Routine Radiographs Research Articles

Routine In-Hospital Radiographs Following Anterior Cervical Discectomy and Fusion Surgery: Neither Necessary nor Cost-Effective?

BackgroundDespite a paucity of evidence or literature to support routine in-hospital post-operative radiographs (POXR) of anterior cervical discectomy and fusion (ACDF) surgery, it remains accepted practice. Most spinal surgeons consider it part of their standard post-operative routine for ACDF despite nearly always documenting a ’satisfactory intra-operative image’ at the end of the operation. With an increasing financial pressure on NHS resources, our investigations should be clinically justified and evidence-based.PurposeTo evaluate whether a post-operative radiograph of the cervical spine before discharge is either clinically justified or cost-effective in patients who have undergone an ACDF, despite having satisfactory intra-operative imaging.DesignA retrospective review of 101 consecutive ACDF patients of radiographs performed before discharge, associated length of inpatient stay, and any complications involved.MethodsA retrospective review was performed of 101 ACDF patients who had single or multi-level instrumentation for degenerative spinal disease from a single neurosurgical centre from all surgeons. Seventy-eight had an in-hospital post-operative anteroposterior (AP) and lateral radiograph, 23 did not. In 95 of these, it was documented that there was ‘satisfactory intra-operative imaging’ before the closure of skin, six lacked documentation of this. All patients had intra-operative imaging of completed instrumentation on the radiology system. Any post-operative complications were noted, and the length of hospital stay (LOS) was recorded. Six patients underwent ACDF following trauma, therefore leaving 95 elective cases. Study parameters also included: number of levels operated on, whether or not a plate was used with a cage, hospital costings for 2-view imaging and additional days of inpatient stay. ResultsThere was one out of our 101 patients where the post-operative radiograph confirmed unsatisfactory placement of metalwork and warranted a return to surgery. However, the decision to perform this x-ray was based purely on the deteriorating post-operative clinical picture. In the cohort that had POXR’s, the average length of stay was 66.7 hours. Without POXR, it was 21 hours. The additional cost to the trust of performing the in-hospital radiographs was calculated to be £71,523 per year.ConclusionIn patients who undergo ACDF surgery with an uneventful post-operative course and have satisfactory intra-operative imaging, in-hospital post-operative radiographs serve no clinical purpose and delay discharge. This gives additional cost to the trust, unnecessary radiation exposure and occupies potential bedspace.

Evaluation of an asymptomatic COVID-19 patient post-surgery with chest radiography: A surgeon’s dilemma

Routine chest radiography is not a requirement in post-surgery cardiac bypass patients. However, the safety of abandoning routine chest radiographs in critically ill patients remains uncertain. Surgery in an asymptomatic coronavirus disease 2019 (COVID-19) patient presents additional challenges in postoperative management. Chest radiography remains a valuable tool for assessment of all patients, even a stable one. Management of surgical patients as an emergency in an asymptomatic COVID-19 case remains a surgeon’s dilemma.

The Feasibility of Utilizing Malunion Criteria to Limit Radiographs After Spica Casting for Pediatric Femur Fractures.

There are no existing guidelines regarding the timing or frequency of postoperative radiographs following spica casting for pediatric femur fractures. The purpose of this study was to evaluate established femoral malunion criteria as a potential screening tool to limit postoperative radiographs by identifying patients at risk for unacceptable alignment in the early treatment period. A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Pediatric femur malunion criteria were applied to radiographs at initial presentation, first follow-up visit, and final follow-up visit. The primary outcome was a change in management based on radiographic findings in the early postoperative period. Secondary outcomes included radiographic measures, number of follow-up visits, and complications. Of 449 consecutive pediatric femur fractures treated at our center, 149 patients aged 1 to 4 years (mean age: 2.5±1.6 y) met inclusion criteria. At initial presentation, 36.9% (55/149) of patients met malunion criteria. Only 4.0% (6/149) of patients had a change in management following initial closed reduction and spica cast application due to radiographic findings at subsequent follow-up. Of these patients, 67% (4/6) were identified on preoperative imaging, and 83.3% (5/6) were identified by their first clinic appointment. Four of the 149 patients were converted to definitive surgical fixation, and 2 patients required cast wedging due to either unacceptable fracture shortening or coronal/sagittal angulation. Routine early postoperative radiographs may not be necessary for all pediatric femur fractures managed with closed reduction and spica casting. The value of this study is that it is the first to demonstrate the feasibility of limiting postoperative radiographs using a preoperative screening tool. However, the established femoral malunion criteria utilized in this study were limited in their predictive value, and further work is necessary to improve the sensitivity and specificity before widespread clinical application. Level IV.

The Utility of Routine Radiographic Monitoring in Pediatric Osteoarticular Infections.

Pediatric musculoskeletal (MSK) infections broadly include isolated osteomyelitis (OM), septic arthritis (SA), and combined infections (OM+SA). These diagnoses are often monitored with serum inflammatory markers and serial radiographs to monitor treatment response and development of negative sequelae, despite limited data supporting these practices. The purpose of this study is to evaluate the utility of obtaining serial radiographic follow-up for pediatric osteoarticular infections. An institutional review board-approved retrospective review was completed. Children 18 years and below admitted to a single institution with a culture/biopsy-proven diagnosis of OM, SA, or OM+SA. All postdischarge radiographs were reviewed and retrospectively categorized as either routine (scheduled) or reactive. Routine radiographs were obtained regardless of clinical presentation. Reactive radiographs were obtained in patients presenting with the sign of an altered clinical course. Negative sequelae, defined as growth arrest/disturbance, pathologic fracture, recurrent MSK infection, and underlying neoplastic process, were recorded and tracked. Descriptive statistics were used to summarize demographic and outcome variables. Number needed to screen (NNS) was defined as the inverse of the incidence of negative sequelae detected. A total of 131 patients were included for analysis, with a mean age of 11.9 years (SD: 4.96 y). Ninety (69%) patients were diagnosed and treated for OM, 25 (19%) for SA, and 16 (12%) for combined infections. A total of 329 radiographs were obtained following discharge. Of those obtained, 287 (88%) were routine, resulting in the detection of 2 (0.7%) negative sequelae and a resultant NNS of 143 radiographs (95% confidence interval: 36-573). The remaining 39 were reactive radiographs, resulting in the detection of 2 (5.1%) negative sequelae with an NNS of 20 radiographs (95% confidence interval: 5-78). While radiographs remain a widely utilized tool to screen for the development of negative sequelae in pediatric osteoarticular infections, they rarely alter management in the absence of other concerning clinical signs or symptoms such as recurrent fevers, swelling of the extremity, or limb deformity. Moreover, routine radiographic surveillance should be replaced with a reactive radiographic protocol. Level III-retrospective comparative study.

Salter-Harris Type 2 Injury of the Proximal Tibial Epiphysis in a 15-year-old Athlete: A Rare Case Report.

Background:Proximal tibial epiphyseal injuries in adolescents are uncommon accounting to 0.5 to 3 % of all epiphyseal injuries. Although rare, the proximity of popliteal artery puts this region at an increased risk of vascular injury and compartment syndrome. Also, premature closure of the growth plate can cause restrictions in growth and angular malformations. The fractures may often be missed on routine X-rays. Frequent monitoring and further testing should be done to better diagnose these injuries.Case History:We present a case of an adolescent football player (15 years old) who injured his left knee and was diagnosed to have Salter- Harris II proximal tibial epiphyseal injury. Routine radiographs revealed minimal widening in his epiphysis anteriorly when compared to his contralateral knee. Magnetic resonance imaging (MRI) findings revealed a fracture passing through the growth plate of proximal tibia exiting posteriorly into the tibial metaphysis. Management included closed manipulation and plaster cast immobilization with regular follow-ups. At the end of 1.5 years, the patient had full range of motion without any residual deformities.Conclusions:High clinical suspicion is required to diagnose these rare injuries. When in doubt, MRI is advocated to better delineate the fracture as the potential complications can be limb threatening. Anatomical reduction and adequate immobilization should be done to prevent deformities and good functional outcome in the long term.

Routine Post-operative Radiographs Following Hip Hemiarthroplasty: Is It a Necessity?

Femoral neck fractures are one of the most common fractures treated by an Orthopaedic surgeon. Arthroplasty is the recommended management for intracapsular neck of femur fractures in the elderly population owing to the high risk of avascular necrosis of the femoral head following an internal fixation. Elderly patients with intracapsular fractures deemed high risk for anaesthesia (American Society of Anaesthesiology Grade more than 2) are recommended a hip hemiarthroplasty. Routine practice throughout the United Kingdom is to obtain a postoperative check radiograph for all hip hemiarthroplasty patients prior to their discharge from the hospital. This may be done for various reasons like checking the presence of any peri-prosthetic fracture, the position of the components along with the presence of any dislocation. However, it is unclear whether a radiograph is the sole identifier of such complications. Through this study, we aim to analyse whether routine recommendation of post-operative radiographs following hip hemiarthroplasty affects the clinical outcome, and whether it is effective in identifying potential complications before the patients report any signs or symptoms.

859 Follow up of distal radius volar plating – No role for post-operative radiographs

Abstract Aim There is no consensus on the follow up for distal radius fractures after fixation. All patients receive intra-operative image intensifier screening to check the adequacy of reduction and implant position. We propose that if a patient is asymptomatic, you do not require post-operative radiographs. Method We conducted a retrospective review of all distal radius fractures operated in our hospital over the last 10 years. Data was collected from electronic records for revision surgery or metalwork removal. Records were assessed for patient symptoms, radiographic findings, and indications for implant removal. Patients had a minimum follow up of 6 months. Results 900 distal radius fixations were performed over a 10-year period, of which 747 were volar plating. 49 patients had volar plates removed. 14 patients had metal work removal and joint release for stiffness. 6 had the plate removal and carpal tunnel neurolysis with release. 11 implant removals for screw prominence. Other operative indications included reduction failure (n = 2), infection (n = 2) and removal in paediatric patients (n = 3). 47 of the 49 patients for implant removal were symptomatic at follow up. Only two patients had implant removal following isolated radiographic evidence of metalwork mal position. Conclusions Intra-operative intensifiers reduce the risk of implant and fixation errors. Routine post-operative radiographs altered the management of only 2 out of 700 (0.3%) patients. We suggest that radiographs have no role in routine post-operative care of distal radius fractures, where patients are asymptomatic with appropriate intra-operative intensifier images.

233 Blood Tests and Radiographs After Hip and Knee Arthroplasty – We May Not Always Need Them

Abstract Aim Routine blood tests and radiographs are routinely performed after total joint arthroplasty as a pre-discharge requirement. This study aims to explore whether there might be sub-group of patients undergoing arthroplasty for whom post-operative blood tests and radiographs might not be mandated in the absence of clinical concern. Method A retrospective study of 612 ASA 1 and 2 patients underwent total hip or knee arthroplasty at a single orthopaedic centre. Variables purported to be of interest were sodium and Potassium levels, Haemoglobin concentration and eGFR. Return to theatre and alterations of the routine Physiotherapy rehabilitation were matched to post-operative radiographs. Results 42 (6.9%) patients had post-operative haemoglobin below 10 g/L. Of these 4 were symptomatic, which required treatment. Acute kidney injury was identified in 13 patients (2.1%); 11 had pre-existing renal disease. The other two had both suffered pro-longed post-operative hypotension. Two patients had severe hyponatraemia and one of whom had pre-existing renal disease. Two patients had hypokalaemia and one of whom had metabolic syndrome but normalised within 24 hours after oral supplement. No patient had abnormal post-operative radiography that altered management. Conclusions Our study indicates that routine post-operative blood tests and radiographs may not be necessary in ASA 1 and 2 patients with normal pre-existing blood tests. Where patient is clinically symptomatic or there is evidence of pre-operative renal dysfunction, metabolic syndrome, electrolyte imbalance or anaemia, we would suggest blood tests are necessary. If there is no surgical concern, it is safe to delay check radiography until their first post-operative follow up.

752 Routine In-Hospital Radiographs Following Anterior Cervical Discectomy and Fusion Surgery: Neither Necessary nor Cost-Effective?

Abstract Aim To evaluate whether a post-operative radiograph of the cervical spine before discharge is either clinically justified or cost-effective in patients who have undergone an ACDF, despite having satisfactory intra-operative imaging. Method A retrospective review of 101 ACDF patients from a single neurosurgical centre. 78 had an in-hospital post-operative radiograph, 23 did not. In 95 of these, it was documented that there was ‘satisfactory intra-operative imaging’. All patients had intra-operative imaging of completed instrumentation. Any post-operative complications were noted, and the length of hospital stay (LOS) recorded. Study parameters also included: levels operated on, whether or not a plate was used with a cage, additional costings to the hospital. Results There was one post-operative complication relating to the metalwork in the 101 patients. However, the decision to perform this x-ray was based purely on the deteriorating post-operative clinical picture. In the cohort that had POXR’s, the average length of stay was 66.7 hours. Without POXR, it was 21 hours. The additional cost to the trust of performing the in-hospital radiographs was calculated to be £71,523 per year. Conclusions In patients who undergo ACDF surgery with an uneventful post-operative course and satisfactory intra-operative imaging, in-hospital post-operative radiographs serve no clinical purpose and delay discharge. This gives additional cost to the trust, unnecessary radiation exposure and occupies potential bedspace.

Protocol for DRAUP: a deimplementation programme to decrease routine chest radiographs after central venous catheter insertion

IntroductionAvoiding low value medical practices is an important focus in current healthcare utilisation. Despite advantages of point-of-care ultrasound (POCUS) over chest X-ray including improved workflow and timeliness of results, POCUS-guided...

GIRAFFE IN THE COVID-19 LUNG: PULMONARY FIBROSIS LIMITING SEVERITY OF THE PNEUMOTHORAX

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: More than a year has passed since the first reported cases of COVID-19 worldwide. We present a case of a patient with COVID-19 who acquired bilateral pulmonary fibrosis then later developed a pneumothorax of the right lung. Ironically, it was this fibrosis that prevented a catastrophic collapse of the lung. CASE PRESENTATION: This is a 60-year-old Caucasian female with hypertension, type II diabetes mellitus and obstructive sleep apnea (OSA) who was admitted due to a four-day history of worsening shortness of breath four days due to COVID pneumonia. She was admitted to the ICU due to worsening respiratory status and was maintained on bi-level positive airway pressure ventilation (BIPAP) for two weeks. Repeated chest radiographs in the ICU showed diffuse infiltrates with ground glass opacities bilaterally. She began to improve on the 3rd week of hospitalization, allowing titration down to high flow nasal cannula with BIPAP at night for OSA. On the 4th week, a routine chest radiograph incidentally revealed a small right apical pneumothorax. She had no desaturations, tachypnea, or increased work of breathing at this time. A CT scan of the chest confirmed the extensive pulmonary fibrosis and ground glass opacities and demonstrated the pneumothorax (Figure 1). A repeat 36 hour chest radiograph (Figure 2) showed expansion of the pneumothorax to a volume of 25% of the right hemithorax, with no signs of tension. The patient's clinical status remained unchanged. Follow-up chest CT scan (Figure 1) showed fibrotic attachments tethering the lungs to the pleura that may have limited its further collapse. Patient underwent a CT-guided pigtail catheter insertion the same day. Follow-up imaging the next day confirmed resolution of the pneumothorax. The pigtail catheter was later removed. The patient remained hospitalized, but improving. DISCUSSION: Pulmonary fibrosis is a known sequelae of COVID pneumonia. Bullae and cyst formation can form as a result of this extensive airspace disease. Secondary spontaneous pneumothorax in COVID-19 could be due to damage to the subpleural alveoli from the formation of cysts and bullae leading to spontaneous alveolar rupture into the pleural space. The use of BIPAP could have contributed to it, due to additional volume and barotrauma. Our patient developed pulmonary fibrosis after remaining hospitalized for more than 4 weeks. The fibrosis caused the lung to tether to portions of the pleura, preventing a quick, catastrophic collapse of the lung. The delay in progression gave the patient an opportunity to undergo a CT-guided pigtail catheter insertion, as opposed to an emergent chest tube thoracostomy which would have been a more invasive, traumatic, and painful procedure. CONCLUSIONS: This case highlights the possibility of extensive lung fibrosis, via thick pleural adhesions, protecting patients from developing fatal pneumothorax. REFERENCE #1: Wu, C., et al., Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med, 2020. 180(7): p. 934-943. REFERENCE #2: Rai, D.K., P. Sharma, and R. Kumar, Post covid 19 pulmonary fibrosis- Is it reversible? Indian Journal of Tuberculosis, 2020. REFERENCE #3: Martinelli, A.W., et al., COVID-19 and pneumothorax: a multicentre retrospective case series. Eur Respir J, 2020. 56(5) DISCLOSURES: No relevant relationships by Patrick Benjamin, source=Web Response No relevant relationships by Marvyn Allen Chan, source=Web Response No relevant relationships by Josemaria Demigillo, source=Web Response No relevant relationships by Ma Pamela Demigillo, source=Web Response No relevant relationships by Stephen Jesmajian, source=Web Response No relevant relationships by Junfeng Xue, source=Web Response

A Systematic Review on the Association Between Clinical Symptoms and CBCT Findings in Symptomatic TMJ Degenerative Joint Disease

To evaluate the association between clinical signs/symptoms and bone changes on CBCT images in patients with degenerative joint disease (DJD) of the temporomandibular joint (TMJ). An electronic literature search of the MEDLINE, PubMed, EMBASE, Scopus, and Web of Science databases, as well as Google Scholar for gray literature, was conducted to identify relevant articles on February 26, 2021. Risk of bias was evaluated using the Joanna Briggs Institute critical appraisal tools. The GRADEpro (Recommendation, Assessment, Development, and Evaluation) system instrument was applied to assess the level of evidence across studies. Nine papers assessing clinical signs/symptoms and CBCT findings were included. TMJ pain (arthralgia) and TMJ noises carried the strongest associations with various CBCT findings, each of which were supported by four studies with significant associations. Only one study found significant associations between masticatory myalgia (muscle pain) and CBCT findings. Range of motion carried no significant associations with CBCT findings in the included studies. Based on the GRADEpro system, the certainty of evidence is low for said associations. The results suggest that TMD patients with TMJ arthralgia and joint noises may benefit from CBCT imaging. There would be less benefit in TMD patients exhibiting primarily myalgia or limited range of motion, and therefore these patients should not be prescribed routine CBCT radiographs unless indicated by other clinical findings. The heterogeneity of reporting in the included studies suggests that embracing universal clinical (DC/TMD) and radiographic diagnostic criteria for TMJ-DJD would benefit both research and clinical outcomes.

Bilateral simple bone cyst in mandible: Rare case report

The simple bone cyst is a benign osteolytic lesion, uncommon in the maxillomandibular region. Its etiology remains unknown, although traumatic injuries are often associated with this injury. Young patients, men and women alike are the most affected. It is asymptomatic in most cases, being diagnosed on routine radiographs. The radiolucent image, uni or multilocular, is well defined, with irregular margins, mainly in the posterior region of the mandible. Bilateral presentation is unusual. The final diagnosis is made during surgical procedures when an empty bone cavity is detected. Simple curettage is the treatment of choice and it consists of causing bleeding and filling the cavity with a blood clot. Bone repair will be observed in the follow-up procedures. The aim of this study was to present a rare case of bilateral simple bone cyst in a young male, treated with curettage of the bone walls.

Iatrogenic hydrohemothorax during percutaneous nephrolithotomy: A case report

Background: Percutaneous nephrolithotomy (PNL) is a widely used surgical method for renal stone management. However, it can be associated with several complications. Case: We report an acute hemothorax during PNL in 57-year-old male patient with a stone. After observing air bubbles at the diaphragm on the laparoscopic screen, we considered pulmonary complications. A chest radiograph demonstrated a shade that measured 130 mm wide and 70 mm long and fluid retention on the right side of the chest. During drainage of 200 ml of blood through a chest tube, the patient’s vital signs became unstable. After the patient received hydration and intravenous injection of vasopressor, his vital signs stabilized. Conclusions: Pulmonary complications due to pleural injury during PNL can result in death, but the complications can be managed by early diagnosis and treatment. Close cooperation between surgeon and anesthesiologist and routine chest radiographs after PNL can reduce the pulmonary complications.

The relationship between knee radiographs and the timing of physical therapy in individuals with patellofemoral pain.

Routine knee radiographs are discouraged for individuals with nontraumatic knee pain, but they are often still ordered despite limited evidence of their value in guiding treatment choices. Radiograph utilization may delay the use of physical therapy, which has been associated with improved outcomes and lower long-term costs. To examine the relationship between obtaining knee radiographs for patients with patellofemoral pain (PFP) and the timing of physical therapy, and the association between ordering radiographs for patients who use physical therapy and the likelihood of knee pain recurrence. Retrospective cohort. United States Military Health System civilian and military clinics. A total of 23,332 individuals ages 18 to 50 years who were diagnosed with PFP between 2010 and 2011 in the United States Military Health System and who received physical therapy. Physical therapy provided to individuals with or without an initial radiograph. Timing of physical therapy and recurrence of knee pain were compared between groups (with and without initial radiographs). If radiographs were obtained, the odds of initiating physical therapy (adjusted odds ratio [aOR]0.78, 95% confidence interval [CI] 0.64-0.94) within 30 days of the initial diagnosis were significantly lower. The mean days from diagnosis to initiating physical therapy was 12.1 (95% CI 9.1-16.1) if patients had radiographs versus 6.9 (95% CI 5.2-9.1) without. The odds of knee pain recurrence were no greater if radiographs were used (aOR1.01, 95% CI 0.83-1.22). Acquisition of knee radiographs as part of initial care for PFP was associated with delayed initiation of physical therapy, but there was no association between early knee radiographs and recurrence of knee pain. Routine use of radiographs for PFP is not warranted, and can potentially delay appropriate treatment.

Clinical efficacy and cost-effectiveness of postoperative radiographs after total knee arthroplasty

BackgroundPostoperative radiographs are commonly ordered after primary total knee arthroplasty (TKA), however, there is limited data on how often these films change management over the entire postoperative time course, and what should prompt imaging to maximize clinical utility. MethodsA retrospective cohort study was conducted of patients ≥ 18 years old who underwent a primary TKA at two level one trauma centers. Postoperative data were collected to determine the frequency of postoperative radiograph series, radiograph findings that did not suggest normal healing or alignment to radiologist and orthopedists, and changes in postoperative management. The total cost and radiation exposure values were calculated for all patient radiographs using estimates from previous literature. ResultsFrom the 1258 patients included, 3831 postoperative radiographs were taken (mean ± 95% confidence interval [CI]: 3.05 ± 0.11 radiographs per patient). Of these 3831 radiographs, 44 (1.1%) contained a positive radiographic finding. Only 13 (0.3% of radiographs) of these positive radiographic findings were positive orthopaedic findings, 11 of which led to changes in management. For all but 1 of these patients (10/11, 91%), these radiographs were taken during a non-routine postoperative visit. Routine postoperative radiographs that did not change management cost $1,008,480 and administered 22.92 mSV of radiation to patients within this study. ConclusionPostoperative radiography obtained after primary TKA were of low clinical utility yet resulted in considerable healthcare costs and unnecessary radiation burden. Radiographs ordered during a non-routine visit, however, were a reliable indicator of when this imaging provided clinical utility.

Incidence of Maxillary Sinus Abnormalities in Asymptomatic Patients: A CBCT Study.

Abstract
 Background: Cone beam computer tomography (CBCT) when imaged for maxillary jaw generally depicts maxillary sinus. This region is frequently neglected by dentist and maxillofacial radiologist. Signs and symptoms in odontogenic diseases of the jaw and the maxillary sinus may overlap each other. A dental surgeon primarily encounters these lesions in routine dental radiographs..
 Aim: The present study was undetaken to evaluate the occurrence of maxillary sinus anomalies in CBCT images of asymptomatic patients and to determine their prevalence, type and location. 
 Materials and methods: Study consisted of 256 CBCT images of the patients depicting maxillary sinus who has been advised limited volume CBCT as part of routine dental investigation for implant planning, orthodontic assessment, oral surgical procedure, oral pathology etc.. The CBCT images were scrutinized for various maxillary sinus pathologies like mucosal thickening, opacification, polyp and retention pseudocyst
 Result: Out of 236 subjects, 106 (44.9%) presented with maxillary sinus abnormalities. The maxillary sinus abnormalities which were found in the study were as follows, mucosal thickening 60 (25.4%), opacification 32 (13.6%), sinus polyp 8 (3.4%) and retention pseudocyst 6 (2.5%). Right maxillary sinus were involved in 58 (24.6%) cases and left in 44 (18.6%) cases respectively, whereas bilateral sinus involvement was seen in 4 (1.7%) cases.
 Conclusion: The results are suggestive of high incidence of abnormalities in asymptomatic maxillary sinus. Thus a prompt recognition of these abnormalities by dental surgeons and referral to specialist may help in treating these diseases at an early stage.

Radiographic analysis of the thickness of the cranial bones in captive compared to wild-living cheetahs and in cheetahs with hypovitaminosis A.

Captive cheetahs often demonstrate a high incidence of diseases in which vitamin A imbalances are implicated. These can occur even under controlled and optimised feeding regimens, which is why surveillance of vitamin A status is mandatory in the successful health management of cheetahs. Serum levels of the vitamin do not reflect the true vitamin A status and liver tissue analysis is rather impractical for routine application in large felids. A biomarker for evaluating overt and subclinical vitamin A deficiency in cheetahs is needed. This study evaluates whether increased calvarial bone thickness can be detected on routine skull radiographs of vitamin A deficient cheetahs compared to unaffected animals, and secondly, evaluates whether there is increased bone thickness in clinically sound captive cheetahs in general compared to wild-living controls. Bone thickness in the neuro- and splanchnocranium was measured in 138 skull radiographs. Significant thickening of the parietal bones was found in latero-lateral radiographs of immature cheetahs (< 12 months) with vitamin A deficiency. This finding may allow a presumptive diagnosis of hypovitaminosis A in immature cheetahs. A general difference in skull thickness between free-living and captive cheetahs was not found.

146. A novel vertebral numbering system for identifying congenital anomalies of the spine using full spine radiographs with the EOS imaging system

<h3>BACKGROUND CONTEXT</h3> The numbering of vertebral transitional anatomy can be challenging and controversial. Disagreement exists on how to best report anomalous vertebra and which imaging modality (CT, MRI, X-ray, etc) is most consistent. For these reasons, there is often a discrepancy in the numbering of transitional levels between radiologists and surgeons. Moreover, correlating levels identified intraoperatively by fluoroscopy with inconsistently numbered vertebrae on preoperative MRI or CT is arduous. Errors in numbering can have devastating implications for patients. A simple and accurate vertebral numbering system that can be applied to routine imaging is needed. <h3>PURPOSE</h3> The purpose of this study was to describe a novel and more simplified vertebral numbering system that can be used amongst surgeons and radiologists. <h3>STUDY DESIGN/SETTING</h3> A retrospective imaging study analyzing full-length spine X-rays was performed with the approval of a Colorado Multiple Institutional Review Board (COMIRB protocol:17-1920). <h3>PATIENT SAMPLE</h3> A total of 5,422 images were obtained that included all adult patients who presented to the Spine Center at the University of Colorado and obtained full-spine X-rays using the EOS imaging system between January 31st of 2018 and March 31st of 2020. Images from the same patient at multiple time points were excluded and 3,250 unique patient images were included in our study. After the initial period of data collection, 103 images were excluded from the final analysis due to poor image quality or missing image files. <h3>OUTCOME MEASURES</h3> Total presacral mobile segments were identified and counted using 24 as the number found in conventional spinal anatomy. The total number of ribs were counted for each patient including hypoplastic ribs, and the level of the first-ribbed vertebrae and last-ribbed vertebrae were recorded. <h3>METHODS</h3> Image analysis was conducted by five experienced researchers. The results were reviewed and verified by the senior authors. Any disagreements were reviewed and resolved by two board-certified musculoskeletal radiologists. Final results were evaluated and a novel vertebral numbering system with the lowest probability of error was agreed upon. <h3>RESULTS</h3> In our study cohort, 91.1% (2,868/3,147) demonstrated the conventional 24 presacral mobile segments, whereas 3.3% (104) had 23 presacral mobile segments, 5.5% (174) had 25, and 0.03% (1) had 26. Transitional anatomy, as defined by a number of presacral segments other than 24, was noted in 8.8% (279) of the total number of patients. Within this same group, the majority (94.6%; 2,976) had 12 ribs (including hypoplastic ribs), 4.5% (143) had 11 ribs, and 0.88% (28) had 13 ribs. Just 3.5% (112) had incomplete or hypoplastic ribs. Furthermore, 1.8% (56) of patients had both transitional anatomy and an abnormal number of ribs, with the pattern of transitional anatomy and 11 ribs being the most common combination identified. Considering the first nonribbed vertebrae as the first lumbar vertebrae yielded the lowest probability of a numbering error. <h3>CONCLUSIONS</h3> We are proposing a novel vertebral numbering system that yields the lowest probability of error in reporting anomalous anatomy which can be applied to routine cervical, thoracic, and lumbar radiographs. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Quantitative bone single-photon emission CT/CT parameters reflect pain and functional status of symptomatic basal joint arthritis of the thumb.

The aim of this study was to assess arthritis of the basal joint of the thumb quantitatively using bone single-photon emission CT/CT (SPECT/CT) and evaluate its relationship with patients' pain and function. We retrospectively reviewed 30 patients (53 hands) with symptomatic basal joint arthritis of the thumb between April 2019 and March 2020. Visual analogue scale (VAS) scores for pain, grip strength, and pinch power of both hands and Patient-Rated Wrist/Hand Evaluation (PRWHE) scores were recorded for all patients. Basal joint arthritis was classified according to the modified Eaton-Glickel stage using routine radiographs and the CT scans of SPECT/CT, respectively. The maximum standardized uptake value (SUVmax) from SPECT/CT was measured in the four peritrapezial joints and the highest uptake was used for analysis. According to Eaton-Glickel classification, 11, 17, 17, and eight hands were stage 0 to I, II, III, and IV, respectively. The interobserver reliability for determining the stage of arthritis was moderate for radiographs (k = 0.41) and substantial for CT scans (k = 0.67). In a binary categorical analysis using SUVmax, pain (p < 0.001) and PRWHE scores (p = 0.004) were significantly higher in hands with higher SUVmax. Using multivariate linear regression to estimate the pain VAS, only SUVmax (B 0.172 (95% confidence interval (CI) 0.065 to 0.279; p = 0.002) showed a significant association. Estimating the variation of PRWHE scores using the same model, only SUVmax (B 1.378 (95% CI, 0.082 to 2.674); p = 0.038) showed a significant association. The CT scans of SPECT/CT provided better interobserver reliability than routine radiographs for evaluating the severity of arthritis. A higher SUVmax in SPECT/CT was associated with more pain and functional disabilities of basal joint arthritis of the thumb. This approach could be used to complement radiographs for the evaluation of patients with this condition. Cite this article: Bone Joint J2021;103-B(8):1380-1385.