = 0.254). One patient with a loosened L4 screw had neurological deficit and subjected for revision of the construct. Out of 26 patients with evidence of loosening, 5 patients reported minor pain or discomfort, 1 patient had a minor proximal junctional kyphosis of about 15° and 3 patients showed evidence of pull-out of 3–5 mm at the upper end of the construct but no clinical complaint. With plain radiography loosening could be observed only in 11 out of 26 cases, 5 were in the lumbar region. Conclusions In a consecutive series of 81 cases with AIS who had underwent scoliosis surgery, one third showed, 2 years after the intervention, minor screw loosening. Males were more prone to develop screw loosening. In CT system that enables low-dose protocol, CT is recommended for the evaluation of evidence of screw loosening.
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Affiliation(s)
- Kasim Abul-Kasim
- Division of Neuroradiology, Diagnostic Centre for Imaging and Functional Medicine, Faculty of Medicine, Lund University, Skåne University Hospital, Malmö 205 02, Sweden
| | - Acke Ohlin
- Department of Orthopaedic Surgery, Faculty of Medicine, Lund University, Skåne University Hospital, Malmö 205 02, Sweden
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Muto M, Marcia S, Guarnieri G, Pereira V. Assisted techniques for vertebral cementoplasty: why should we do it? Eur J Radiol 2014; 84:783-8. [PMID: 24801264 DOI: 10.1016/j.ejrad.2014.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 03/31/2014] [Accepted: 04/02/2014] [Indexed: 11/18/2022]
Abstract
Assisted techniques (AT) for vertebral cementoplasty include multiple mini-invasive percutaneous systems in which vertebral augmentation is obtained through mechanical devices with the aim to reach the best vertebral height restoration. As an evolution of the vertebroplasty, the rationale of the AT-treatment is to combine the analgesic and stability effect of cement injection with the restoration of a physiological height for the collapsed vertebral body. Reduction of the vertebral body kyphotic deformity, considering the target of normal spine biomechanics, could improve all systemic potential complications evident in patient with vertebral compression fracture (VCF). Main indications for AT are related to fractures in fragile vertebral osseous matrix and non-osteoporotic vertebral lesions due to spine metastasis or trauma. Many companies developed different systems for AT having the same target but different working cannula, different vertebral height restoration system and costs. Aim of this review is to discuss about vertebral cementoplasty procedures and techniques, considering patient inclusion and exclusion criteria as well as all related minor and/or major interventional complications.
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Affiliation(s)
- M Muto
- Department of Diagnostic Imaging, Section of Neuroradiology-"A. Cardarelli" Hospital, Naples, Italy.
| | - S Marcia
- Section of Radiology-Santissima Trinità Hospital, Cagliari, Italy
| | - G Guarnieri
- Department of Diagnostic Imaging, Section of Neuroradiology-"A. Cardarelli" Hospital, Naples, Italy
| | - V Pereira
- Unit of Interventional Neuroradiology-HUG, Geneva, Switzerland
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Henes FO, Groth M, Kramer H, Schaefer C, Regier M, Derlin T, Adam G, Bannas P. Detection of occult vertebral fractures by quantitative assessment of bone marrow attenuation values at MDCT. Eur J Radiol 2013; 83:167-72. [PMID: 24144447 DOI: 10.1016/j.ejrad.2013.09.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/10/2013] [Accepted: 09/17/2013] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To determine a cut-off value of Hounsfield attenuation units (HU) at multidetector computed tomography (MDCT) for valid and reliable detection of bone marrow oedema (BME) related to occult vertebral fractures. METHODS 36 patients underwent both MDCT and Magnetic Resonance Imaging (MRI) for evaluation of vertebral fractures of the thoracolumbar spine and were included in this retrospective study. Two readers independently assessed HU values at MDCT in a total of 196 vertebrae. Reliability was assessed by intraclass correlation coefficient and Bland-Altman analysis. For each patient we determined the vertebra with the lowest HU value and calculated the HU-difference to each other vertebral body. HU-differences were subjected to receiver operating characteristic (ROC) curve analysis to determine the diagnostic accuracy for detection of BME as determined by MRI, which served as the reference standard. Results of HU-measurements were compared with standard visual evaluation of MDCT. RESULTS HU measurements demonstrated a high interrater reliability (ICC=0.984). ROC curve analysis (AUC=0.978) exhibited an ideal cut-off value of 29.6 HU for detection of BME associated with vertebral fractures with an accuracy of 97.4% as compared to 93.4% accuracy of visual evaluation. Particularly, HU-measurements increased the sensitivity for detection of vertebral fractures from 78.0% to 92.7% due to the detection of 7 of 9 occult fractures that were missed by visual evaluation alone. CONCLUSIONS Assessing bone marrow density by HU measurements using the cut-off of 29.6 HU is a valid and reliable tool for detection of BME related to occult vertebral fractures in MDCT. The introduced technique may allow more accurate treatment decisions and may make further diagnostic work-up with MRI unnecessary.
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Affiliation(s)
- Frank Oliver Henes
- Department of Diagnostic and Interventional Radiology, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
| | - Michael Groth
- Department of Diagnostic and Interventional Neuroradiology, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Harald Kramer
- Department of Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Marchioninistr. 15, 81377 Munich, Germany; Department of Radiology, University of Wisconsin - Madison, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Christian Schaefer
- Department of Trauma-, Hand- and Reconstructive Surgery, Spine Center, Center for Surgical Sciences, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Marc Regier
- Department of Diagnostic and Interventional Radiology, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Thorsten Derlin
- Department of Diagnostic and Interventional Radiology, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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Intra and interobserver reliability and agreement of semiquantitative vertebral fracture assessment on chest computed tomography. PLoS One 2013; 8:e71204. [PMID: 23940719 PMCID: PMC3733867 DOI: 10.1371/journal.pone.0071204] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 07/03/2013] [Indexed: 12/02/2022] Open
Abstract
Objectives To evaluate the reliability of semiquantitative Vertebral Fracture Assessment (VFA) on chest Computed Tomography (CT). Methods Four observers performed VFA twice upon sagittal reconstructions of 50 routine clinical chest CTs. Intra- and interobserver agreement (absolute agreement or 95% Limits of Agreement) and reliability (Cohen's kappa or intraclass correlation coefficient(ICC)) were calculated for the visual VFA measures (fracture present, worst fracture grade, cumulative fracture grade on patient level) and for percentage height loss of each fractured vertebra compared to the adjacent vertebrae. Results Observers classified 24–38% patients as having at least one vertebral fracture, giving rise to kappa's of 0.73–0.84 (intraobserver) and 0.56–0.81 (interobserver). For worst fracture grade we found good intraobserver (76–88%) and interobserver (74–88%) agreement, and excellent reliability with square-weighted kappa's of 0.84–0.90 (intraobserver) and 0.84–0.94 (interobserver). For cumulative fracture grade the 95% Limits of Agreement were maximally ±1,99 (intraobserver) and ±2,69 (interobserver) and the reliability (ICC) varied from 0.84–0.94 (intraobserver) and 0.74–0.94 (interobserver). For percentage height-loss on a vertebral level the 95% Limits of Agreement were maximally ±11,75% (intraobserver) and ±12,53% (interobserver). The ICC was 0.59–0.90 (intraobserver) and 0.53–0–82 (interobserver). Further investigation is needed to evaluate the prognostic value of this approach. Conclusion In conclusion, these results demonstrate acceptable reproducibility of VFA on CT.
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Screening for thoracolumbar spinal injuries in blunt trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2013; 73:S326-32. [PMID: 23114489 DOI: 10.1097/ta.0b013e31827559b8] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thoracolumbar spine (TLS) injuries have an incidence rate of 5% in blunt trauma patients. The Eastern Association for the Surgery of Trauma published Practice Management Guidelines for the Screening of Thoracolumbar Spine Fracture in 2007. The Practice Management Guidelines Committee was assembled to reevaluate the literature. METHODS A search of the United States National Library of Medicine and the National Institutes of Health database was performed using MEDLINE through PubMed (www.pubmed.gov). The search retrieved English-language articles from March 2005 to December 2011 that referenced traumatic TLS injuries and fractures. The questions posed were the following: (1) What is the appropriate imaging modality to screen patients for TLS injuries? (2) Which trauma patients require radiographic screening for TLS injuries? (3)Does a patient who is awake and alert without distracting injuries require radiologic workup to rule out TLS injuries? RESULTS Thirty-seven articles that referenced traumatic TLS injuries in association with screening published between March 2005 and December 2011 were collected and disseminated to the committee. Twelve were found to be relevant. Nine publications from the previous 2006 guidelines were reviewed and referenced to create and validate the updated guidelines. CONCLUSION Practice patterns have changed regarding screening blunt trauma patients for TLS injuries. Software reformatted multidetector computed tomographic scans are more sensitive and accurate than plain films. Multidetector computed tomographic scans have become the screening modality of choice and the criterion standard in screening for TLS injuries. The literature supports a Level 1 recommendation to validate this based on a preponderance of Class II data. Patients without altered mentation or significant mechanism may be excluded by clinical examination without imaging. Patients with gross neurologic deficits or concerning clinical examination findings with negative imaging should receive a magnetic resonance imaging expediently, and the spine service should be consulted.
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Izzo R, Guarnieri G, Guglielmi G, Muto M. Biomechanics of the spine. Part II: Spinal instability. Eur J Radiol 2013; 82:127-38. [DOI: 10.1016/j.ejrad.2012.07.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 07/20/2012] [Accepted: 07/21/2012] [Indexed: 11/30/2022]
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Venkatesan M, Fong A, Sell PJ. CT scanning reduces the risk of missing a fracture of the thoracolumbar spine. ACTA ACUST UNITED AC 2012; 94:1097-100. [DOI: 10.1302/0301-620x.94b8.29397] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of ‘missed injury’. We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk. Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury.
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Affiliation(s)
- M. Venkatesan
- University Hospitals of Leicester, Infirmary
Square, Leicester LE1 5WW, UK
| | - A. Fong
- University Hospitals of Leicester, Infirmary
Square, Leicester LE1 5WW, UK
| | - P. J. Sell
- University Hospitals of Leicester, Infirmary
Square, Leicester LE1 5WW, UK
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