Cervical Spine CT Research Articles

Assessment of cervical spine CT by an image quality audit using qualitative and quantitative methods.

To study the feasibility and assess the correlation of qualitative and quantitative methods for an image quality (IQ) audit of a Cervical spine CT. Five radiologists retrospectively performed a blinded visual grading analysis (VGA) on 20 studies (10 from Protocol 1 and 10 from Protocol 2), using the RANZCR CT IQ Self-Audit worksheet. A Visual Grading Analysis Score (VGAS) and Area under the curve using Visual Grading Characteristics (AUCVGC) were the figures of merit. Quantitative metrics for noise and contrast were correlated to the qualitative assessment. No statistically significant difference was observed in the IQ, VGASProtocol1 = 0.65, 95% CI [0.54, 0.75] and VGASProtocol 2 = 0.73, 95% CI [0.67, 0.79] and AUCVGC = 0.548, 95% CI [0.40, 0.69]. Protocol 2 indicated a statistically significant average dose reduction of 35% in CTDIvol (P = 0.020) and a higher noise; however, the difference was statistically insignificant. There was a moderate correlation between the manual noise measurements in soft tissue and air (P = 0.035) and a strong correlation between the manual and automated noise measurements (P < 0.001). The contrast resolution-based quantitative parameter, EdgeGradientSoft, correlated to the qualitative scores (P = 0.031). Validated VGA tools can be used for IQ audits; however, tailoring the image criteria and rating scale to the clinical practice is suggested. The use of contrast-based IQ metrics showed encouraging results, and further larger-scale studies are needed to explore their potential use in quality management.

8584 Quite High Thyroglobulin Levels in Thyroid Cancer in the Absence of Structural Lesion: Lab Interference or Microscopic Disease with Elevated Thyroglobulin?

Abstract Disclosure: M. Ahmad: None. A.P. Calimag: None. B. Arshad: None. J.T. Chaiban: None. Introduction: Thyroglobulin (Tg) is standard practice for follow-up of differentiated thyroid cancer (TC). Due to existence of thyroglobulin antibodies (Tg Ab) and Heterophile antibodies, Tg immunometric assays may be subject to interference. We present 2 challenging cases of TC with elevated Tg with absence of structural disease. Both tested positive for Epstein-Barr virus antibodies to viral capsid antigen (EBV anti VCA ab). DESCRIPTION: Case 1: 70 y.o Pt found to have calcified thyroid nodule on CT cervical spine. Thyroid ultrasound (U/S) revealed a left thyroid nodule- FNA being papillary thyroid cancer (PTC) with Bethesda 6. She had total thyroidectomy and central left lateral neck dissection. Pathology revealed PTC with 3/14 l.nodes +ve for cancer. Her Tg was 40.5 (1.2 - 35.0 ng/mL) 6 days after surgery, she received 100 mCi of radioactive Iodine (RAI). Subsequent WBS showed uptake in thyroid bed only. On follow ups, Tg started to rise persistently. PET CT unremarkable and her commensurate unstimulated Tg was 12. PET CT with interval development of a hypermetabolic focus in the postsurgical bed of thyroid and hypermetabolic cervical l.nodes. She received 100 mCi RAI + WBS that was negative for recurrence. Her Tg transiently improved but then was persistently elevated in the range 8.1-11.6 ng/ml on multiple checks. Repeat thyroid U/S did not show residual disease. Her Tg antibodies (Tg Ab) as well as Heterophile Antibody and HAMA were negative. Tg by LC-MS, was elevated in the range of 7.5 to 10.8 ng/ml. EBV anti VCA ab, IgG were positive. Case 2: 76 y.o lady initially diagnosed with toxic compressive goiter, found to have follicular thyroid cancer (FTC) after total thyroidectomy: a 5.5 cm FTC with minimal capsular/lymphatic invasion, no extrathyroidal extension, and negative margins. She received 103.7 mCi RAI after surgery. Subsequent WBS showed uptake only in the thyroid bed. Postoperatively Tg levels decreased to the range 1.6 to 5.1 ng/ml. Follow-up WBS a year later was unremarkable, and the Tg started to rise. CT scan of the chest and neck were negative. Tg by LC-MS was elevated in the range 1.6-9.2 ng/ml. PET CT was negative. Tg Ab as well as Heterophile Antibody and HAMA were negative. She tested positive for EBV anti VCA ab, IgG as well. Conclusion: Both case were elderly females- almost similar age, one with PTC and one with FTC- that had excellent structural response, but incomplete biochemical response. Measurement of Tg by LC-MS is recognized as an accurate method for Tg quantification. LC-MS assays are based on peptide quantitation after tryptic digestion which itself can have limitations due to existence of abnormal polymorphic tumor thyroglobulin (for which not much literature is available). The elevated Tg could be related to assay interference from EBV anti VCA ab (a cause or coincidence!?) or a possibility of persistent microscopic disease, hence longitudinal follow up of patients is important. Presentation: 6/2/2024

Differences in Cervical Spine Fractures in Patients Younger or Older Than 65 Years of Age: Implications for the Canadian C-Spine Rule.

There has been a distinction made in the 2001 Canadian C-Spine Rule regarding patients 65 and older and younger than 65 years of age as far as indications for cervical spine CT scanning. We sought to determine if there are differences in the symptoms, mechanisms of injury, fracture locations, and types that are still relevant in 2024. The institutional review board approved this retrospective study of cervical spine CT emergency department results from 2 hospitals in our health system after reviewing 5 years of data in patients experiencing trauma. In addition to the primary variable of age (younger than 65 years and 65 years and older), we looked at injury mechanism, fracture types, sites, symptoms, and operative or medical treatments. Because the demographics of our home site is different from most towns in the United States, we provide race/ethnicity data. Of 21,986 cervical spine CTs, 190/9455 (2.0%) participants 65 years of age and older and 199/12,531 (1.6%) participants younger than 65 years of age had fractures (total, 389/21,986, 1.8%). There were more cases of falls from standing (106, 55.8%) and falls from a height (46, 4.2%) in those 65 years and older and this mechanism was associated with a higher risk of C1 and C2 fractures (52, 27.4%; and 78, 41.1%, respectively). Among the C1 fractures, anterior and posterior arch fractures predominated (37, 19.5%). For C2 fractures, types 2 and 3 odontoid fractures (39, 20.5%; and 12, 6.3%) were more common in the older cohort. Motor vehicle collisions were more common in the younger cohort (89, 44.7%), and they were associated with more C5-C7 fractures (47, 23.6%; 60, 30.2%; and 66, 33.2%, respectively) including the facets (49, 24.6%), spinous processes (31, 15.6%), and transverse processes (52, 26.1%). Overall, the rates of instability, surgical intervention, and asymptomatic fractures were similar in the 2 age groups. Cervical spine fractures appear in about 1.8% of the CT scans performed in a busy emergency department environment. Fractures in the elderly occur more commonly due to falls, are located at C1 and C2, and may involve ligamentous injuries. Younger patients incur trauma more commonly due to motor vehicle collisions, and they are more likely to affect the posterior elements, especially C5-C7. The differences in trends for fractures in the 65 years of age and older and younger than 65 years of age groups have persisted since the Canadian C-Spine Rule 1996-1998 data were collected.

Digital anatomical features of morphological development in C2–C7 neurocentral synchondrosis in children aged 1–6 years: a retrospective study of CT images

BackgroundWith the continuous improvement of diagnosis and treatment technology for cervical spine-related diseases in children at home and abroad, the demand for exploring the developmental anatomy and function of children's cervical spine of different ages is increasing. So the aim of this study was to investigate the changes of anatomical indicators in neurocentral synchondrosis (NCS) of C2–C7 with age and the developmental characteristics of different vertebrae in children aged 1–6 years old.MethodA retrospective collection of 160 cases of normal cervical spine CT images of children aged 1–6 years old in provincial tertiary hospitals, according to the age group of 1-year-old into 6 groups. The original data of continuously scanned cervical spine tomography images were imported into Mimics16.0 software, under the two-dimensional image window, selected the measurement tool under the Measurements toolbar to measure and statistically analyzed the anatomical indicators such as cross diameter, sagittal diameter, height, perimeter and area of NCS in the C2–C7 segment of the cervical spine on the coronal plane and cross-section.ResultsThere was no significant difference in the anatomical indexes of cervical spine NCS in children compared with the left and right sides of the same vertebrae (P > 0.05). The same cervical spine generally had differences between the age groups of 1–4 years old and 5–6 years old (P < 0.05).The transverse diameter and circumference gradually decreased with age; the sagittal diameter and height showed a slight increase trend; there was a maximum area at 2 years of age. In different cervical vertebrae of the same age group, the NCS values of C3, C4, and C5 varied greatly, which showed that the ossification process of cervical cartilage was faster than that at the upper and lower ends. There were obvious differences between C2 and the rest of the cervical vertebral segments’ NCS ossification process. C7 was also very different from the rest of the cervical vertebrae segments, presumably more similar to the thoracic spine.ConclusionsThe anatomical indexes of C2–C7 NCS in children have obvious developmental regularities at different ages, and there are also regularities between cervical segments.

Is older age an appropriate criterion alone for ordering cervical spine CT after trauma.

Is older age an appropriate criterion alone for ordering cervical spine CT after trauma.

Nonquantitative CT scan Hounsfield unit as a determinant of cervical spine bone density.

Hounsfield unit (HU) values measured using CT have been increasingly recognized to stand as a reliable corollary to dual-energy x-ray absorptiometry (DEXA) scores in evaluating bone mineral density. The authors examined the correlation between cervical HU values and DEXA T- and Z-scores and determined novel cervical HU thresholds for determining bone quality classification. One hundred patients who underwent both cervical spine CT and DEXA, 85 patients who underwent both lumbar CT and DEXA, and 128 patients who underwent cervical and lumbar CT within 24 months at a single institution were included in this retrospective review. Two independent reviewers collected HU values from 3 cervical vertebral levels (C4-6) and 4 lumbar vertebral levels (L1-4), and the averaged values were used. Pearson's correlation coefficient analysis was performed to compare the association of cervical HU values with lumbar HU values and T- and Z-scores. The mean cervical HU values for each DEXA classification were calculated and compared. Receiver operating characteristic (ROC) curves were created to determine the threshold and its sensitivity and specificity for diagnosis. Cervical (C4-6) HU values and average, lumbar, and femoral T- and Z-scores had significant correlations (0.436 > r > 0.274, all p < 0.01). A strong positive correlation between cervical and lumbar HU values was found (r = 0.79, p < 0.01). The average cervical HU value of healthy patients was 361.2 (95% CI 337.1-385.3); of osteopenic patients, 312.1 (95% CI 290.3-333.8); and of osteoporotic patients, 288.4 (95% CI 262.6-314.3). There was a significant difference between the cervical HU values of healthy and osteopenic patients (p = 0.0134) and between those of healthy and osteoporotic patients (p = 0.0304). The cervical HU value of 340.98 was 73.5% specific and 57.9% sensitive for diagnosing osteopenia with an area under the ROC (AUROC) curve of 0.655. The cervical HU value of 326.5 was 88.9% specific and 63.2% sensitive for diagnosing osteoporosis with an AUROC curve of 0.749. This is the second large-scale study and first with a patient population from the United States to show that HU values obtained using cervical CT were significantly correlated with bone quality based on DEXA T- and Z-scores and to establish a cervical HU threshold for determining bone quality classification. These results show that cervical HU values can and should be used to predict poor bone quality in surgical cervical spine patients.

Early effects of unilateral biportal endoscopic posterior total laminectomy decompression in the treatment of cervical stenosis

To investigate the early efficacy and safety of unilateral biportal endoscopic posterior total laminectomy decompression in the treatment of cervical stenosis (CS). The clinical data of 28 patients with CS treated by unilateral biportal endoscopic posterior total laminectomy decompression from January 2021 to October 2022 in the Henan NO.3 Provincial People's Hospital were retrospectively analyzed. Of the patients, 16 were male and 12 were female, the mean age was (55.6±9.6) years. The CS occurred at C3-4 level in 1 cases, at C4-5 level in 3 cases, at C5-6 level in 16 cases and at C6-7 level in 8 cases. Each case was compared at the moment of pre-operation and final follow-up by the Japanese Orthopedic Association (JOA) score. The postoperative complications were recorded. The JOA improvement rate was computed at the final follow-up. As a result, all patients underwent successful surgery and were followed up for (11.6±4.7) months. The operation time was (43.0±5.3) min. Intraoperative blood loss (7.9±2.8) ml; Postoperative drainage volume (8.1±2.3) ml. The JOA score increased from 7.9±1.2 before surgery to 13.5±1.3 six months after surgery, and it was 13.7±1.2 at the last follow-up, the differences between postoperative and preoperative were both statistically significant (both P<0.001). No complications occurred, such as cerebrospinal fluid leakage, nerve injury and intraspinal hematoma. At the last follow-up, cervical spine X-ray or CT evaluation showed no instability in the operative segment. The overall curative effect was evaluated according to JOA score at the last follow-up: 16 cases got excellent outcome, 7 cases got good and 2 cases got medium outcome, with an excellent and good rate of 89.3% (25/28). This study shows that unilateral biportal endoscopic posterior total laminectomy decompression in the treatment of single-level cervical stenosis can achieve satisfactory efficacy, has no impact on spinal stability, and has a high safety.

Does ponticulus posticus affect vertebral artery diameter.

Ponticulus Posticus, atlantooccipital ligament ossification-induced anomaly, surrounds the vertebral artery and the first cervical nerve root. It is believed to wrap around the first cervical nerve root and the vertebral artery, causing compression. We hypothesized that it would also reduce the diameter of the vertebral artery. Between January 1, 2022, and December 31, 2022, cervical spine CT scans taken for any reason were retrospectively reviewed. The images of 1365 patients suitable for evaluation were evaluated by two expert radiologists in 3 dimensions. Among patients with PP, those who underwent cervical angiography were identified for vertebral artery diameter measurement. The average age of the 1365 individuals included in the study (732 males, 633 females) was 55.78 (± 18.85) with an age range of 1-96. Among this group, PP was detected in 288 individuals, resulting in a total prevalence of 21.1%. Right and left vertebral artery diameters were significantly lower in patients with complete PP compared to the absent group (p < 0,001, p < 0,001, respectively). Additionally, it was observed that width and height diameters and artery diameters were positively correlated in patients with Complete PP. Ponticulus posticus can cause vertebrobasilar insufficiency by reducing the diameter of the vertebral artery. Therefore, imaging and detailed evaluation of this region are important in symptomatic patients.

Tuina Inhibits Chondrocyte Apoptosis by Regulating the FAK/PI3K/Akt Pathway in Rabbits with IVDD.

Intervertebral disc degeneration (IVDD), a key contributor to degenerative spinal diseases such as cervical spondylosis, significantly influences the quality of life of patients. Tuina, historically employed in the clinical management of cervical spondylosis, has demonstrated positive therapeutic outcomes; however, the mechanism of Tuina remains unclear. This study examined the efficacy of Tuina in correcting the imbalanced structure of the cervical spine and its impact on apoptotic chondrocytes within the cervical disc. The underlying mechanisms were explored using a rabbit model of IVDD induced by dynamic and static imbalances. The IVDD rabbit model was established by restraining the head in a downward position for 12 weeks (Model group). In the Tuina1 group, treatment was performed on the posterior cervical trapezius muscle daily for 2 weeks, whereas in the Tuina2 group, treatment was performed on both the posterior cervical trapezius and anterior sternocleidomastoid muscles daily for 2 weeks. After treatment, X-ray, micro-computed tomography (CT), histological staining, qRT-PCR, and western blotting were used to evaluate the mechanism by which Tuina inhibits chondrocyte apoptosis. The results demonstrated that Tuina treatment inhibited chondrocyte apoptosis in cervical discs by adjusting the neck structure balance, and a more significant therapeutic effect was observed in the Tuina2 group. Lateral cervical spine X-ray and CT scans in rabbits revealed notable improvements in cervical spine curvature and vertebral structure in the treatment groups compared with those in the Model group. Hematoxylin and eosin staining and TUNEL staining further confirmed the positive impact of Tuina treatment on intervertebral disc tissue morphology and chondrocyte apoptosis. Additionally, western blotting and immunohistochemical analysis showed that Tuina treatment suppressed chondrocyte apoptosis by downregulating Bax and caspase-3 while upregulating Bcl-2. Western blotting results further indicated that Tuina could activate the FAK/PI3K/Akt signaling pathway by mediating integrin-β1. Tuina treatment inhibited chondrocyte apoptosis in cervical discs by activating the FAK/PI3K/Akt signaling pathway, providing convincing evidence to support Tuina treatment as a promising method for IVDD.

Evaluation of the diagnostic efficacy of computed tomography imaging in trauma patients

Aims: The objective of this study was to assess the efficacy of computed tomography imaging tests ordered for trauma patients in the emergency medicine service and to identify pathologies in the imaging. Methods: A retrospective evaluation was conducted on trauma patients who applied to our hospital's Emergency Medicine Department between 01 January 2023 and 01 October 2023 and underwent diagnostic computed tomography imaging (CT). Results: A total of 4193 CT scans were analysed in 3641 patients. Falls were the most common etiological cause (n=3451, 82.3%). Pathology was detected in 25.87% of CT orders. The most frequently used CT type was cranial CT (n=1687, 40.22%). The highest rate of pathology was found in scapula CT (75%), while the lowest rate was observed in cervical spine CT (13%). The most common pathology was detected in cranial CT (n=457). The highest rate of pathology was found in scapula CT (75%), while the lowest rate was observed in cervical spine CT (13%). Conclusion: The accessibility of relevant specialists to emergency physicians reduces the number of unnecessary CT imaging orders. In the emergency department, physicians should adhere to internationally accepted guidelines when ordering advanced imaging studies.

Feasibility of a novel type of complex anterior cervical fixation by using Mimics software

To investigate the feasibility of mimics software in analyzing a new type of complex anterior cervical fixation -- anterior transpedicular screw fixation+zero notch internal fixation. From January 2021 to September 2022, 50 normal pedestrians who underwent cervical spine CT scanning were selected for C1-C7 segment scanning, including 27 males and 23 females, aged from 25 to 65 years old with an average of (46.0 ± 9.0) years old. The dicom format is exported and engraved into the CD, and use the mimics software to perform 3D reconstruction of each segment. A simulated screw is placed on the image according to the critical value of zero notch screw (head and tail angle 44°, internal angle 29°). The position of zero notch screw in each segment is observed to determine the feasibility of anterior transpedicular screw fixation plus zero notch internal fixation. For the upper zero notch screws the three-dimensional images of the cervical spine across all 50 subjects within the C3-C7 segments demonstrated safe position, with no instances of intersection with ATPS. For the lower zero notch screw, in C3-C4 and C4-C5, 4 out of 50 subjects are in the safe position in the three-dimensional images of cervical vertebrae, and 46 cases could achieve secure screw placement when the maximum caudal angle is(32.3±1.9) ° and (36.1±2.2) °, respectively. In C5-C6 and C6-C7 segments, no lower zero notch screws intersected with ATPS, and all screws are in safe positions. Lower cervical anterior pedicle screw fixation plus zero notch internal fixation can achieve successful nail placement through the selected entry point and position.

Correction of pediatric cervical kyphosis: our experience and systematic-literature review.

Pediatric cervical kyphosis is a distinct entity with diverse etiology (congenital, syndromic, traumatic, metabolic or neoplastic). Surgical correctionin pediatric population is challenging due to their growing spine and low blood volume. To analyse their presentation, surgical techniques and outcome of pediatric cervical kyphosis and systematically review the pertinent literature. Retrospective study. 16 patients aged ≤ 18years who underwent correction for cervical kyphosis between 2009 and 2021. Nurick's grading, mJOA score and Global cobb's angle. Clinical parameters (Nurick grading and mJOA score) were noted from database on admission and on follow-up at 6months. Radiological parameters of assessment included Global Cobb's angle. The C2-C7 Cobb angle was the angle of C2 vertebra lower end plate and C7 vertebra lower end plate. For C1-2 kyphosis, anterior border of C1 and anterior border of C2 angle was taken. Radiographic parameters were studied on CT and radiographs of cervical spine to assess for stability, the degree of deformity correction and fusion status at 6months follow-up. 16 patients with mean age of 14.2 ± 3years (9 syndromic, 4 post-traumatic, 2 metabolic and 1 post-laminectomy). All underwent surgical correction, 6 underwent Antero-posterior spinal fusion, 6 underwent Posterior spinal fusion and 4 underwent Anterior spinal fusion. There was significant clinical improvement postoperatively with-Nurick grade (pre vs. post: 2.8 vs. 1.8, p = 0.004), mJOA score (pre vs. post: 11.3 vs. 14, p = 0.003). There was significant deformity correction of Cobb's angle from 40.7 ± 26.5° to 14.9 ± 10° (p = 0.001). Early complications included intraoperative hemodynamic instability (3) and wound complication (1). Mean follow-up was 76.9 ± 59.3months. Pediatric cervical kyphosis is a debilitating condition which are managed surgically. Approach has to be individualized to the pathology and good results can be achieved. Patients should be screened for syndromic association and followed-up regularly.

Diagnostic accuracy of an artificial intelligence algorithm versus radiologists for fracture detection on cervical spine CT.

To compare diagnostic accuracy of a deep learning artificial intelligence (AI) for cervical spine (C-spine) fracture detection on CT to attending radiologists and assess which undetected fractures were injuries in need of stabilising therapy (IST). This single-centre, retrospective diagnostic accuracy study included consecutive patients (age ≥18 years; 2007-2014) screened for C-spine fractures with CT. To validate ground truth, one radiologist and three neurosurgeons independently examined scans positive for fracture. Negative scans were followed up until 2022 through patient files and two radiologists reviewed negative scans that were flagged positive by AI. The neurosurgeons determined which fractures were ISTs. Diagnostic accuracy of AI and attending radiologists (index tests) were compared using McNemar. Of the 2368 scans (median age, 48, interquartile range 30-65; 1441 men) analysed, 221 (9.3%) scans contained C-spine fractures with 133 IST. AI detected 158/221 scans with fractures (sensitivity 71.5%, 95% CI 65.5-77.4%) and 2118/2147 scans without fractures (specificity 98.6%, 95% CI 98.2-99.1). In comparison, attending radiologists detected 195/221 scans with fractures (sensitivity 88.2%, 95% CI 84.0-92.5%, p < 0.001) and 2130/2147 scans without fracture (specificity 99.2%, 95% CI 98.8-99.6, p = 0.07). Of the fractures undetected by AI 30/63 were ISTs versus 4/26 for radiologists. AI detected 22/26 fractures undetected by the radiologists, including 3/4 undetected ISTs. Compared to attending radiologists, the artificial intelligence has a lower sensitivity and a higher miss rate of fractures in need of stabilising therapy; however, it detected most fractures undetected by the radiologists, including fractures in need of stabilising therapy. Clinical relevance statement The artificial intelligence algorithm missed more cervical spine fractures on CT than attending radiologists, but detected 84.6% of fractures undetected by radiologists, including fractures in need of stabilising therapy. The impact of artificial intelligence for cervical spine fracture detection on CT on fracture management is unknown. The algorithm detected less fractures than attending radiologists, but detected most fractures undetected by the radiologists including almost all in need of stabilising therapy. The artificial intelligence algorithm shows potential as a concurrent reader.

Utility of Magnetic Resonance Imaging for Ligamentous Injury in Cervical Spine Trauma: A 2-Year Consecutive Case Cohort

Magnetic resonance imaging (MRI) is increasingly used as an adjunct to spinal soft tissue evaluation in cervical spine (C-spine) trauma; however, the utility of this information remains controversial. In this consecutive observational study, we reviewed the utility of MRI in patients with C-spine trauma. We identified patients in real time over a 2-year period as they presented to our level 1 trauma center for C-spine computed tomography (CT) scan followed by MRI. MRI was obtained by the trauma team prior to the spine service consultation if (1) they were unable to clear the C-spine according to protocol or (2) if the on-call radiologist reported a concern for ligamentous integrity from the CT findings. Thirty-three patients, including 19 males (58%) and 14 females, with a mean age of 54 years, were referred to the spine service for concerns of ligamentous instability. The most common mechanisms of injury were motor vehicle accidents (n= 13) and falls (n= 11). MRI demonstrated ligamentous signal change identified by the radiologist as potentially unstable in all patients. Fifteen patients (45%) had multiple C-spine ligaments affected. The interspinous ligament was involved most frequently (28%), followed by the ligamentum flavum (21%) and supraspinous ligament (15%). All patients underwent dynamic upright C-spine X-rays that were interpreted by both the ordering surgeon and radiologist. There was no evidence of instability in any patient; concurrence between X-ray interpretation was 100%. The cervical collar was successfully removed in all cases. No patients required late surgical intervention, and there were no return visits to the emergency department of a spinal nature. MRI signal change within the ligaments of the C-spine should be interpreted with caution in the setting of trauma. To physicians less familiar with spinal biomechanics, MRI findings may be perceived in an inadvertently alarming manner. Bony alignment and, when indicated, dynamic upright X-rays remain the gold standard for evaluating the ligamentous integrity of the C-spine.

“Skip” corpectomy technique in multilevel cervical spondylotic myelopathy and ossified posterior longitudinal ligament: Outcomes with over 10-years follow-up

Objective Skip corpectomy is a surgical technique that includes C4 and C6 corpectomies and fusion via autografts and a cervical plate and is frequently performed in patients with CSM and OPLL. This study presents long-term clinical and radiological outcomes of 48 patients who underwent skip corpectomy with 10-year follow-up. Methods 48 patients who were diagnosed with CSM or OPLL were included. All patients underwent spinal canal decompression and fusion via skip corpectomy. Clinical assessment was performed using the JOA scoring system. The radiological assessment was performed using plain anteroposterior, lateral, and flexion-extension cervical spine radiographs; cervical spine MR imaging; and cervical spine CT scans. The spinal canal size, spinal cord occupation ratio, cervical lordosis, and T2 signal changes were evaluated preoperatively, and postoperatively. Results The mean follow-up period was 14.6 years (13–20 years). Preoperatively, the JOA score was 11.06 ± 3.09. The mean cervical lordosis was 2.08°±11.74 and the average SCOR was 62.1 ± 14.22. There was a significant improvement in SCOR in the early postoperative period. The average cervical lordosis increased to 13.81 ± 2.51 in the 2nd month and minimal loss of cervical lordosis was observed on the 10th year in two patients. Fusion was achieved in all patients, regardless of the graft type. None of the patients had implant failure and graft or hardware-related complications at the 10th-year follow-up. Conclusion Skip corpectomy provides efficient decompression of the spinal cord and provides adequate sagittal alignment and fusion in patients with CSM and OPLL. Long-term radiological and clinical outcomes of the technique are favorable.

Measurement of anatomical parameters of anterior transpedicular root screw intervertebral fusion system of cervical spine

ObjectiveThis study aims to investigate the feasibility of the anterior transpedicular root screw (ATPRS) intervertebral fusion system for the cervical spine and provide a basis for the design of the ATPRS intervertebral fusion system.MethodsA total of 60 healthy adult cervical spine CT images examined from our hospital were selected, including 30 males and 30 females, with an average age of 39.6 ± 4.8 years. The image data was imported into Mimics 21.0 software in DICOM format for 3D model reconstruction. Simulated screw insertion was performed on both sides of the midline of the intervertebral space. The entry point (P1) was determined when the upper and lower screw paths did not overlap. When the screw was tangent to the medial edge of the Luschka joint, the insertion point was determined as the entry point (P2). Measurements were taken and recorded for the following parameters: distance from the screw entry point to the midline of the intervertebral space (DPM), the simulated screw length, inclination angle, cranial/caudal tilted angle, the anterior–posterior (AP) and mediolateral (ML) diameters of the cervical intervertebral space, the heights of the anterior, middle, and posterior edges of the cervical intervertebral space, and the curvature diameter of the lower end plate of the cervical vertebral body. Statistical analysis was performed on the measurement results.ResultsThe screw entry area (P1P2) showed an increasing trend from C3-C7 in both male (2.92–6.08 mm) and female (2.32–5.12 mm) groups. There were statistical differences between men and women at the same level (P < 0.05). The average screw length of men and women was greater than 20 mm, and the upper and lower screw lengths showed an increasing trend from C3 to C7. In the area where screws could be inserted, the range of screw inclination was as follows: male group upper screw (47.73–66.76°), lower screw (48.05–65.35°); female group upper screw (49.15–65.66°) and lower screw (49.42–63.29°); The range of cranial/caudal tilted angle of the screw was as follows: male group upper screw (32.06–39.56°), lower screw (29.12–36.95°); female group upper screw (30.97–38.92°) and lower screw (27.29–37.20°). The anterior–posterior diameter and mediolateral diameter of the cervical intervertebral space showed an increasing trend from C3 to C7 in both male and female groups. The middle height (MH) of the cervical intervertebral space was greater than the anterior edge height (AH) and posterior edge height (PD), with statistical differences (P < 0.05). ConclusionsThrough the study of CT images of the cervical spine, it was determined that the ATPRS intervertebral fusion system has a feasible area for screw insertion in the cervical intervertebral space.

Establishing national clinical diagnostic reference levels and achievable doses for CT examinations in Brazil: A prospective study

PurposeDiagnostic reference levels (DRL) and achievable doses (AD) are important tools for radiation dose optimization. Therefore, a prospective study was performed which aimed to establish a multi-parametric, clinical indication based – DRL(DRLCI) and clinical indication – AD (ADCI) for adult CT in Brazil. MethodsThe prospective study included 4787 patients (50 ± 18 years old; male:female 2041:2746) at 13 Brazilian sites that have been submitted to head, paranasal sinus, cervical spine, chest, or abdomen-pelvis CT between January and October 2021 for 13 clinical indications. The sites provided the following information: patient age, gender, weight, height, body mass index[BMI], clinical indications, scanner information(vendor, model, detector configuration), scan parameters (number of scan phases, kV, mA, pitch) and dose-related quantities (CT dose index volume- CTDIvol, dose length product- DLP). Median(AD) and 75th(DRL) percentile CTDIvol and DLP values were estimated for each body region and clinical indications. Non-normal data were analyzed with the Kruskal-Wallis test. ResultsIn majority of Brazilian sites, body region and clinical indications based DRLs were at or lower than the corresponding DRLs in the US and higher than Europe. Although radiation doses varied significantly for patients in different body mass index groups (p < 0.001), within each body region, there were no differences in radiation doses for different clinical indications (p > 0.1). Radiation doses for 7/13 clinical indications were higher using iterative reconstruction technique than for the filtered back projection. ConclusionsThere was substantial variation in Brazil DRLCI across different institutions with higher doses compared to the European standards. There was also a lack of clinical indication-based protocol and dose optimization based on different clinical indications for the same body region.

Early efficacy and safety of mini open (air/water medium) endoscopy assisted anterior cervical discectomy and fusion in the treatment of cervical spondylotic myelopathy

Objective: To investigate the efficacy and safety of mini open (air/water medium) endoscopy assisted anterior cervical discectomy and fusion (MOEA-ACDF) for the treatment of cervical spondylotic myelopathy (CSM). Methods: A follow-up study. The clinical data of 30 patients with CSM treated by MOEA-ACDF from January to December in 2021 in the Henan NO.3 Provincial People's Hospital were retrospectively analyzed. Of the patients, 20 were male and 10 were female, the mean age was (49.8±9.3) years (ranged 28-70 years). The CSM occurred at C3-4 level in 2 cases, at C4-5 level in 3 cases, at C5-6 level in 22 cases and at C6-7 level in 3 cases. Each case was compared at the moment of pre-operation and final follow-up by the Japanese Orthopedic Association (JOA) score, C2-7 Cobb angle, and anterior column height of surgical segment. The postoperative complications were recorded. Prevertebral soft tissue edema and hydrops were assessed. The fusion rate was evaluated. The JOA improvement rate was computed at the final follow-up. Results: All the operations were successfully completed and all the patients received follow-up for (12.7±2.7) months (ranged 9-20 months). The mean operation time was (85.3±11.0) min (ranged 65-110 min). The postoperative drainage volume was (16.7±7.4) ml (ranged 5-35 ml). The JOA score and the C2-7 Cobb angle both improved at the final follow-up when compared with those before the operation (15.3±1.3 vs 12.2±2.3, 15.5°±6.1° vs 12.3°±6.0°, both P<0.001). The anterior column height of surgical segment at the final follow-up was (35.6±2.5) mm, and it was higher than that before the operation [(34.1±2.4) mm](P<0.001). No postoperative complications such as dysphagia, hoarseness, cerebrospinal fluid leakage, nerve injury, hematoma occurred. Postoperative review of cervical MRI revealed 3 cases of prevertebral soft tissue edema and hydrops without obvious symptoms. At the final follow-up, cervical spine X-ray or CT showed that all fusion segments met the criteria for osseous fusion, and the fusion rate was 100%. No complications such as neurological aggravation, internal fixation failure, fusion cage sinking, and adjacent segment degeneration was recorded at the final follow-up. At the final follow-up, the comprehensive efficacy evaluated by JOA improvement rate indicated the excellent and good rate was 90.0%(27/30): 19 cases got an excellent outcome, 8 cases got good and 3 cases got medium outcome. Conclusion: MOEA-ACDF combines the endoscopic system with ACDF technology in the treatment of CSM can achieve satisfactory clinical efficacy with high safety, and effectively restore the cervical intervertebral height and physiological curvature.

The RSNA Cervical Spine Fracture CT Dataset.

This dataset is composed of cervical spine CT images with annotations related to fractures; it is available at https://www.kaggle.com/competitions/rsna-2022-cervical-spine-fracture-detection/.

A Case of Hematomyelia in a Teenager with Behcet’s Disease due to both Warfarin and Intramedullary Cavernous Malformation (P6-5.029)

<h3>Objective:</h3> Highlight the importance of recognizing bleeding of intramedullary cavernous malformation or cavernoma as a cause of spinal cord lesion. <h3>Background:</h3> Intramedullary spinal cord hemorrhage, or hematomyelia, is a rare cause of acute myelopathy. Vascular malformations, anticoagulation therapy, and other bleeding diathesis are the most common causes. Cavernoma is a vascular malformation made of closely clustered, enlarged capillaries with a single layer of endothelium and without the elements of normal vascular structure or normal intervening brain parenchyma. Although they can bleed, cavernomas have a relatively benign prognosis. Hemorrhage of an intramedullary cavernoma during anticoagulation with warfarin was not previously reported. <h3>Design/Methods:</h3> Nineteen-year-old man with Behçet’s disease taking warfarin for intraventricular thrombus and multiple pulmonary emboli complained of acute back pain, unilateral leg weakness, and urinary retention. He had no personal or family history of vascular malformations. Examination was remarkable for paraplegia, a sensory level at T10, lower limb hyporeflexia and Babinski reflex bilaterally. INR was supratherapeutic at 3.6. CT of head, cervical and thoracic spine was unremarkable. <h3>Results:</h3> MRI of spine showed an enhancing intramedullary lesion at T8–T9, 3.8 cm in length, with surrounding edema. The mixed T1 hyperintensity and T2 hypointensity was suggestive of hemorrhage caused by a cavernoma. Warfarin was reversed with prothrombin complex concentrate. He was not a candidate for neurosurgical intervention. At discharge, the patient had not regained any motor or sensory function. <h3>Conclusions:</h3> This case highlights the need to suspect hematomyelia as a cause of acute myelopathy in a patient taking anticoagulation. While anticoagulation is not contraindicated in patients with known cavernoma, there should be a low threshold for considering the presence of a bleeding intramedullary cavernoma in a patient with acute myelopathy. <b>Disclosure:</b> Dr. Sacks has nothing to disclose. Dr. Treidler has nothing to disclose.