Routine Postoperative Computed Tomography Scans Research Articles

Postoperative Computed Tomography Scans of Acetabular Fractures Routinely Identify Indications for Revision Surgery.

To investigate the utility of postoperative computed tomography (CT) scans in identifying indications for revision surgery after surgical fixation of acetabular fractures. Retrospective cohort study. Urban level 1 trauma center. Patients with surgically treated acetabular fractures with surgical fixation (open reduction and internal fixation or percutaneous fixation) with routine postoperative CT scans. Primary outcome-revision surgery based on postoperative imaging, including intra-articular osteochondral fragments, implant complications, and malreductions. Secondary outcome-quality of reduction on radiographs versus CT scans. One hundred forty-eight patients were included. The revision surgery rate was 15.5% (23/148); indications included malpositioned implants (6.7%, n = 10), malreductions (5.4%, n = 8), and intra-articular loose bodies (3.4%, n = 5). Only 8.7% (2/23) of the indications for revision surgery were identified on postoperative radiographs, with the remainder being identified on CT scans. Revision surgeries were found to be associated with male gender (proportional difference: 19.6%, 95% confidence interval [CI]: 3.4%-29.4%; P = 0.04) and T-type fractures (PD 28.7%; CI, 9.0%-48.9%; P = 0.001). Revision surgery was not found to be associated with age, body mass index, posterior wall fractures, concurrent pelvic ring fractures, or surgical approach. On radiographs, 51.3% (n = 76/148) had anatomic reductions (<2 mm) compared with only 10.2% (n = 15/148) on CT scans. Indications for revision of acetabular fixation surgeries and poor reductions were frequently missed on plain radiography and identified on postoperative CT scans. This suggests that the use of advanced imaging such as intraoperative 3D imaging or postoperative CT scans may be beneficial. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Routine postoperative computed tomography (CT) scans following acetabulum open reduction internal fixation (ORIF): A survey of orthopaedic traumatologists

ObjectiveThe purpose of this study was to assess the practices related to obtaining postoperative pelvic CT scans following acetabular ORIF and revision surgery rates. DesignA 20-question survey published on the Orthopaedic Trauma Association (OTA) website assessed each surgeon's preference and rationale for or against the routine use of postoperative CT scans for acetabular fractures. ParticipantsFellowship-trained orthopaedic traumatologists. Main outcome measurementsWe examined the percentage of surgeons ordering routine postoperative CT scans, surgeon demographics, and revision surgery rates based on these routine CT scan results. ResultsResponses were received from 57 surgeons. Practices varied regarding postoperative CT scans, with 16 surgeons (28%, Group A) routinely ordering them and 41 surgeons (72%, Group B) not ordering them on all patients. No significant difference in surgeon demographics were found between the groups. Majority of Group A report a revision surgery rate of <1% based on the results of the postoperative CT.Group A report routine postoperative scans were obtained to assess reduction, hardware placement, identify intra-articular fragments, and for educational purposes. Group B did not obtain routine postoperative CTs due to the following: unlikely to change postoperative treatment, adequate reduction and instrumentation placement assessed intraoperatively and by postoperative radiographs, and increased radiation exposure and cost to patients. Group B did report obtaining postop CT scans on select patients, with inadequate intraoperative imaging and postoperative neurological changes being the most common indications. ConclusionThe routine use of postoperative CTs following open reduction internal fixation of acetabular fractures is a controversial topic. While we recognize the role for postoperative CT scans in select patients, our study questions the clinical utility of these scans in all patients and in conclusion do not recommend this protocol.

Routine Postoperative Computed Tomography Scans Following Posterior Pelvic Fixation of Pelvic Ring Fractures: A Survey of (OTA) Orthopaedic Traumatologists.

To assess practices related to ordering computed tomography (CT) scans routinely after posterior pelvic ring fixation and revision surgery rates. A 20-question cross-sectional survey. Fellowship-trained orthopaedic traumatologists. (1) Percentage of surgeons ordering a routing postoperative CT after posterior pelvic ring fixation, (2) Revision surgery rates based on routine CT scan results. Responses were received from 57 surgeons. Practices varied regarding postoperative CT scans, with 20 surgeons (35%, group A) routinely ordering them and 37 surgeons (65%, group B) not ordering them on all patients. Group A were younger and with less years of experience than those in Group B. Most group A surgeons report a revision surgery rate of <1% based on results of the postoperative CT. Group A report routine postoperative scans were obtained to assess reduction, instrumentation placement, and for educational purposes. Group B did not obtain routine postoperative CTs because of the following: unlikely to change postoperative treatment course, adequate reduction and instrumentation placement assessed intraoperatively and by postoperative radiographs, and increased radiation exposure and cost to patients. Group B did report obtaining postop CT scans on select patients, with postoperative neurological deficit being the most common indication. The routine use of postoperative CTs following posterior fixation of pelvic ring fractures is a controversial topic. Although we recognize the role for postoperative CT scans in select patients, our study questions the clinical utility of these scans in all patients and in conclusion do not recommend this protocol.

Routine postoperative computed tomography scan after craniotomy: systematic review and evidence-based recommendations.

Over the last few years, the role of early postoperative computed tomography (EPOCT) after cranial surgery has been repeatedly questioned, but there is yet no consensus on the practice. We conducted a systematic review to address the usefulness of EPOCT in association with neurological examination after elective craniotomies compared to the neurological examination alone. Studies were eligible if they provided information about the number of patients scanned, how many were asymptomatic or presented neurological deterioration before the scan and how many of each of those groups had their management changed due to imaging findings. CTs had to be performed in the first 48 h following surgery to be considered early. Eight studies were included. The retrospective studies enrolled a total of 3639 patients, with 3737 imaging examinations. Out of the 3696 CT scans performed in asymptomatic patients, less than 0.8% prompted an intervention, while 100% of patients with neurological deterioration were submitted to emergency surgery. Positive predictive values of altered scans were 0.584 for symptomatic patients and 0.125 for the asymptomatic. The number of altered scans necessary to predict (NNP) one change in management for the asymptomatic patients was 8, while for the clinically evident cases, it was 1.71. The number of scans needed to diagnose one clinically silent alteration is 134.75, and postoperative imaging of neurologically intact patients is 132 times less likely to issue an emergency intervention than an altered neurological examination alone. EPOCT following elective craniotomy in neurologically preserved patients is not supported by current evidence, and CT scanning should be performed only in particular conditions. The authors have developed an algorithm to help the judgment of each patient by the surgeon in a resource-limited context.

Intraoperative cone beam computed tomography is as reliable as conventional computed tomography for identification of pedicle screw breach in thoracolumbar spine surgery

ObjectivesTo test the hypothesis that intraoperative cone beam computed tomography (CBCT) using the Allura augmented reality surgical navigation (ARSN) system in a dedicated hybrid operating room (OR) matches computed tomography (CT) for identification of pedicle screw breach during spine surgery.MethodsTwenty patients treated with spinal fixation surgery (260 screws) underwent intraoperative CBCT as well as conventional postoperative CT scans (median 12 months after surgery) to identify and grade the degree of pedicle screw breach on both scan types, according to the Gertzbein grading scale. Blinded assessments were performed by three independent spine surgeons and the CT served as the standard of reference. Screws graded as Gertzbein 0 or 1 were considered clinically accurate while grades 2 or 3 were considered inaccurate. Sensitivity, specificity, and negative predictive value were the primary metrics of diagnostic performance.ResultsFor this patient group, the negative predictive value of an intraoperative CBCT to rule out pedicle screw breach was 99.6% (CI 97.75–99.99%). Among 10 screws graded as inaccurate on CT, 9 were graded as such on the CBCT, giving a sensitivity of 90.0% (CI 55.5–99.75%). Among the 250 screws graded as accurate on CT, 244 were graded as such on the CBCT, giving a specificity of 97.6% (CI 94.85–99.11%).ConclusionsCBCT, performed intraoperatively with the Allura ARSN system, is comparable and non-inferior to a conventional postoperative CT scan for ruling out misplaced pedicle screws in spinal deformity cases, eliminating the need for a postoperative CT.Key Points• Intraoperative cone beam computed tomography (CT) using the Allura ARSN is comparable with conventional CT for ruling out pedicle screw breaches after spinal fixation surgery.• Intraoperative cone beam computed tomography can be used to assess need for revisions of pedicle screws making routine postoperative CT scans unnecessary.• Using cone beam computed tomography, the specificity was 97.6% and the sensitivity was 90% for detecting pedicle screw breaches and the negative predictive value for ruling out a pedicle screw breach was 99.6%.

Stone-Free Rate after Treating Kidney Stones Exceeding 10 mm via Flexible Ureteroscopy: Can Endoscopic Assessment Replace Low-Dose Computed Tomography Control?

Introduction: It is unclear whether endoscopic assessment of the stone-free rate after flexible ureteroscopy (fURS) is as effective as assessment with low-dose computed tomography (CT) scan. Methods: Prospective documentation of patients with kidney stones > 10 mm diameter from 2 different centers (Freiburg, Regensburg), who underwent fURS and were declared to be endoscopically completely stone-free. Low-dose CT control performed 4–8 weeks postoperatively. Results/Conclusion: Thirty-eight patients were treated between October 2015 and August 2016 (12 F, 26 M). Average age was 55.9 years (range 19–82, SD 17.24), and body mass index was 29.7 kg/m² (range 23.5–42.5, SD 4.37). There were 2.0 (range 1–7, SD 1.55) stones with a mean diameter of 15 mm (range 10–40, SD 6.78) per kidney. Mean surgery time was 74 min (range 38–124, SD 24.28), and lithotripsy was necessary in 33 cases. CT was performed 5.4 weeks afterwards (range 4–8, SD 1.43). One patient had a 2 mm residual which was extracted by URS. Strictly speaking, endoluminal stone removal control failed in only that patient, yielding a negative predictive value of 97%. A routine postoperative CT scan would thus appear unnecessary in the case of negative endoscopic control for residual fragments and should be avoided to reduce radiation exposure. Further investigations with larger patient populations are necessary.

Intraoperative Cone Beam Tomography and Navigation for Displaced Acetabular Fractures: A Comparative Study.

To evaluate the accuracy of reduction of the acetabular articular surface using an intraoperative computed tomography scanner (O-Arm) and screw navigation compared with a classical open technique. Prospective matched cohort study. Tertiary referral center. Adult patients with acute acetabular fractures were included in the study. All patients were treated by 2 senior surgeons using intraoperative imaging and screw navigation. The primary outcome measure was articular reduction. Secondary outcomes were radiation dosage, operative variables [operative time, time for image acquisition, intraoperative bleeding (cell saver), number of surgical plates, and number of screws], and postoperative variables (first postoperative day pain on the visual analog scale, postoperative transfusion, and hemoglobin change). P < 0.05 was considered statistically significant. Thirty-five patients were treated in the inclusion period (2016-2017) and were matched to 35 cases in our database (2013-2016). Mean age was 43 years, and the most common fracture type was a both-column fracture (OTA/AO type C). Postoperative image analysis showed that reduction was achieved in 87.1% of the cases in the O-Arm group versus 64.7% in the control group (P < 0.05). Mean gap of the articular fragments was 3.6 mm in the O-Arm group compared with 5.6 mm (P = 0.01) in the control group. There was no significant difference between the 2 groups in regards to all other studied variables except a decrease in intraoperative blood loss and transfusions and an increase in surgical time with the O-Arm group. Finally, the total radiation dose was decreased using the intraoperative O-Arm compared with a routine postoperative computed tomography scan (dose length product in O-Arm: 498 mGy.cm; dose length product in historical group: 715 mGy.cm). Using intraoperative imaging and screw navigation for displaced acetabular fractures allow screw navigation with increasing articular surface reduction accuracy. Operative and anesthesia times were not increased, whereas radiation exposure to the patient was significantly decreased. We recommend the use of intraoperative imaging for the treatment of displaced acetabular fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Routine Postoperative Computed Tomography Is Not Helpful After Elective Craniotomy

Next-day postoperative computed tomography (CT) has been routinely used to obtain radiographic "clearance" for transferring patients after elective craniotomy out of the intensive care unit. The value of this traditional policy, however, has repeatedly been questioned. However, the limited patient numbers might have underestimated the very rare, but catastrophic, events. Therefore, we analyzed the value of routine postoperative CT in a larger cohort of elective tumor, epilepsy, and vascular cases. All the patients who had undergone elective craniotomy were included in our study. The routine postoperative CT scans were analyzed by a neuroradiologist who was unaware of the clinical data. The medical records were retrospectively reviewed for events of arterial hypertension and clinical deterioration. The data from 660 patients with tumors (n= 393; 59.5%), aneurysms (n= 107; 16.2%), and skull base lesions were evaluated. In nearly one half of the patients (n= 264; 45.8%), CT depicted the presence of blood that was not associated with symptoms. Of the 660 patients, 21 (3.6%) showed a mass effect radiographically, 11 of whom underwent revision surgery. Arterial hypertension was documented in only 8 patients (1.3%) and was related to the revision surgery (P= 0.018). The overall revision rate was 2.7% (n= 18). All patients who had undergone revision for postoperative hematoma had presented with a new neurological deficit immediately before CT. Routine postoperative CT did not reveal 1 patient with a serious hematoma that would not have been identified by clinical examination. Patients could be transferred safely from the intensive care unit, if the weaning process and clinical observation findings were uneventful, without deterioration of neurological symptoms or consciousness.

The Value of Computed Tomography Imaging of the Head After Ventriculoperitoneal Shunt Surgery in Adults

Patients with a ventriculoperitoneal shunt for hydrocephalus often undergo multiple follow-up computed tomography (CT) scans of the head, increasing the risk for long-term effects of ionizing radiation. The purpose of our study was to evaluate the necessity as a routine diagnostic procedure and cost analysis of routine postoperative CT scan of the head after ventriculoperitoneal shunt surgery. In this study, we comprised adults with ventriculoperitoneal shunt operations who underwent early CT scans within 48 hours postoperatively. We reviewed the correlation between revision surgery rate and the experience of surgeons who performed surgery and provided a cost analysis. In total, 479 surgeries were performed in 439 patients. Early revision surgery was performed in 11 (2.3%) patients. Reason for revision surgery was malposition in 9 cases and intracerebral hemorrhage in 2 patients. There was no significant correlation between the surgeon's experience and the rate of revision surgery. Placement of the ventricular catheter via an approach other than a standard right or left frontal burr hole resulted in risk of need for surgical shunt revision (P ≥ 0.002, odds ratio 54, confidence interval 13.5-223). A total of 468 CT scans of the head revealed a normal finding; thus, ∼$562,000 could be saved by omitting postoperative head CT scans. Routine postoperative head CT scans after fentriculoperitoneal shunting are not necessary in all cases. The reduction of exposure to ionization radiation and the beneficial economic factor are main advantages.

Malpositioned Pedicle Screw Compressed Thoracic Aorta of a Patient With Adolescent Idiopathic Scoliosis: Case Report and Literature Review

Background: Aortic injuries because of pedicle screw placement are quite rare, consequently management strategies to avoid vascular complications are lacking. Intraoperative or postoperative images to reveal the accuracy of screw placement in scoliotic misalignment with freehanded placed pedicle screws is therefore essential. Case Report: A 13-year-old girl with adolescent idiopathic scoliosis (AIS) was presented at the outpatient clinic of the authors department. Operative correction of the scoliotic misalignment including dorsal pedicle screw and rod placement with fusion from T3 to L4 was performed. Computed tomography scan after surgery showed left T9 screw malposition, accompanied by lateral compression of thoracic aorta. No clinical manifestations of aortic stenosis were noted. To avoid severe vascular complications, the thoracic screw was removed with the help of a specialized team of vascular as well as thoracic surgeons through extrapleural thoracotomy. After the removal of the malpositioned screw, the correction maneuvres were applied without the left T9 screw. No posttraumatic aortic aneurysm and other wall injury were identified after the revision surgery. The patient was discharged after 20 days of inpatient stay without the use external immobilization. The girl was in a good clinical condition after the 1-year follow-up visit without vascular or neurological complications. Conclusions: Malpositioned pedicle screws after dorsal correction in patients with adolescent idiopathic scoliosis might be challenging. Aortic injuries because of malpositioned screws are rare; nevertheless, the presence might be a life-threatening condition despite a clinical asymptomatic patient. As a consequence, the authors recommend to perform routine postoperative computed tomography scans combined with angiography in the case of significant lateral screw positioning.

Routine Postoperative Imaging Is Not Indicated in the Management of Mandibular Fractures

Prior literature has shown that routine postoperative computed tomography (CT) scans for mandibular fractures have no effect on outcomes and complications; however, past surveys have reported that most clinicians continue to order routine scans. We aimed to determine the current use of routine postoperative CT scans, evaluate what factors contribute to this practice, and identify differences in outcomes and complications among patients with either routine, indicated, or no postoperative CT scans. We conducted a retrospective review of consecutive patients treated for a mandibular fracture at Vancouver General Hospital from January 1, 2007, to March 1,2012. We included 167 patients in the study for analysis. No significant differences in outcomes or complications were found between patients who had an indicated postoperative CT scan (27%) and patients with no scans (64%). Only the treating surgeon had a statistically significant effect on whether a patient received a postoperative CT scan (P < .001), and those patients who had an indicated postoperative CT scan (9%) were more likely to have a decreased level of temporomandibular joint function (P= .002) and increased incidence of complications and secondary operations (P < .001 and P < .001, respectively). Routine postoperative CT scans were found to have no significant effect on outcomes and complications, and a clinician's individual practice was the most significant factor for whether a patient received a routine postoperative CT scan. Future work should aim at providing well-defined indications for postoperative imaging.

Efficacy of Routine Postoperative CT Scan After Open Reduction and Internal Fixation of the Acetabulum.

The purpose of this study was to evaluate the efficacy of routine postoperative computed tomography (CT) scan after open reduction and internal fixation of acetabular fractures. Retrospective review of prospectively collected acetabulum fracture database. Level I trauma center. A total of 606 consecutive patients underwent surgical fixation of 612 acetabular fractures. All patients were evaluated with intraoperative fluoroscopy in addition to 3 standard plain radiographs (AP pelvis and two 45 degrees oblique Judet views). Reduction and fixation were believed to be adequate and definitive before exiting the operative suite based on these imaging modalities. Axial postoperative CT scan of the pelvis was obtained in 563 of the patients (93%) after 569 operative cases. Revision acetabular surgery based on routine postoperative CT scan findings. There were no significant differences between index and revision surgery groups regarding age, gender, body mass index, fracture pattern, mechanism of injury, or surgical approach (P > 0.05). Evaluation of 563 postoperative CT scans of the pelvis resulted in revision acetabular surgery for 2.5% of patients (n = 14). There were 6 (1.1%) cases of intraarticular hardware not recognized on the intraoperative fluoroscopy or pelvic radiographs. Four patients (0.7%) had residual intraarticular osteochondral fragments deemed too large to leave in the hip joint. There were 3 cases (0.5%) of unacceptable malreduction, and 1 case (0.2%) of both malreduction and an intraarticular osteochondral fragment. A small percentage of patients (2.5%) will benefit from a routine CT scan after acetabular fracture fixation. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Value of routine early post-operative computed tomography in determining short-term functional outcome after drainage of chronic subdural hematoma: An evaluation of residual volume

Background:Computed tomography (CT) scans are widely used in managing chronic subdural hematoma (CSDH). Factors that determine early post-operative volume have not been examined. The value of routine early post-operative residual volume have not been evaluated. Our study aims to compare pre-operative and early post-operative CT findings to determine the factors affecting residual hematoma and evaluate if early post-operative CT scans are useful in the management of CSDH.Methods:Forty-three patients who underwent burr hole drainage of unilateral CSDH from August 2006 to January 2013 and had routine post-operative CT scans within 48 hours of surgery were selected. Data regarding age, sex, neurological deficit, Glasgow Coma Scale (GCS), pre-existing medical conditions, use of antiplatelets or anticoagulation, operative time, usage of drains, and number of burr holes were obtained. The pre-operative CSDH volume, CSDH density, and midline shift were measured. Residual volume was calculated from early post-operative CT scans. Clinical outcome was evaluated with Glasgow Outcome Scale (GOS) at the time of discharge. Statistical analysis was performed to look for correlation between the pre-operative factors and residual volume, and the residual volume and GOS.Results:Pre-operative volume was found to correlate significantly with post-operative residual volume. There was no significant correlation between all other pre-operative factors and residual volume. There was also no correlation between residual volume and GOS at discharge.Conclusion:Routine post-operative CT brain for burr hole drainage of CSDH may be unnecessary in view of the good predictive value of pre-operative volume, and also because it is not predictive of the clinical outcome.

Efficacy and Safety of Local Versus General Anesthesia in Stereotactic Biopsies

Frame-based stereotactic biopsies remain the gold standard for the diagnosis of intracerebral lesions. A major advantage is the ability to perform these procedures under local anesthesia (LA). However, there is no consensus on whether or when to use LA or general anesthesia (GA). It has been postulated that the use of LA may reduce the risk of complications. This study aims to objectify the efficacy and safety of stereotactic biopsies under LA versus GA by analyzing a prospective registry for stereotactic biopsies. A prospective registry for stereotactic procedures was analyzed for the activities performed between May 2009 and August 2011. Inclusion criteria were patients undergoing a stereotactic biopsy. Patients with functional stereotactic procedures, cyst or abscess evacuation, and children were excluded. Of the remaining 274 patients, 204 could be randomly matched considering sex, age, American Society of Anesthesiologists (ASA) classification, and type of hospitalization. The primary endpoint was the diagnostic yield. Secondary endpoints were safety and procedural time intervals. Ninety-six percent of diagnosis was achieved in the LA group and 94% within the GA group. There was no significant difference in the overall complication rate. However, the rate of pulmonary complications was higher in the GA group (P=0.059). The rate of bleeding was significantly higher in the LA group (P=0.003) intraoperatively. However, no significant difference was found clinically or on routine postoperative computed tomography scan reports. There was a significant reduction in the time spent in the operating room within the LA group (P<0.001). The type of anesthesia may not interfere with the diagnostic yield in stereotactic biopsies. Patients operated under LA are less likely to suffer pulmonary complications. Furthermore, LA could spare hospital resources in this setting.

Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make?

The use of thoracic pedicle screws for the treatment of adolescent idiopathic scoliosis (AIS) has gained widespread popularity. However, the placement of pedicle screws in the deformed spine poses unique challenges, and surgeons experience a learning curve. The in vivo accuracy as determined by computed tomography (CT) of placement of thoracic pedicle screws in the deformed spine as a function of surgeon experience is unknown. We undertook a retrospective review to determine the effect of surgeon experience on the accuracy of thoracic pedicle screw placement in AIS. In 2005, we started to obtain routine postoperative CT scans on patients undergoing a spinal fusion. From a database of these patients, we selected AIS patients, who underwent a posterior spinal fusion. Fifteen consecutive patients for each of the following three groups stratified by attending surgeon experience were selected (N = 45): A) less than 20 cases of all pedicle screw constructs for AIS (surgeons <2 years of practice), B) 20-50 cases (surgeons 2-5 years of practice), and C) greater than 50 cases (surgeons greater than 5 years of practice). Intraoperative evaluation of all screws included probing of the pedicle screw tract, neurophysiologic monitoring, and fluoroscopic confirmation. A total of 856 thoracic pedicle screws were studied. Postoperative CT scans were evaluated by two spine surgeons and a consensus read established as follows: (1) In: intraosseous placement or <or=2-mm breach, (2) Out: >2-mm breach, either medial or lateral. Of the 856 screws, 104 demonstrated a >2-mm breach, for an overall rate of 12.1% (medial = 55, lateral = 49, P = 0.67). When the breach rates were stratified by surgeon experience, there was a trend toward decreased rate of breach for the most experienced surgeons, although this did not attain statistical significance (Group A: 12.7%, Group B: 12.9%, Group C: 10.8%, P = 0.58). However, the most experienced group (C) had a markedly decreased rate of medial breaches (3.5 vs. 7.4% and 8.4% for groups A and B, respectively, P < 0.01). The breach rate for the concave periapical screws was not statistically different from the overall breach rate (13.0% vs. 12.1%, P = 0.93). In conclusion, the overall accuracy of placement of pedicle screws in the deformed spine was 87.9%, with no neurologic, vascular, or visceral complications. Meticulous technique allows spine surgeons with a range of surgical experience to accurately and safely place thoracic pedicle screws in the deformed spine. The most experienced surgeons demonstrated the lowest rate of medial breaches.