Lateral Lumbar Spine Radiographs Research Articles

Deep learning-based detection of lumbar spinal canal stenosis using convolutional neural networks

BACKGROUND CONTEXTLumbar spinal canal stenosis (LSCS) is the most common spinal degenerative disorder in elderly people and usually first seen by primary care physicians or orthopedic surgeons who are not spine surgery specialists. Magnetic resonance imaging (MRI) is useful in the diagnosis of LSCS, but the equipment is often not available or difficult to read. LSCS patients with progressive neurologic deficits have difficulty with recovery if surgical treatment is delayed. So, early diagnosis and determination of appropriate surgical indications are crucial in the treatment of LSCS. Convolutional neural networks (CNNs), a type of deep learning, offers significant advantages for image recognition and classification, and work well with radiographs, which can be easily taken at any facility. PURPOSEOur purpose was to develop an algorithm to diagnose the presence or absence of LSCS requiring surgery from plain radiographs using CNNs. STUDY DESIGNRetrospective analysis of consecutive, nonrandomized series of patients at a single institution. PATIENT SAMPLEData of 150 patients who underwent surgery for LSCS, including degenerative spondylolisthesis, at a single institution from January 2022 to August 2022, were collected. Additionally, 25 patients who underwent surgery at 2 other hospitals were included for extra external validation. OUTCOME MEASURESIn annotation 1, the area under the curve (AUC) computed from the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were calculated. In annotation 2, correlation coefficients were used. METHODSFour intervertebral levels from L1/2 to L4/5 were extracted as region of interest from lateral plain lumbar spine radiographs totaling 600 images were obtained. Based on the date of surgery, 500 images derived from the first 125 cases were used for internal validation, and 100 images from the subsequent 25 cases used for external validation. Additionally, 100 images from other hospitals were used for extra external validation. In annotation 1, binary classification of operative and nonoperative levels was used, and in annotation 2, the spinal canal area measured on axial MRI was labeled as the output layer. For internal validation, the 500 images were divided into each 5 dataset on per-patient basis and 5-fold cross-validation was performed. Five trained models were registered in the external validation prediction performance. Grad-CAM was used to visualize area with the high features extracted by CNNs. RESULTSIn internal validation, the AUC and accuracy for annotation 1 ranged between 0.85–0.89 and 79–83%, respectively, and the correlation coefficients for annotation 2 ranged between 0.53 and 0.64 (all p<.01). In external validation, the AUC and accuracy for annotation 1 were 0.90 and 82%, respectively, and the correlation coefficient for annotation 2 was 0.69, using 5 trained CNN models. In the extra external validation, the AUC and accuracy for annotation 1 were 0.89 and 84%, respectively, and the correlation coefficient for annotation 2 was 0.56. Grad-CAM showed high feature density in the intervertebral joints and posterior intervertebral discs. CONCLUSIONSThis technology automatically detects LSCS from plain lumbar spine radiographs, making it possible for medical facilities without MRI or nonspecialists to diagnose LSCS, suggesting the possibility of eliminating delays in the diagnosis and treatment of LSCS that require early treatment.

Radiographic characteristics-based classification system for percutaneous endoscopic lumbar discectomy surgical approach selection in patients with L5-S1 disc herniation: a hierarchical clustering analysis.

No classification system exists for aiding the selection of surgical approaches in L5-S1 disc herniation when undergoing percutaneous endoscopic lumbar discectomy (PELD). We aimed to identify radiographic subtypes to aid the selection of percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) in patients with L5-S1 disc herniation via unsupervised hierarchical clustering analysis. In this retrospective case-control study, we gathered 296 anteroposterior and lateral lumbar spine radiographs (dataset 1) from Tianjin Hospital between January 2016 and October 2021 for clustering analyses. Additionally, we analyzed 111 patients who underwent PEID or PETD for L5-S1 disc herniation at Tianjin Hospital from January 2016 to August 2022. We included patients with radicular leg pain or back pain associated with intra-canal disc herniation who failed in conservative treatments over 6 weeks. First, pair-wise Spearman correlation coefficients were calculated among plain radiographic metrics in dataset 1 to reveal the association among these radiographic metrics. Second, hierarchical clustering analysis was conducted to unsupervised cluster the plain films into several subtypes. Last, for each radiographic subtype, the intraoperative blood loss (IBL), operation time (OT), total operating room time (TORT) along with visual analogue scale (VAS) and Oswestry Disability Index (ODI) were compared between patients underwent PETD or PEID with age as covariates. This study yielded 3 main findings: (I) iliac height (IH) was negatively correlated with intervertebral foramen width (IFW), intervertebral foramen height (IFH), and intertransverse height (ITH) (R=-0.50, -0.42, and -0.46, all P<0.001), ITH was positively correlated with IFW and IFH (R=0.40 and 0.53, all P<0.001); (II) 2 lumbosacral radiographic subtypes were identified via hierarchical clustering analysis; (III) relative to subtype 1, the patients identified as subtype 2 exhibited lesser IBL, shorter OT, and shorter TORT following PETD (t=2.92, P=0.006; t=2.65, P=0.012; t=3.17, P=0.003). The morphology pattern of the lumbosacral region affect the ease of different PELD procedures when performing percutaneous discectomy at the segment of L5-S1. Without considering the type of disc herniation, this classification system might aid spine surgeons in the selection of an appropriate surgical approach.

The effect of breast shielding outside the field of view on breast entrance surface dose in axial X-ray examinations: a phantom study.

The purpose of this study was to evaluate the effect of outside-field-of-view (FOV) lead shielding on the entrance surface dose (ESD) of the breast on an anthropomorphic X-ray phantom for a variety of axial skeleton X-ray examinations. Using an anthropomorphic phantom and radiation dosimeter, the ESD of the breast was measured with and without outside-FOV shielding in anterior-posterior (AP) abdomen, AP cervical spine, occipitomental 30° (OM30) facial bones, AP lumbar spine, and lateral lumbar spine radiography. The effect of several exposure parameters, including a low milliampere-seconds technique, grid use, automatic exposure control use, wraparound lead (WAL) use, trolley use, and X-ray table use, on the ESD of the breast with and without outside-FOV shielding was investigated. The mean ESD (μSv) and standard deviation for each radiographic protocol were calculated. A one-tailed Student's t-test was carried out to evaluate whether ESD to the breast was reduced with the use of outside-FOV shielding. A total of 920 breast ESD measurements were recorded across the different protocol parameters. The largest decrease in mean ESD of the breast with outside-FOV shielding was 0.002 μSv (P = 0.084), recorded in the AP abdomen on the table with a grid, OM30 on the table with a grid, OM30 standard protocol on the trolley, and OM30 on the trolley with WAL protocols. This decrease was found to be statistically non-significant. This study found no significant decrease in the ESD of the breast with the use of outside-FOV shielding for the AP abdomen, AP cervical spine, OM30 facial bones, AP lumbar spine, or lateral lumbar spine radiography across a range of protocols.

A Prospective Observational Study on Lumbar Spinal Canal Diameter, Vertebral Body Width and Pedicle Width and Height Measured in Plain X-Rays of Lumbar Spine in Normal Nepalese Adults

Introduction: Determining the lumbar spinal canal diameter and the horizontal and vertical diameter of lumbar pedicles by using plain x-ray in different age groups, sex and ethnic groups in adult Nepalese population will simplify the transpedicular procedures in our country and can aid in making early diagnosis in persons who have lower diameters of lumbar spinal canal. Methods: The present study was conducted on 195 adult lumbar spine X-rays in the Department of Orthopedics of Civil Service Hospital. antero-posterior and lateral radiographs of lumbar spine were taken and the measurements were made for the coronal bony canal, vertebral body width and pedicle width using Vernier calipers and recorded values to the nearest tenth of a millimeter. Results: This study included 195 patients, the age range was 18 to 45 years, out of them 111 (56.9%) were male and 84 (43.1%) were female. Mean values for interpedicular distance, coronal and vertebral body width was increasing from L1 to L5 at each vertebral level. The observations showed that there is always an increase in width of lumbar pedicles proceeding from L1 to L5 levels and the width being maximum at L5 level. The observations also showed that the height of lumbar pedicles decreases as we move from L3 to L5 levels. The values obtained were compared with previous literatures, which showed similar pattern with the values of Indian population studies as compared to western population may be due to the fact that various socioeconomic, cultural and structural similarities between Nepalese and Indian population. Conclusion: Figures obtained for this population differ from other previous reports and appears to be subject to individual and racial variations. These lumbar canal and pedicle diameter of our study are similar to the measurement in the Indian population; the radiological criteria of spinal canal stenosis could be identical between these two populations.

Change in prevalence of vertebral fractures over two decades: a Japanese medical examination-based study.

Although remarkable progress has been made in osteoporosis treatment over the last two decades, no study has reported the change in the prevalence of vertebral fractures (VFs) during this time. This study aimed to compare the prevalence and pattern of VFs at three time points from 1997 to 2019 in a Japanese medical examination-based study. The participants of this study were inhabitants of a typical Japanese mountain village who participated in these surveys at three time points: 1997 (group A), 2009 or 2011 (group B), and 2019 (group C). The age- and sex-adjusted groups were defined as groups A', B', and C', respectively (39 men and 85 women; mean age 73.6-74.0years old). The type and extent of deformities of the prevalent fractures from T4 to L4 on the lateral thoracic and lumbar spine radiographs were semiquantitatively evaluated. The prevalence of VFs has significantly decreased over the past two decades. In group A, the percentages of thoracic level, biconcave type, and severe deformity of VFs were significantly higher than expected. The bone mineral density of the participants increased significantly over time. The treatment rate for osteoporosis in participants with osteoporosis has improved over the past two decades. This study demonstrated that the prevalence of VFs has decreased, and the pattern of VFs has changed over the last two decades in a typical Japanese mountain village due to multifactorial improvements in skeletal fragility, including improvement in osteoporosis treatment rate.

Association of abdominal aortic calcification with longitudinal changes in left ventricular mass of patients on hemodialysis and its prognostic value.

Vascular calcification (VC) and myocardial hypertrophy are very common in patients on hemodialysis (HD). Previous studies have only assessed the cross-sectional associations of VC with left ventricular mass (LVM) and the predictive value of individual factors. The present study investigated the relationship between abdominal aortic calcification (AAC) and LVM increment over time, and the combined effect of these factors on the outcomes of HD patients. 104 HD patients were enrolled. AAC scores were evaluated on left lateral lumbar spine radiographs. Echocardiography was performed to calculate the LVM changes during a 2-year period. At baseline, 91 patients (87.5%) had varying degrees of AAC (median score 6.0, range 2.0-11.0). After 2 years, the mean LVM change was 7.49g (range -5.03-26.00 g), and 68 patients (65%) had an increased LVM. Patients with higher baseline AAC scores had significantly larger LVM and LVM index increments. Patients with increased LVM had significantly higher baseline AAC scores and hemoglobin, serum phosphate, and hypersensitive C-reactive protein levels. Multiple stepwise linear regression demonstrated that the baseline AAC was the only independent predictor of increased LVM after 2years. 28 patients (26.9%) died in the subsequent 5 years. Patients with lower baseline AAC scores had a significantly higher cumulative survival rate than those with higher AAC scores. However, the LVM change (either alone or in combination with the AAC score) had no significant effect on survival. In conclusion, AAC is an independent predictor of LVM increase over time in HD patients. Prevention and treatment of VC may be a promising intervention target to improve left ventricular remodeling and outcomes in HD patients.

Long-term Radiological and Clinical Outcome after Lumbar Spinal Fusion Surgery in Patients with Degenerative Spondylolisthesis: A Prospective 6-Year Follow-up Study.

ObjectiveTo assess which radiological alignment parameters are associated with a satisfactory long‐term clinical outcome after performing lumbar spinal fusion for treating degenerative spondylolisthesis.MethodsThis single‐center prospective study assessed the relation between radiological alignment parameters measured on standing lateral lumbar spine radiographs and the patient‐reported outcome using four different questionnaires (COMI, EQ‐5D, ODI and VAS) as primary outcome measures (level of evidence: II). The following spinopelvic alignment parameters were used: gliding angle, sacral inclination, anterior displacement, sagittal rotation, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence. Furthermore, the length of stay and perioperative complications were documented. Only cases from 2013 to 2015 of low‐grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) were considered. The patients underwent open posterior lumbar fusion surgery by pedicle screw instrumentation and cage insertion. The operative technique was either a posterior lumbar interbody fusion (PLIF) or a transforaminal lumbar interbody fusion (TLIF) performed by three different senior orthopedic surgeons. Exclusion criteria were spine fractures, minimally invasive techniques, underlying malignant diseases or acute infections, previous or multisegmental spine surgery as well as preoperative neurologic impairment. Of 89 initially contacted patients, 17 patients were included for data analysis (11 males, six females).ResultsThe data of 17 patients after mono‐ or bisegmental lumbar fusion surgery to treat low‐grade lumbar spondylolisthesis and with a follow‐up time of least 72 months were analyzed. The mean age was 66.7 ± 11.3 years. In terms of complications two dural tears and one intraoperative bleeding occurred. The average body mass index (BMI) was 27.6 ± 4.4 kg/m2 and the average inpatient length of stay was 12.9 ± 3.8 days (range: 8–21). The long‐term clinical outcome correlated significantly with the change of the pelvic tilt (r s = −0.515, P < 0.05) and the sagittal rotation (r s = −0.545, P < 0.05). The sacral slope was significantly associated with the sacral inclination (r s = 0.637, P < 0.01) and the pelvic incidence (r s = 0.500, P < 0.05). In addition, the pelvic incidence showed a significant correlation with the pelvic tilt (r s = 0.709, P < 0.01). The change of the different clinical scores over time also correlated significantly between the different questionnaires.ConclusionsThe surgical modification of the pelvic tilt and the sagittal rotation are the two radiological alignment parameters that can most accurately predict the long‐term clinical outcome after lumbar interbody fusion surgery.

Correlation between the Severity of the Lumbar Degenerative Disease and Sagittal Spinopelvic Alignment.

Objective To evaluate the impact of the severity of lumbar degenerative disease (LDD) on sagittal spinopelvic alignment. Methods In total, 130 patients (mean age: 57 years; 75% female) with LDD-associated low-back pain were prospectively included. The severity of the LDD was defined by the following findings on anteroposterior and lateral lumbar spine radiographs: osteophytosis; loss of of height of the intervertebral disc; terminal vertebral plate sclerosis; number of affected segments; deformities; and objective instability. The disease was classified as follows: grade 0–absence of signs of LDD in the lumbar spine; grade I – signs of LDD in up to two segments; grade II – three or more segments involved; grade III – association with scoliosis, spondylolisthesis, or laterolisthesis. Spinopelvic radiographic parameters, including pelvic incidence (PI), lumbar lordosis (LL), discrepancy between the PI and LL (PI-LL), pelvic tilt (PT), and sagittal vertical axis (SVA), were analyzed according to the LDD grades. Results The radiographic parameters differed according to the LDD grades; grade-III patients presented higher SVA ( p = 0.001) and PT ( p = 0.0005) values, denoting greater anterior inclination of the trunk and pelvic retroversion when compared to grade-0 andgrade-I subjects. In addition, grade-III patients had higher PI-LL values, which indicates loss of PI-related lordosis, than grade-I subjects ( p = 0.04). Conclusion Patients with more severe LDD tend to present greater spinopelvic sagittal misalignment compared to patients with a milder disease.

P011 Radiological pattern in juvenile onset Spondylarthritis differ from the adult onset spondylarthritis

Abstract Background Spondylarthritis (SpA) is a chronic inflammatory disease of the axial spine that may be affect the peripheral joints. SpA occurs predominantly in adulthood: Adult onset Ankylosing Spondylitis (AoAS). However, it can occur earlier in childhood (≤16 years old), also termed as juvenile onset Ankylosing Spondylitis (JoAS). In the second group, delay in diagnosis may lead to further structural damage. The aim of our study was to compare the differences in radiographic features between JoAS and AoAS. Methods We conducted a retrospective study in our department of rheumatology of Kassab Institute of orthopedics, including patients diagnosed with SpA according to the ASAS criteria (≥17 years at symptom onset) or to the ILAR criteria (≤16 years at symptom onset). Were not included AS patients whose disease onset was ≥ 45 years. Sociodemographic as well as disease characteristics were recorded. The lateral cervical and lumbar spine radiographs were used to assess structural damage by the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) and The Bath Ankylosing Radiologic Index (BASRI). The total score of mSASSS and BASRI vary between 0–72 and 0–16 respectively with higher scores indicating evolved structural damage. Radiographic features were then compared between AoAS and JoAS. The level of significance was fixed for a P &amp;lt; 0.05. Results Of 140 AS patients, 40 had JoAS and 100 had AoAS. The average age at disease onset was 12.4 ± 3 [8–16] and 25.4 ± 10.1 [17–42] respectively (P &amp;lt; 0.001). The disease duration was 10.6 years [1–44]. The average current age was 25.3 ± 10.2 [9–59] and 32.5 ± 7.5 [18–46] (P &amp;lt; 0.001). The JoAS group showed a more frequent onset with peripheral joint involvement than the AoAS group (80% vs 50%,P = 0.001). Similarly, hip involvement was more frequent among JoAS patients (57.7% vs 25%, P = 0.000). There was no significant differences between the two groups regarding the mean mSASSS score, the total BASRI score and the BASRI score for the sacroiliac joints (P = 0.9, P = 0.49, P = 0.06 respectively). Similarly, there was no differences in the mean spine BASRI score between the two groups, although there was a trend of higher scores among AoAS patients (3.2 vs 3.9, P = 0.15 respectively). On the contrary, JoAS patients had a significantly higher BASRI score for the hip than AoAS patients (2.4 vs 1.3, P = 0.000). Conclusion Our study showed that JoAS patients are more likely to suffer from early hip damage than AoAS patients. The spine BASRI was similar between the two groups despite the shorter disease duration in the juvenile group. This highlights the need for screening for hip involvement and for a closer monitoring in this subset of children.

123. A novel comprehensive model to describe vertebral body motion following interbody fusion

<h3>BACKGROUND CONTEXT</h3> Subsidence of interbody fusion spinal implants occurs in up to 30% of interbody fusions. Previous methods to quantify subsidence of interbody implants have focused on quantifying changes in disc height or magnitude of erosion of the implant into the vertebral body. These studies focus on the description of subsidence in a cranial-caudal direction. A comprehensive description of subsidence should report cranial-caudal shift, anterior-posterior shift and angular shift of one vertebra with respect to its adjacent vertebra. <h3>PURPOSE</h3> The purpose of the study is to develop and validate a novel method that describes the motion of one vertebral body with respect to its adjacent vertebral body in terms of translation and rotation. We hypothesize this method would have satisfactory interobserver reliability. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of lumbar spine radiographs at a tertiary academic center. <h3>PATIENT SAMPLE</h3> Patients undergoing anterior lumbar interbody fusion at L4-5 or L5-S1 with at least one year radiographic follow-up. <h3>OUTCOME MEASURES</h3> The amount of cranial-caudal shift, anterior-posterior shift and angular shift on preoperative, postoperative, and 1-year postoperative radiographs was recorded according to the novel measurement technique. <h3>Methods</h3> A retrospective review of lateral lumbar spine radiographs was performed by seven physicians (3 residents, 2 fellows, and 2 attendings). The review included radiographic analysis of 10 patients who underwent L4-5 or L5-S1 anterior interbody fusion. Preoperative, postoperative (day 1), and 12-month postoperative radiographs were analyzed. Each vertebra was defined in two-dimensional space by 4 peripheral points at the corners of the vertebral body and a centroid. The upper vertebra was designated as a reference plane by which the motion of the lower vertebra was measured. We measured the movement of the lower vertebra in terms of anterior-posterior translation, cranial caudal translation, and angular change immediately following lumbar interbody fusion and 12 months postoperatively to detect translational and rotational subsidence. Inter-observer reliability was measured using SPSS software. <h3>Results</h3> A model was successfully developed to describe the angular and translational change of one vertebral body with respect to its adjacent segment. The intraclass correlation coefficients of anterior-posterior, cranial-caudal, and angular change were calculated to be 0.75, 0.90, and 0.86, respectively. The average standard deviations of translational and rotational change were 3.3% and 2°, respectively. <h3>Conclusions</h3> A model to comprehensively describe vertebral body motion as a method of characterizing subsidence was successfully developed. The model had good to excellent reliability. Further refinement of the protocol may yield improved intraclass correlation coefficients. This method of measuring vertebral body motion is applicable to measuring modes of failure beyond subsidence such as fracture or delayed fusion. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

MO784ABDOMINAL AORTIC CALCIFICATIONS AND ARTERIOVENOUS FISTULA CLINICAL OUTCOMES ON HAEMODIALYSIS PATIENTS

Abstract Background and Aims Vascular calcification has now been recognized as a major problem in dialysis patients because of its strong influence on the prognosis of this population. Several reports have shown the strong relationship between vascular calcification and clinical outcomes including cardiovascular events and arteriovenous fistula (AVF)survival. The aim of this study is to evaluate the severity of vascular calcifications in our hemodialysis patients and to determine its impact on the AVF survival. Method It is a transversal descriptive and analytical study including chronic haemodialysis patients in our unit of the nephrology department. A lateral lumbar spine radiograph was taken: the aortic arch calcification(ACC) score (VCS) was calculated according to the score validated by Kauppila and Schousboe. The overall VCS ranged from 0 to 24. Results Our study included 55 patients divided into 31 men and 24 women with a sex ratio of 1.29. The mean age was 49.54 ± 12.66 years. The mean duration in HD was 96.16± 73 months. 76.8% of the patients have hypertension, 26.8% are diabetic and 14.3% are smokers. AVF failure was noted in 34 patients (60.7%). We divided our population in 3 groups: G1:23 patients with a low VCS (41.1%), G2: 15 patients with a moderate VCS (26.8%) and G3: 17 patients with a severe VCS (30.4%). Patients in G2 and G3 were more frequently diabetics (p=0.05): over 50% of patients in G3 were diabetic and the mean duration in HD was longer: 133 months in G3, 102 months in G2 and 74 months in G1 with a significant difference p=0.03. We noted that AVF failure was more frequent in patients in G2 and G3 (65.7%) patients) versus patients in G1 (39.13%) with a significant difference (p=0.01) Conclusion vascular access dysfunction is one of the leading causes of morbidity and mortality in haemodialysis patients We have demonstrated throw this study the relation between the presence of higher AAC grade and the poor survival of AVF in our patients. So, an identification of these ACC by a simple lateral lumbar spine radiograph would allow the clinician to implement more rigorous and planned monitoring for such AVFs.

Effect of different phantom positions in lateral lumbar spine radiography on effective dose and absorbed dose to selected organs

This study aimed to investigate the different positioning of the patient in left and right lateral position during lumbar spine radiography and its effects on effective dose and absorbed dose for selected organs. The study was performed on a Siemens Multix/Vertix X-ray unit using Agfa's computer radiography system. Two anthropomorphic phantoms (PBU 60 and RS 113T) were imaged in both lateral projections with a tube voltage from 79 kV to 90 kV. The dose was measured with a DAP meter placed under the collimator of the X-ray unit. The effective dose and absorbed dose for selected organs were calculated using the Monte Carlo simulation programme PCXMC 2.0. Based on Monte Carlo simulation calculations, the results of effective dose on a PBU 60 phantom showed a decrease of 15.2%, while the decrease in effective dose on a RS 113T phantom was 14.2% in favour of the right lateral projection. An absorbed organ dose to selected organs showed a significant dose reduction for lymph nodes, pancreas, small intestine, spleen, and stomach in favour of this projection. Based on the results, we can conclude that right lateral projection should be the method of choice when imaging the lumbar spine in the lateral projection.

An evaluation of the effect of tube potential on clinical image quality using direct digital detectors for pelvis and lumbar spine radiographs.

IntroductionHigh kVp techniques, 15% or 10‐kVp rules, are well‐known dose reduction methods. Traditionally, the use of high tube potential (i.e. increased kVp) is associated with decreased radiographic contrast and overall image quality. Recent studies suggest contrast and image quality are not heavily reliant on kVp with digital systems. This study aims to assess the effects of the high tube potential technique on clinical radiographic image quality when using digital systems, to validate high kVp as a dose saving technique.MethodsA selection of comparable pelvis and lumbar spine radiographs were collected from the hospital’s picture archiving and communication system (PACS), with technical factors recorded. All clinical radiographs were assessed by 5 senior radiographers using a 15‐point visual grading analysis (VGA) rubric.ResultsFor 40 AP pelvis radiographs and 40 lateral lumbar spine radiographs, reduction in the dose area product (DAP) with higher kVp is seen. Average pelvis DAP at 75 kVp = 14.06 mGy.cm2; 85 kVp = 7.47 mGy.cm2. Average lumbar spine DAP at 80 kVp = 15.76 mGy.cm2; 90 kVp = 14.83 mGy.cm2. Image quality and contrast scores showed no statistically significant difference between the high and low kVp groups (z = 0.06 and 0.12, respectively). Average pelvis VGA score at 75 kVp = 11.26; 85 kVp = 12.55. Average lumbar spine VGA score at 80 kVp = 9.23; 90 kVp = 10.64.ConclusionsThe high tube potential techniques allowed for reduced patient radiation doses whilst showing no degradation of diagnostic image quality in a clinical setting. This study successfully validates the high kVp technique as a useful tool for reducing patient radiation doses whilst maintaining high diagnostic image quality for digital pelvis and lumbar spine radiography.

Effective dose and image optimisation of lateral lumbar spine radiography: a phantom study

BackgroundTo investigate lateral lumbar spine radiography technical parameters for reduction of effective dose whilst maintaining image quality (IQ).MethodsThirty-six radiograms of an anthropomorphic phantom were acquired using different exposure parameters: source-to-detector distance (SDD) (100, 130 or 150 cm), tube potential (75, 85 or 95 kVp), tube current × exposure time product (4.5, 9, 18 mAs) and additional copper (Cu) filter (no filter, 0.1-, 0.2-, or 0.3-mm thickness. IQ was assessed using an objective approach (contrast-to-noise-ratio [CNR] calculation and magnification measurement) and a perceptual approach (six observers); ED was estimated using the PCXMC 2.0 software. Descriptive statistics, paired t test, and intraclass correlation coefficient (ICC) were used.ResultsThe highest ED (0.022 mSv) was found with 100 cm SSD, 75 kVp, 18 mAs, and without Cu filter, whilst the highest CNR (7.23) was achieved at 130 cm SSD, 75 kVp, 18 mAs, and without Cu filter. The lowest ED and CNR were generated at 150 cm SDD, 95 kVp, 4.5 mAs, and 0.3-mm Cu filter. All observers identified the relevant anatomical structures on all images with the lowest ED and IQ. The intra-observer (0.61–0.79) and inter-observer (0.55–0.82) ICC ranged from moderate to excellent.ConclusionAll relevant anatomical structures were identified on the lateral lumbar spine radiographs despite using low-dose protocols. The lowest ED (0.002 mSv) was obtained with 150 cm SDD, 95 kVp, 4.5 mAs, and 0.3-mm Cu filter. Further technical and clinical studies are needed to verify these preliminary findings.

Optimisation of the lateral lumbar spine projection using an air-gap technique

IntroductionLumbar spine radiography is considered as having a high radiation dose compared to other planar radiography examinations. The aim of this study was to investigate the feasibility of replacing an antiscatter grid with an air gap technique to achieve dose reduction for lateral lumbar spine radiography while maintaining image quality on a direct digital radiography (DDR) system. MethodsIn phase 1, an experimental study using an anthropomorphic phantom identified the optimal airgap technique. In phase 2, lateral projections of the lumbar spine were performed on 50 patients randomly assigned equally into a control group (using the antiscatter grid) and an experimental group (using the airgap technique). The dose area product (DAP) was recorded, keeping other variables constant. Image quality evaluation was performed by 5 radiologists performing Absolute Visual Grading Analysis (VGA) using an image quality score tool, with resultant scores analysed using Visual Grading Characteristics (VGC). ResultsA 10 cm airgap in conjunction with a source to image distance (SID) of 121 cm was found as the optimal airgap technique. The clinical application of this technique resulted in a statistically significant (p < 0.05) reduction in DAP of 72%. Image quality scores were higher for the antiscatter grid but variation between the two techniques was not significant (p > 0.05). ConclusionReplacing the antiscatter grid with an airgap technique in lateral lumbar spine digital radiography, provides a significant dose reduction whilst still maintaining diagnostic image quality. Implications for practiceThe airgap technique is a simple and easy technique to implement and radiographers should find no difficulties in applying it, as It involves no additional cost and no additional equipment.

Are osteoporotic vertebral fractures or forward head posture associated with performance-based measures of balance and mobility?

The main objective of this study was to explore whether vertebral fracture characteristics (number, severity, location) or occiput-to-wall distance (OWD) is independently associated with physical performance. This was a secondary data analysis using baseline data from a randomized controlled trial, of community-dwelling women aged 65years and older with a suspected vertebral fragility fracture. Lateral thoracic and lumbar spine radiographs were used to determine the number, location, and severity of fracture. The dependent variables were timed up and go (TUG), five times sit-to-stand, four-meter walk, and step test. The independent variables were number, severity, location of fracture, and OWD. Pain during movement and age were covariates. Multivariable regression analyses determined the association between each of the dependent and independent variables. Participants' (n = 158) mean (standard deviation [SD]) age was 75.9 (6.5) years. They had a mean (SD) BMI, OWD, and number of fractures of 26.7 (5.3) kg/m2, 5.7 (4.6) cm, and 2.2 (1.8), respectively. OWD was independently associated with TUG (estimated coefficient [B] = 0.29, 95% confidence interval [CI] = 0.16, 0.42), five times sit-to-stand (B = 0.33, 95% CI = 0.12, 0.55), four-meter walk (B = 0.09, 95% CI = 0.05, 0.13), and step test (B = - 0.36, 95% CI = - 0.50, - 0.23) in the unadjusted model. OWD was independently associated with TUG (B = 0.25, 95% CI = 0.12, 0.38), five times sit-to-stand (B = 0.29, 95% CI = 0.07, 0.50), four-meter walk (B = 0.08, 95% CI = 0.03, 0.12), and step test (B = - 0.22, 95% CI = - 0.47, - 0.19) in the adjusted model. OWD was significantly associated with physical performance but fracture characteristics were not. These analyses were exploratory and require replication in future studies.

Spinal radiographic progression over 2\xa0years in ankylosing spondylitis patients treated with secukinumab: a historical cohort comparison

ObjectiveThe aim of this study was to compare radiographic progression in patients with ankylosing spondylitis (AS) treated for up to 2 years with secukinumab (MEASURE 1) with a historical cohort of biologic-naïve patients treated with NSAIDs (ENRADAS).MethodsBaseline and 2-year lateral cervical and lumbar spine radiographs were independently evaluated using mSASSS by two readers, who were blinded to the chronology and cohort of the radiographs. The primary endpoint was the proportion of patients with no radiographic progression (mSASSS change ≤ 0 from baseline to year 2). The Primary Analysis Set included patients with baseline (≤ day 30) and post-baseline day 31–743 radiographs. Sensitivity analyses were performed to assess the robustness of the comparison between the two cohorts, as follows: Sensitivity Analysis Set 1 included all patients with baseline (≤ day 30) and year 2 (days 640–819) radiographs; Sensitivity Analysis Set 2 included all patients with baseline and post-baseline (> day 30) radiographs.ResultsA total of 168 patients (84%) from the MEASURE 1 cohort and 69 (57%) from the ENRADAS cohort qualified for the Primary Analysis Set. Over 2 years, the LS (SE) mean change from baseline in mSASSS for the primary analysis was 0.55 (0.139) for MEASURE 1 vs 0.89 (0.216) for ENRADAS (p = 0.1852). Mean changes from baseline in mSASSS were lower in MEASURE 1 vs ENRADAS for the primary and sensitivity analyses. The proportion of patients with no radiographic progression was consistently higher in the MEASURE 1 vs ENRADAS cohort across all cutoffs for no radiographic progression (change in mSASSS from baseline to year 2 of ≤ 0, ≤ 0.5, ≤ 1, and ≤ 2), but the differences were not statistically significant.ConclusionSecukinumab-treated patients demonstrated a numerical, but statistically non-significant, higher proportion of non-progressors and lower change in mSASSS over 2 years versus a cohort of biologic-naïve patients treated with NSAIDs.

Sagittal Imbalance Does Not Influence Cup Anteversion in Total Hip Arthroplasty Dislocations.

Retrospective Cohort. Studies have shown that lumbar fusion procedures are associated with an increased risk of total hip arthroplasty (THA) dislocation. Some have speculated that the increased risk of dislocation is caused by mispositioning of the acetabular component because of spinal sagittal imbalance. Unfortunately, the exact relationship between spinal sagittal balance and cup orientation is unknown. The objective of this study was to investigate the effect of spinal sagittal alignment on cup anteversion in THA dislocation. Patients that suffered a THA dislocation were retrospectively identified. Cross-table lateral hip radiographs were used to measure cup anteversion with normal acetabular anteversion defined as 15±10 degrees. Lateral lumbar spine radiographs were used to measure lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt, and sacral slope. Normal sagittal balance was defined as a PI-LL difference of <10 degrees. The association between sagittal balance and THA characteristics was assessed using Pearson correlation coefficient, χ analysis, and independent t tests. A total of 29 patients had full radiographic imaging. Among these patients, 62.1% dislocated following a primary THA and 37.9% following a revision THA. Abnormal spinal sagittal balance was identified in 20 patients (69.0%). Eight (27.6%) patients had undergone spinal fusion prior to THA. Abnormal cup anteversion was demonstrated in 51.7% of all patients. Presence of a spinal fusion was not associated with cup anteversion, sagittal balance, or time to dislocation. Sagittal balance was not associated with direction of dislocation, time to dislocation, or cup anteversion. A majority of patients with a THA dislocation demonstrated abnormal sagittal balance. However, sagittal balance was not associated with acetabular cup anteversion. As such, the relationship between spinal deformity and dislocation rates after THA may not be because of inaccurate cup orientation.

Vertebral Fractures in Type 2 Diabetes Patients: Utility of Trabecular Bone Score and Relationship With Serum Bone Turnover Biomarkers

Background: Patients with type 2 diabetes (T2D) have an increased risk for vertebral fracture (VF). The aim of this study is to determine the utility of trabecular bone score (TBS) in T2D patients with VF and the relationship of TBS with serum bone turnover biomarkers (SBTBs). Methodology: Postmenopausal T2D female patients were prospectively enrolled. All patients received: (1) dual-energy X-ray absorptiometry exam for bone mineral density (BMD), T-score, and TBS values; (2) lateral lumbar spine radiographs for VF assessment; and (3) SBTBs: bone specific alkaline phosphatase and Beta-C-Terminal telopeptides. BMD, T-score, TBS, and SBTBs were tested for association with VF. Results: The study included 285 T2D patients (mean age = 61.1 years) and 32 patients had VF (11.2%). TBS had the strongest association with VF in T2D patients (area under curve 0.775). The TBS cutoff values for VF are 1.279 in T-score ≥1 and 1.236 in T-score <−1. In patients without VF, all sites of BMD and TBS are significantly associated with SBTBs, but in patients with VF, no associations are found between SBTBs and all sites of BMD and TBS. Conclusions: TBS can assess bone quality in the spine. The low TBS cutoff values for T2D patients with VF imply T2D does impair bone quality. Thus, TBS should be incorporated in VF risk assessment in T2D patients. In addition, a dissociated relationship between BMD and TBS with SBTBs represents imbalanced bone turnover rate and results in bone fragility and VF.

Relationship of Serum Soluble Klotho Levels and Echocardiographic Parameters in Patients on Maintenance Hemodialysis

Background: Cardiovascular disease is the leading cause of morbidity and mortality in maintenance hemodialysis (MHD) patients. Uremic cardiomyopathy, characterized by myocardial hypertrophy and fibrosis, has a significant contribution to these adverse cardiac outcomes. The protective effect of soluble Klotho (s-Klotho) on myocardial damage was demonstrated in in vitro and animal experiments. However, data from MHD patients is limited. The present study was designed to identify potential correlations between echocardiographic parameters and serum s-Klotho levels in MHD patients. Methods: This is a cross-sectional study involving 105 MHD patients from the Dialysis Center of Capital Medical University affiliated Beijing Friendship Hospital between March and October 2014. The general information for each patient was recorded. Fasting blood samples were collected prior to hemodialysis during the mid-week session in all patients. The echocardiogram and left lateral lumbar spine radiograph were performed after the same mid-week session. The dialysis records for each session within 3 months before the blood tests were documented. According to the quartiles of s-Klotho levels, patients were divided into four groups (Group 1–4). The demographic and clinical characteristics, echocardiographic parameters, and abdominal aortic calcification scores among the groups were compared. Results: The enrolled 105 patients were predominantly male (54.3%) with an average age of 59.9 ± 11.2 years. Previous hemodialysis durations were 76 (42–133) months. Sixteen (15.2%) patients had diabetes mellitus. Mean serum s-Klotho level was 411.83 ± 152.95 pg/mL, and the 25th percentile, 50th percentile, and 75th percentile values of serum s-Klotho levels were 298.9, 412, and 498.2 pg/mL, respectively. Individuals in the bottom quartile of s-Klotho levels (Group 1) had significantly increased interventricular septal thickness (IVST) compared to those in the other three quartiles of s-Klotho levels (Group 1: 1.12 ± 0.16 cm; vs. Group 2: 1.12 ± 0.16 cm, p = 0.008; vs. Group 3: 0.94 ± 0.13 cm, p < 0.001; vs. Group 4: 1.03 ± 0.1 5 cm, p = 0.022). There were significant differences in the ratios of IVST and posterior wall thickness (PWT) between patients of Group 1 and Group 3 (1.12 ± 0.1 2 vs. 1.00 ± 0.1 4, p = 0.004). No significant differences were found for other parameters among the groups. The univariate correlation analyses showed that gender (r = –0.211, p = 0.030), Kt/V urea (r = –0.240, p = 0.014), hypersensitive C reactive protein (hs-CRP) (r = 0.196, p = 0.045), and serum s-Klotho levels (r = –0.260, p = 0.007) significantly correlated with IVST. Ultimately, only hs-CRP and serum s-Klotho levels were entered into a multiple regression model. Conclusions: The present study showed that patients with lower circulating s-Klotho levels were more often associated with larger IVST and greater ratios of IVST and PWT. There was an independent association between s-Klotho and IVST, and lower s-Klotho levels seem to be a potential risk factor of uremic cardiomyopathy in MHD patients.